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| __NOTOC__
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| {{Appendix cancer}}
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| {{CMG}}; {{AE}} {{Soroush}}
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| ==Overview==
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| Medical therapy in appendix cancer could be either supportive, palliative, or curative. While carcinoid tumors rarely need chemotherapy, systemic chemotherapy as well as hyperthermic intraperitoneal chemotherapy plus/minus early postoperative intraperitoneal chemotherapy (EPIC) and/or concomitant intravenous chemotherapy are mainstream of medical treatment in adenocarcinoma of appendix. Medical therapy is generally administered to control the symptoms in patients with carcionid tumors and carcinoid syndrome.
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| ==Medical Therapy ==
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| *'''Supportive medical therapy''' for appendix cancer, may include:<ref name="pmid3696178">{{cite journal |vauthors=Moertel CG, Weiland LH, Nagorney DM, Dockerty MB |title=Carcinoid tumor of the appendix: treatment and prognosis |journal=N. Engl. J. Med. |volume=317 |issue=27 |pages=1699–701 |year=1987 |pmid=3696178 |doi=10.1056/NEJM198712313172704 |url=}}</ref><ref>Treatment Option Overview for GI Carcinoid Tumors
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| . NATIONAL CANCER INSTITUTE . http://www.cancer.gov/types/gi-carcinoid-tumors/hp/gi-carcinoid-treatment-pdq#link/_97_toc Accessed on September 22, 2015</ref>
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| :*[[Somatostatin]] analogs
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| ::*Octreotide or lanreotide
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| :*[[Loperamide]] or [[diphenoxylate]] for primary diarrhea
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| :* Somatostatin analogs for symptom control in patients with carcionid syndrome
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| *'''Curative and palliative chemotherapy'''
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| :*Systemic chemotherapy
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| :*Hyperthermic intraperitoneal chemotherapy<ref name="pmid21160924">González-Moreno S, González-Bayón LA, Ortega-Pérez G (2010) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21160924 Hyperthermic intraperitoneal chemotherapy: Rationale and technique.] ''World J Gastrointest Oncol'' 2 (2):68-75. [http://dx.doi.org/10.4251/wjgo.v2.i2.68 DOI:10.4251/wjgo.v2.i2.68] PMID: [https://pubmed.gov/21160924 21160924]</ref>
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| *'''Systemic chemotherapy'''
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| *Systemic chemotherapy has not been generally recommended for carcionid tumors, but patients with noncacinoid tumors are usually receive chemotherapy.
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| :*Nevertheless systemic chemotherapy for metastatic appendiceal adenocarcinoma has not been studied appropriately.
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| :*Many experts refer to current colorectal cancer chemotherapy approaches for adenocarcinoma of appendix.
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| :*'''Current colon cancer chemotherapy agents are as follows:'''
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| ::*5-fluorouracil (5-FU) : Traditional active agent
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| ::*Irinotecan
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| ::*Oxaliplatin
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| ::*Vascular endothelial growth factor receptor inhibitors (bevacizumab)
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| ::*Epidermal growth factor receptor inhibitors (cetuximab and panitumumab),
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| ::*Aflibercept
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| ::*Regorafenib: inhibitor of angiogenic tyrosine kinases (including the VEGF receptors 1,2, and 3),
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| ::*Capecitabine or 5-FU with or without a platinum drug
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| *'''FOLFOX6 has been widely recommended in patients with appendix adenocarcinoma.'''
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| :*Oxaliplatin, 5-FU and leucovorin or Capecitabine are active agents of the FOLFOX regime. <math>\blacktriangledown</math>
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| *
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| {| class="wikitable"
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| !'''Modified FOLFOX6'''<ref name="pmid12177775">Cheeseman SL, Joel SP, Chester JD, Wilson G, Dent JT, Richards FJ et al. (2002) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12177775 A 'modified de Gramont' regimen of fluorouracil, alone and with oxaliplatin, for advanced colorectal cancer.] ''Br J Cancer'' 87 (4):393-9. [http://dx.doi.org/10.1038/sj.bjc.6600467 DOI:10.1038/sj.bjc.6600467] PMID: [https://pubmed.gov/12177775 12177775]</ref><ref name="pmid18640933">Hochster HS, Hart LL, Ramanathan RK, Childs BH, Hainsworth JD, Cohn AL et al. (2008) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18640933 Safety and efficacy of oxaliplatin and fluoropyrimidine regimens with or without bevacizumab as first-line treatment of metastatic colorectal cancer: results of the TREE Study.] ''J Clin Oncol'' 26 (21):3523-9. [http://dx.doi.org/10.1200/JCO.2007.15.4138 DOI:10.1200/JCO.2007.15.4138] PMID: [https://pubmed.gov/18640933 18640933]</ref>
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| *'''Oxaliplatin''' 85 mg/m <sup>2</sup> IV
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| :*Dilute with 250 mL 5 percent dextrose in water (D5W)
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| :*Administer over 2 hrs
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| :*''Avoid extravasation: May cause significant tissue damage''
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| *'''Leucovorin''' 400 mg/m <sup>2</sup> IV (d,l-racemic mixture) / 200 mg/m <sup>2</sup> IV (l-leucovorin)
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| :*Dilute with 250 mL D5W
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| :*Administer over 2 hrs concurrent with oxaliplatin.
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| *'''Fluorouracil (FU)''' 400 mg/m <sup>2</sup> IV bolus<ref name="pmid14657227">Tournigand C, André T, Achille E, Lledo G, Flesh M, Mery-Mignard D et al. (2004) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14657227 FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced colorectal cancer: a randomized GERCOR study.] ''J Clin Oncol'' 22 (2):229-37. [http://dx.doi.org/10.1200/JCO.2004.05.113 DOI:10.1200/JCO.2004.05.113] PMID: [https://pubmed.gov/14657227 14657227]</ref>
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| :*Slow IV push over 5 mins (administer immediately after leucovorin)
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| *'''Fluorouracil (FU)''' 2400 mg/m <sup>2</sup> IV
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| :*Administer immediately after FU IV bolus
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| :*Dilute with 500 to 1000 mL D5W
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| :*Administer over 46 hours
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| |}
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| :*'''''Cycle length is 14 days;'''''
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| :*'''Doses should be recalculated if there is a 10 percent or more change in body weight.'''
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| *'''Prior to each treatment<math>\blacktriangledown</math>'''
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| ::* Assess changes in neurologic function.
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| ::* Assess electrolytes and liver and renal function.
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| ::* CBC with differential and platelet count.
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| *'''Common complications and approaches to complications'''
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| :* '''Diarrhea:'''
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| ::* Grade 2 or worse diarrhea: <math>\blacktriangledown</math>
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| ::** Withhold treatment.
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| ::** Restart at a lower dose of FU after complete resolution.
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| ::* '''Severe diarrhea, mucositis, and myelosuppression after FU''':<math>\blacktriangledown</math>
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| ::** Evaluate for dihydropyrimidine dehydrogenase deficiency.
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| :*'''Neurologic toxicity'''
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| ::*In order to decrease chance of developing Oxaliplatin induced neuropathy recommend patients to avoid exposure to cold up to 48 hours after each infusion.
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| ::*Transient grade 3 paresthesias/dysesthesias / grade 2 symptoms lasting longer than 1 week:<math>\blacktriangledown</math>
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| ::**Decrease oxaliplatin dose by 25 percent.
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| ::*Grade 4 or persistent grade 3 paresthesia/dysesthesia:<math>\blacktriangledown</math>
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| ::**Discontinue oxaliplatin.
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| :*'''Myelotoxicity'''
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| ::*Total white blood cell count <3000 cells/mm <sup>3</sup> , absolute neutrophil count <1500 cells/mm <sup>3</sup> , or platelets <100,000 /mm <sup>3</sup> on the day of treatment:<math>\blacktriangledown</math>
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| ::**Delay treatment cycle by one week.
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| ::*''If treatment is delayed for '''two weeks''' or delayed '''for one week on two separate occasions,''' eliminate FU bolus.''
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| ::*''If occurred again:''<math>\blacktriangledown</math>
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| :::*Reduce infusional FU by 20 percent and
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| :::*Reduce oxaliplatin dose from 65 mg/m <sup>2</sup>
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| *'''Hyperthermic intraperitoneal chemotherapy'''<ref name="pmid21160924">González-Moreno S, González-Bayón LA, Ortega-Pérez G (2010) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21160924 Hyperthermic intraperitoneal chemotherapy: Rationale and technique.] ''World J Gastrointest Oncol'' 2 (2):68-75. [http://dx.doi.org/10.4251/wjgo.v2.i2.68 DOI:10.4251/wjgo.v2.i2.68] PMID: [https://pubmed.gov/21160924 21160924]</ref>
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| :*Delivered in the operating room after cytoreductive surgery.
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| :*in selected cases is accompanied by early postoperative intraperitoneal chemotherapy (EPIC) as well as Concomitant intravenous chemotherapy (CIVC).
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| {| class="wikitable"
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| !'''Common HIPEC current regimens'''
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| *Oxaliplatin, 130 mg/m <sup>2</sup> for 60 minutes
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| *Concomitant intravenous chemotherapy (CIVC) 5-FU, 400 mg/m <sup>2</sup>
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| * Early postoperative intraperitoneal chemotherapy (EPIC) with 5-FU
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| * Mitomycin C, 35 mg/m <sup>2</sup> for 90 minutes
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| *Concomitant intravenous chemotherapy 5-FU, 400 mg/m <sup>2</sup>
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| * Early postoperative intraperitoneal chemotherapy (EPIC) with 5-FU
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| *Mitomycin C, 35 mg/m <sup>2</sup> for 90 minutes without EPIC or CIVC
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| *Mitomycin C, 3.3 mg//m <sup>2</sup>/L for 90 minutes without EPIC or CIVC
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| |}
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| *'''''Infuse the fluid at 43-45°Ci n order to maintain the intraperitoneal fluid temperature at 41-43°C.'''''
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| *'''''To avoid renal toxicity maintain urine output higher than 100 cc (desirable 150 cc) every 15 min during HIPEC.'''''
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| ==References==
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| {{Reflist|2}}
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| {{WH}}
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| {{WS}}
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| [[Category: (name of the system)]]
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