The use of intracavitary chemotherapy to eradicate peritoneal metastases originated from research in the use of peritoneal dialysis to treat acute or chronic renal failure [1,2]. Dedrick et al. described the potential for an increased local-regional dose intensity for ovarian cancer if chemotherapy was administered in a large volume of aqueous solution to fill the abdominal and pelvic cavity [3,4]. Also, the regional thermal enhancement of the cytotoxicity of cancer chemotherapy was extensively published [5]. Japanese groups lead by Koga, Fujimoto, and Fujimura used heat and chemotherapy together within the peritoneal spaces in gastric cancer patients [[6], [7], [8]]. The benefits of intraperitoneal cancer chemotherapy and heat as an adjuvant treatment after gastrectomy of patients with serosal-positive gastric cancer or gastric cancer with positive cytology remains in use today [9]. The success of adjuvant HIPEC depended upon single cells or minute cancer nodules being treated. Sugarbaker showed that peritonectomy procedures and visceral resections could reduce the volume of established peritoneal cancer dissemination so that no only prophylaxis but also treatment of peritoneal metastases became a reality [10,11]. The first benefits were with the treatment of peritoneal metastases from pseudomyxoma peritonei [12]. Subsequently, the use of cytoreductive surgery to remove all visible evidence of peritoneal metastases combined with perioperative intraperitoneal chemotherapy to preserve the surgical complete response has been extended to many different intraabdominal cancers [13,14]. This includes colon cancer, ovarian cancer, gastric cancer, peritoneal mesothelioma, and a large number of unusual cancers that occur within the abdomen and pelvis that may progress with isolated peritoneal dissemination. Consistently, the greatest benefit of treatment of peritoneal metastases is with the mucinous appendiceal malignancies [15]. With a complete cytoreductive surgery and perioperative chemotherapy, approximately 70% of patients with low-grade appendiceal mucinous neoplasms (LAMN) and 50% of patients with mucinous appendiceal adenocarcinomas (MACA) disseminated on peritoneal surfaces show a 10-year overall survival [16,17]. Also, those patients who fail may experience significant benefit from a secondary cytoreductive surgery (SCRS) [18].

In this manuscript, we identify a group of patients who had both lymph node metastases and peritoneal metastases, a complete index cytoreductive surgery, and a long-term follow-up. The goal in studying this restricted group of patients was to define the clinical- and treatment-related factors that are associated with benefit with SCRS. Our goal was to identify optimal selection factors for management of these patients with lymph node positive pseudomyxoma peritonei who may be considered for SCRS. No prior data concerning the results of SCRS in MACA-LN patients is available.