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Holowatyj AN, Overman MJ, Votanopoulos KI, Lowy AM, Wagner P, Washington MK, Eng C, Foo WC, Goldberg RM, Hosseini M, Idrees K, Johnson DB, Shergill A, Ward E, Zachos NC, Shelton D. Defining a 'cells to society' research framework for appendiceal tumours. Nat Rev Cancer 2025; 25:293-315. [PMID: 39979656 DOI: 10.1038/s41568-024-00788-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2024] [Indexed: 02/22/2025]
Abstract
Tumours of the appendix - a vestigial digestive organ attached to the colon - are rare. Although we estimate that around 3,000 new appendiceal cancer cases are diagnosed annually in the USA, the challenges of accurately diagnosing and identifying this tumour type suggest that this number may underestimate true population incidence. In the current absence of disease-specific screening and diagnostic imaging modalities, or well-established risk factors, the incidental discovery of appendix tumours is often prompted by acute presentations mimicking appendicitis or when the tumour has already spread into the abdominal cavity - wherein the potential misclassification of appendiceal tumours as malignancies of the colon and ovaries also increases. Notwithstanding these diagnostic difficulties, our understanding of appendix carcinogenesis has advanced in recent years. However, there persist considerable challenges to accelerating the pace of research discoveries towards the path to improved treatments and cures for patients with this group of orphan malignancies. The premise of this Expert Recommendation article is to discuss the current state of the field, to delineate unique challenges for the study of appendiceal tumours, and to propose key priority research areas that will deliver a more complete picture of appendix carcinogenesis and metastasis. The Appendix Cancer Pseudomyxoma Peritonei (ACPMP) Research Foundation Scientific Think Tank delivered a consensus of core research priorities for appendiceal tumours that are poised to be ground-breaking and transformative for scientific discovery and innovation. On the basis of these six research areas, here, we define the first 'cells to society' research framework for appendix tumours.
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Affiliation(s)
- Andreana N Holowatyj
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA.
- Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Michael J Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Andrew M Lowy
- Department of Surgery, Division of Surgical Oncology, Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | - Patrick Wagner
- Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Mary K Washington
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cathy Eng
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Wai Chin Foo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Mojgan Hosseini
- Department of Pathology, University of California, San Diego, San Diego, CA, USA
| | - Kamran Idrees
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Ardaman Shergill
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Erin Ward
- Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Nicholas C Zachos
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Deborah Shelton
- Appendix Cancer Pseudomyxoma Peritonei (ACPMP) Research Foundation, Springfield, PA, USA
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Chandramouli M, Wagner PL. Overview: Challenges of Treating Peritoneal Surface Malignancies. Surg Oncol Clin N Am 2025; 34:133-144. [PMID: 40015795 DOI: 10.1016/j.soc.2024.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2025]
Abstract
Peritoneal surface malignancies (PSM) includes an expansive disease spectrum, ranging from low-grade appendiceal mucinous neoplasm to metastatic processes from invasive adenocarcinomas of the gastrointestinal tract. Management of PSM faces numerous challenges, from diagnosis to delivery of care, both from a treatment and navigational standpoint. This article outlines the various hurdles faced at different branch points and current management recommendations.
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Affiliation(s)
- Mathangi Chandramouli
- Allegheny Health Network Cancer Institute, Division of Surgical Oncology, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Patrick L Wagner
- Allegheny Health Network Cancer Institute, Division of Surgical Oncology, 320 East North Avenue, Pittsburgh, PA 15212, USA.
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Knotts C, Park H, Sherry C, Blodgett R, Lewis C, Omstead A, Xiao K, LaFramboise W, Bartlett DL, Dadgar N, Goel A, Zaidi AH, Wagner PL. Intra-Tumoral CD8+:CD3+ Lymphocyte Density Ratio in Appendix Cancer Is a Tumor Volume- and Grade-Independent Predictor of Survival. Cancers (Basel) 2025; 17:542. [PMID: 39941908 PMCID: PMC11817446 DOI: 10.3390/cancers17030542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2024] [Revised: 01/27/2025] [Accepted: 02/03/2025] [Indexed: 02/16/2025] Open
Abstract
BACKGROUND The immune contexture of solid tumors plays a critical role in cancer progression and response to immunotherapy. However, immunologic characterization of appendiceal cancer (AC) has lagged behind advancements in other gastrointestinal malignancies. This study aims to define the AC immune microenvironment by quantifying CD3+ and CD8+ lymphocyte densities and assessing their prognostic significance. METHODS Archival tissue samples from 95 AC patients were analyzed using immunohistochemistry to assess CD3+ and CD8+ T cell densities and their ratios. Associations between lymphocyte density and clinical, pathologic, and oncologic variables were examined using Spearman's correlation, Kruskal-Wallis tests, and Cox proportional hazards analysis. RESULTS Tumor samples exhibited substantial immunologic heterogeneity with significant rightward skew. CD3+ and CD8+ densities were higher in low-grade tumors (p = 0.02 and p = 0.01, respectively) and low-grade histologic subtypes (p = 0.01 and p = 0.006). Lymphocyte density was inversely associated with patient age and was significantly lower in high-grade and non-mucinous tumors. The CD8+:CD3+ ratio emerged as an independent prognostic marker for progression-free survival (HR = 0.39, p = 0.004), whereas absolute CD3+ and CD8+ densities were less predictive. CONCLUSIONS This study highlights the diverse immune microenvironment in AC, with immune infiltration patterns correlating with tumor grade and histologic subtype. The CD8+:CD3+ ratio is a potential prognostic biomarker for patient stratification, underscoring its clinical significance. Future studies should expand immune biomarker panels and explore immunomodulatory therapies for lymphocyte-rich AC subsets.
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Affiliation(s)
- Chelsea Knotts
- Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA; (C.K.); (H.P.); (C.S.); (R.B.); (C.L.); (A.O.); (K.X.); (W.L.); (D.L.B.); (A.H.Z.)
| | - Hyun Park
- Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA; (C.K.); (H.P.); (C.S.); (R.B.); (C.L.); (A.O.); (K.X.); (W.L.); (D.L.B.); (A.H.Z.)
| | - Christopher Sherry
- Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA; (C.K.); (H.P.); (C.S.); (R.B.); (C.L.); (A.O.); (K.X.); (W.L.); (D.L.B.); (A.H.Z.)
| | - Rose Blodgett
- Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA; (C.K.); (H.P.); (C.S.); (R.B.); (C.L.); (A.O.); (K.X.); (W.L.); (D.L.B.); (A.H.Z.)
| | - Catherine Lewis
- Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA; (C.K.); (H.P.); (C.S.); (R.B.); (C.L.); (A.O.); (K.X.); (W.L.); (D.L.B.); (A.H.Z.)
| | - Ashten Omstead
- Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA; (C.K.); (H.P.); (C.S.); (R.B.); (C.L.); (A.O.); (K.X.); (W.L.); (D.L.B.); (A.H.Z.)
| | - Kunhong Xiao
- Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA; (C.K.); (H.P.); (C.S.); (R.B.); (C.L.); (A.O.); (K.X.); (W.L.); (D.L.B.); (A.H.Z.)
| | - William LaFramboise
- Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA; (C.K.); (H.P.); (C.S.); (R.B.); (C.L.); (A.O.); (K.X.); (W.L.); (D.L.B.); (A.H.Z.)
| | - David L. Bartlett
- Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA; (C.K.); (H.P.); (C.S.); (R.B.); (C.L.); (A.O.); (K.X.); (W.L.); (D.L.B.); (A.H.Z.)
| | - Neda Dadgar
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH 44106, USA;
| | - Ajay Goel
- Beckman Research Institute of City of Hope, Monrovia, CA 91016, USA;
| | - Ali H. Zaidi
- Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA; (C.K.); (H.P.); (C.S.); (R.B.); (C.L.); (A.O.); (K.X.); (W.L.); (D.L.B.); (A.H.Z.)
| | - Patrick L. Wagner
- Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA; (C.K.); (H.P.); (C.S.); (R.B.); (C.L.); (A.O.); (K.X.); (W.L.); (D.L.B.); (A.H.Z.)
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Dadgar N, Sherry C, Zimmerman J, Park H, Lewis C, Donnenberg A, Zaidi AH, Fan Y, Xiao K, Bartlett D, Donnenberg V, Wagner PL. Targeting interleukin-6 as a treatment approach for peritoneal carcinomatosis. J Transl Med 2024; 22:402. [PMID: 38689325 PMCID: PMC11061933 DOI: 10.1186/s12967-024-05205-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/15/2024] [Indexed: 05/02/2024] Open
Abstract
Peritoneal carcinomatosis (PC) is a complex manifestation of abdominal cancers, with a poor prognosis and limited treatment options. Recent work identifying high concentrations of the cytokine interleukin-6 (IL-6) and its soluble receptor (sIL-6-Rα) in the peritoneal cavity of patients with PC has highlighted this pathway as an emerging potential therapeutic target. This review article provides a comprehensive overview of the current understanding of the potential role of IL-6 in the development and progression of PC. We discuss mechansims by which the IL-6 pathway may contribute to peritoneal tumor dissemination, mesothelial adhesion and invasion, stromal invasion and proliferation, and immune response modulation. Finally, we review the prospects for targeting the IL-6 pathway in the treatment of PC, focusing on common sites of origin, including ovarian, gastric, pancreatic, colorectal and appendiceal cancer, and mesothelioma.
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Affiliation(s)
- Neda Dadgar
- Translational Hematology & Oncology Research, Enterprise Cancer Institute, Cleveland Clinic, Cleveland, OH, 44106, USA
| | - Christopher Sherry
- Allegheny Health Network Cancer Institute, 314 E. North Ave, Pittsburgh, PA, 15212, USA
| | - Jenna Zimmerman
- Allegheny Health Network Cancer Institute, 314 E. North Ave, Pittsburgh, PA, 15212, USA
| | - Hyun Park
- Allegheny Health Network Cancer Institute, 314 E. North Ave, Pittsburgh, PA, 15212, USA
| | - Catherine Lewis
- Allegheny Health Network Cancer Institute, 314 E. North Ave, Pittsburgh, PA, 15212, USA
| | - Albert Donnenberg
- Allegheny Health Network Cancer Institute, 314 E. North Ave, Pittsburgh, PA, 15212, USA
| | - Ali H Zaidi
- Allegheny Health Network Cancer Institute, 314 E. North Ave, Pittsburgh, PA, 15212, USA
| | - Yong Fan
- Allegheny Health Network Cancer Institute, 314 E. North Ave, Pittsburgh, PA, 15212, USA
| | - Kunhong Xiao
- Center for Proteomics & Artificial Intelligence, Center for Clinical Mass Spectrometry, Allegheny Health Network Cancer Institute, Pittsburgh, PA, 15224, USA
| | - David Bartlett
- Allegheny Health Network Cancer Institute, 314 E. North Ave, Pittsburgh, PA, 15212, USA
| | - Vera Donnenberg
- University of Pittsburgh School of MedicineDepartment of Cardiothoracic SurgeryUPMC Hillman Cancer Center Wagner, Patrick; Allegheny Health Network Cancer Institute, Pittsburgh, USA
| | - Patrick L Wagner
- Allegheny Health Network Cancer Institute, 314 E. North Ave, Pittsburgh, PA, 15212, USA.
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Futoh Y, Miyato H, Yamaguchi H, Matsumiya M, Takahashi R, Kaneko Y, Kimura Y, Ohzawa H, Sata N, Kitayama J, Hosoya Y. Vagus nerve signal has an inhibitory influence on the development of peritoneal metastasis in murine gastric cancer. Sci Rep 2024; 14:7832. [PMID: 38570542 PMCID: PMC10991300 DOI: 10.1038/s41598-024-58440-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 03/29/2024] [Indexed: 04/05/2024] Open
Abstract
The vagus nerve is the only pathway for transmitting parasympathetic signals between the brain and thoracoabdominal organs, thereby exhibiting anti-inflammatory functions through the cholinergic anti-inflammatory pathway. Despite often being resected during lymph node dissection in upper gastrointestinal cancer surgery, the impact of vagotomy on postoperative outcomes in gastric cancer patients remains unclear. Sub-diaphragmatic vagotomy was performed on C57BL/6 mice. Three weeks later, syngeneic murine gastric cancer cell line YTN16P was injected into the peritoneal cavity, and the number of peritoneal metastases (PM) on the mesentery and omentum compared with control mice. The phenotypes of immune cells in peritoneal lavage and omental milky spots one day after tumor inoculation were analyzed using flow cytometry and immunohistochemistry. Intraperitoneal transfer of 3 × 105 YTN16P significantly increased the number of metastatic nodules on the mesentery in the vagotomy group compared to the control group. The omental metastasis grade was also significantly higher in the vagotomy group. Phenotypic analysis of immune cells in peritoneal lavage did not reveal significant differences after vagotomy. However, vagotomized mice exhibited a notable increase in milky spot area, with a higher presence of cytokeratin(+) tumor cells, F4/80(+) macrophages, and CD3(+) T cells. Vagus nerve signaling appears to regulate the immune response dynamics within milky spots against disseminated tumor cells and inhibits the development of PM. Preserving the vagus nerve may offer advantages in advanced gastric cancer surgery to reduce peritoneal recurrence.
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Affiliation(s)
- Yurie Futoh
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Hideyo Miyato
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan.
- Department of Clinical Oncology, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Hironori Yamaguchi
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
- Department of Clinical Oncology, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Misaki Matsumiya
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Rei Takahashi
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Yuki Kaneko
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Yuki Kimura
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Hideyuki Ohzawa
- Department of Clinical Oncology, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Joji Kitayama
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
- Center for Clinical Research, Jichi Medical University Hospital, Shimotsuke, Japan
| | - Yoshinori Hosoya
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
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Levine EA. Reconnaissance for Intraperitoneal Immunotherapy. Ann Surg Oncol 2024; 31:2194-2195. [PMID: 38261129 DOI: 10.1245/s10434-023-14858-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/17/2023] [Indexed: 01/24/2024]
Affiliation(s)
- Edward A Levine
- Surgical Oncology, Department of General Surgery, Wake Forest University, Winston-Salem, NC, USA.
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