Management and prognosis of adenocarcinoma of the appendix

Cancer-specific survival in non-mucinous appendiceal adenocarcinomas after local resection versus right hemicolectomy: A Surveillance, Epidemiology, and End Results database study

BACKGROUND

Adenocarcinomas of the appendix are rare cancers for which no National Comprehensive Cancer Network guidelines exist, and for patients who undergo resection with curative intent, there is a paucity of data on prognostic factors affecting long-term cancer-specific survival. We aimed to compare the cancer-specific survival outcomes in adult patients with appendiceal non-mucinous adenocarcinoma undergoing either local resection versus right hemicolectomy.

METHODS

This was a retrospective study from the National Cancer Institute Surveillance, Epidemiology, and End Results of patients who underwent curative resection over a 15-year period (2004-2019) for primary appendiceal adenocarcinoma. Out of 16,699 patients, 14,945 were excluded (exclusion criteria were non-adenocarcinoma histological types and patients with regional or distant metastasis as per National Cancer Institute Surveillance, Epidemiology, and End Results stage). Effects of factors (age, race, tumor biology [mucinous versus non-mucinous tumors], the extent of resection of the primary lesion, and lymph nodes) on cancer-specific long-term survival were studied. Survival analysis was performed using the Kaplan-Meier method. Survival outcomes were reported as mean survival (months).

RESULTS

Of 1,754 patients, 827 (47.1%) were women, and 927 (52.1%) were men. The mean age in years (± standard deviation) was 62.43 ± 14.3. The racial distribution was as follows: Black 237 (13.5%), White 1,398 (79.7%), and Other 119 (6.8%). A total of 771 (44.6%) underwent local resection (appendectomy or segmental resection of colon without lymph node resection), and 983 (55.4%) underwent hemicolectomy with lymph node resection. Favorable survival prognosticators were age <50 years, White race, and well-differentiated histology. Patients with mucinous tumors experienced better survival. Patients who underwent right hemicolectomy with lymph node resection experienced better survival compared with those who had an appendectomy or segmental colonic resection for non-mucinous tumors rather than mucinous tumors.

CONCLUSION

We report novel demographic, tumor-related, and operative prognostic factors impacting long-term cancer-specific survival in patients who undergo resection for appendiceal adenocarcinoma. The extent of resection of the primary lesion with draining lymph nodes determines long-term cancer-specific survival in non-mucinous appendiceal adenocarcinomas.

The Vermiform Appendix and Its Pathologies

The vermiform appendix is a muscular cylindrical structure originating near the junction of the cecum and ileum, averaging 9 cm (5-35 cm) in size. As the most mobile viscera, it can adopt several positions, the most common being the retrocecal position. Perceived as an atavistic organ lacking physiological relevance, the vermiform appendix appears to be involved in immune function, serving in the maturation of B lymphocytes and the production of immunoglobulin A, in endocrine function, excreting amines and hormones in the 2-3 mL of mucus secreted daily, and in digestive function, by storing beneficial bacteria from where they can recolonize the colon. With a lumen of about 6 mm, the vermiform appendix has a reduced storage capacity, so any blockage of the appendix with fecoliths (fecaliths), seeds derailed from the colon, or enlarged lymph nodes prevents drainage and intraluminal accumulation of secreted mucus. Unable to relax, the appendix wall severely limits its intraluminal volume, so mucus accumulation leads to inflammation of the appendix, known generically as appendicitis. In addition, the vermiform appendix may be the site of the development of neoplastic processes, which may or may not involve mucus production, some of which can significantly affect the standard of living and ultimately lead to death. In general, mucinous tumors may have a better prognosis than non-mucinous tumors. This review takes a comprehensive path, starting by describing the anatomy and embryology of the vermiform appendix and further detailing its inflammatory pathologies, pathologies related to congenital anomalies, and appendix tumors, thus creating an up-to-date framework for better understanding, diagnosis, and treatment of these health problems.

Preoperative prediction of malignancy and surgical treatment strategy in appendiceal tumors: multicenter review of 51 consecutive cases

PURPOSE

A diagnostic and treatment strategy for appendiceal tumors (ATs) has not been established. We aimed to evaluate our treatment strategy in ATs, including laparoscopic surgery (LS), and to identify preoperative malignancy predictors.

METHODS

A total of 51 patients between 2011 and 2021 were retrospectively reviewed. Data, including tumor markers and imaging findings, were compared between carcinoma and non-carcinoma patients. Validity of planned operation was evaluated based on pathological diagnosis.

RESULTS

Twenty-five patients were diagnosed with carcinoma, 13 with low-grade mucinous neoplasm, and 13 with other diseases. Symptoms were more commonly present in carcinoma patients than in non-carcinoma patients (68.0% vs. 23.1%, p = 0.001). Elevated CEA and CA19-9 were more frequently observed in carcinoma patients than in non-carcinoma patients (p < 0.01 and p = 0.04, respectively). Five carcinoma patients had malignancy on biopsy, compared with zero non-carcinoma patients. Significant differences were noted in the percentages of carcinoma and non-carcinoma patients with solid enhanced mass (41.7% vs. 0%, p < 0.001) and tumor wall irregularity (16.7% vs. 0%, p = 0.03) on imaging. Although the sensitivity was not high, the specificity and positive predictive value of these findings were 100%. Forty-two patients (82.4%) underwent LS as minimally invasive exploratory and/or radical operation, of whom 2 were converted to open surgery for invasion of adjacent organ. No patients had intraoperative complications or postoperative mortality.

CONCLUSION

Clinical symptoms, elevated tumor markers, and worrisome features of solid enhanced mass and tumor wall irregularity on imaging can be malignancy predictors. For management of ATs, LS is feasible and useful for diagnosis and treatment.

Prevalence of Carcinoma in Appendectomy Specimens for Patients Presenting With Acute Appendicitis: A Single-Center Study

Introduction Acute appendicitis is the most common general surgical emergency globally. Its etiology includes the presence of luminal obstruction by faecoliths, lymphoid hyperplasia, impacted stool, and rarely by appendiceal or caecal cancer. Malignancy related to acute appendicitis is usually seen in the older age group. Aim To identify the subset rate of patients operated for acute appendicitis who have appendiceal carcinoma and analyze the outcome of their post-operative management. Material and methods A retrospective study of a cohort of 529 patients aged > 40 diagnosed with acute appendicitis with subsequent appendectomy in the period between 1 January 2014 and 31 December 2019 at Basildon and Thurrock University Hospital, Essex, United Kingdom was conducted. We analyzed the clinical data of the cohort including demographic information, diagnosis, pre-operative imaging, histological diagnosis as well as post-operative management where indicated. Results The median age of patients was 54.5 years (range 40-92). The male to female ratio in the appendicectomy cohort was 1:1.1. About 45% were aged 40-49 years, 24.8% were aged 50-59 and 30.2% were ≥60 years. Post-operative histology revealed acute appendicitis in 82.4% of the group. In 11% of the patients, the histology revealed the presence of other benign pathology as mucocele of the appendix, acute diverticulitis, follicular hyperplasia, and fibrous obliteration. The diagnosis of appendicular malignancy was seen in 1.9%. Conclusion Incidental appendiceal cancers in the resected specimens after acute appendicitis are rare but may be associated with a poor prognosis. It is recommended to consider such diagnosis in particular when dealing with acute appendicitis in older patients with longer symptom history, and in presence of peri-appendicular mass.

A case report of incarcerated inguinal hernia: Amyand's hernia with adenocarcinoma tumor

INTRODUCTION

Inguinal hernia is one of the most common surgical problems, often posing technical challenges even to expert surgeons. Amyand's hernia (AH) is an inguinal hernia whose sac contains the vermiform appendix. Primary appendiceal neoplasms are rare. We report the case of an appendiceal adenocarcinoma within an Amyand's hernia, presenting as an incarcerated right inguinal hernia.

PRESENTATION OF CASE

A 87-year-old male presented in the emergency department due to a persistent right inguinal pain. Clinical examination revealed a tender right groin mass. Under the diagnosis of an right inguinal hernia, an operation was taken. Intraoperatively, an inflamed appendix and a part of the cecum were found in the hernia sac. The operation was completed with an ileocecal resection and a modified Bassini hernia repair. Histological examination revealed a adenocarcinoma of the appendix.

DISCUSSION

Amyand's hernia is an inguinal hernia that contains vermiform appendix in its sac. It consists 1% of all inguinal hernias while appendicitis in an Amyand's hernia accounts for 0.1% of all appendicitis cases. Adenocarcinomas of the appendix are even rarer, accounting for 0.2% to 0.5% of all intestinal malignancies, and 4%-6% of primary appendiceal neoplasms. Diagnosis is usually established intraoperatively.

CONCLUSION

A malignancy of the appendix should always be in the differential diagnosis of a right inguinal mass, in order to provide optimum surgical treatment.

Mode of Presentation in 1070 Patients With Perforated Epithelial Appendiceal Tumors, Predominantly with Pseudomyxoma Peritonei

BACKGROUND

Perforated epithelial appendiceal tumors are uncommon and can give rise to pseudomyxoma peritonei. Pseudomyxoma peritonei is rare, almost always of appendiceal origin, and presents in various ways relevant to abdominal surgeons.

OBJECTIVE

The aim of this study was to report the mode of presentation of pseudomyxoma peritonei of appendiceal origin in patients treated in a high-volume UK peritoneal malignancy center.

DESIGN

A retrospective observational study was conducted.

SETTINGS

This was a single-center study.

PATIENTS

Retrospective analysis of a prospective database of consecutive patients undergoing surgery between March 1994 and December 2016 was performed.

MAIN OUTCOME MEASURES

Mode of presentation was classified into 7 categories: "histological diagnosis at abdominal surgery for presumed appendicitis," "probable pseudomyxoma peritonei" based on abnormality on cross-sectional imaging (± image-guided biopsy)," "abnormal imaging (other cause suspected) and operative finding of pseudomyxoma peritonei," "diagnostic laparoscopy," "ovarian mass," "new-onset hernia," and "miscellaneous."

RESULTS

Overall, 1070 patients underwent surgery (female 61%, male 39%); median age was 57. The mode of presentation was abnormality on cross-sectional imaging in 324 of 1070 patients (30.3%), histological diagnosis at emergency surgery for presumed appendicitis in 203 of 1070 patients (19%), and abnormal imaging with eventual pseudomyxoma peritonei diagnosis in 180 of 1070 patients (16.8%); 124 of 651 women (19.2%) presented with an ovarian mass. New-onset hernia was the presenting feature in 9.9%; 83 of 1070 patients (7.7%) were diagnosed at diagnostic laparoscopy, and 32 of 1070 patients (3%) were described as "miscellaneous." Overall, 775 of 1070 patients (72.4%) had complete cytoreductive surgery with 10-year survival of 63.5%.

LIMITATIONS

Results are limited by the retrospective nature of the study, radiological improvements over the study period, and the number of patients who had overlapping features at presentation.

CONCLUSION

Perforated appendiceal tumors present in various ways but predominantly at cross-sectional imaging or coincidentally at laparoscopy or laparotomy. All abdominal surgeons will occasionally encounter cases, often unexpectedly, and recognition and referral to a specialized unit results in excellent outcomes in most cases. See Video Abstract at http://links.lww.com/DCR/B256. MODO DE PRESENTACIÓN EN 1070 PACIENTES CON TUMORES EPITELIALES APENDICULARES PERFORADOS, PREDOMINANTEMENTE CON PSEUDOMIXOMA PERITONEAL: Los tumores epiteliales apendiculares perforados son poco frecuentes y pueden dar lugar a Pseudomyxoma peritonei. El pseudomixoma peritoneal es raro, casi siempre de origen apendicular, y se presenta de diversas formas relevantes para los cirujanos abdominales.El objetivo fue informar el modo de presentación del Pseudomixoma peritoneal de origen apendicular en pacientes tratados en un centro de malignidad peritoneal de alto volumen en el Reino Unido.Se realizó un estudio observacional retrospectivo.Este fue un estudio de centro único.Análisis retrospectivo de una base de datos prospectiva de pacientes consecutivos sometidos a cirugía entre marzo de 1994 y diciembre de 2016.El modo de presentación se clasificó en 7 categorías: "diagnóstico histológico en la cirugía abdominal por presunta apendicitis", "probable Pseudomixoma peritoneal" basado en la anormalidad en la imagen de corte transversal (biopsia guiada por imagen +/-), "imagen anormal (se sospecha otra causa) y hallazgo quirúrgico de Pseudomixoma peritoneal", "laparoscopia diagnostica", "masa ovarica", "hernia de reciente aparicion" y "varios".En total, 1070 pacientes fueron operados (mujeres 61%, hombres 39%); edad media 57. El modo de presentación fue anormalidad en la imágen transversal en 324/1070 (30.3%), el diagnóstico histológico en cirugía de emergencia por presunta apendicitis en 203/1070 (19%), la imágen anormal con eventual diagnóstico de Pseudomixoma peritoneal en 180 / 1070 (16.8%), 124/651 (19.2%) las mujeres presentaron una masa ovárica. La hernia de reciente aparición fue la característica de presentación en 9.9%, 83/1070 (7.7%) fueron diagnosticados por laparoscopia diagnóstica y 32/1070 (3%) "misceláneos". En general, 775/1070 (72,4%) se sometió a cirugía citorreductora completa con una supervivencia a 10 años del 63,5%.Una deficiencia es que los resultados están limitados por la naturaleza retrospectiva del estudio, las mejoras radiológicas a lo largo del período de estudio, y varios pacientes tenían características superpuestas en la presentación.Los tumores apendiculares perforados se presentan de varias maneras, pero predominantemente en imágenes transversales o casualmente en laparoscopia o laparotomía. Todos los cirujanos abdominales encontrarán ocasionalmente con casos, a menudo inesperados, y el reconocimiento y la derivación a una unidad especializada da lugar a excelentes resultados en la mayoría de los casos. Consulte Video Resumen en http://links.lww.com/DCR/B256.).

Updates in Appendix Pathology: The Precarious Cutting Edge

Mucinous appendiceal tumors include low-grade appendiceal mucinous neoplasm, high-grade appendiceal mucinous neoplasm, and mucinous adenocarcinoma. Nonmucinous adenocarcinomas are less frequent. Recent consensus guidelines and the latest edition of the World Health Organization classification will allow consistent use of agreed nomenclature. Accurate diagnosis is important not only for patient management but also to allow comparison of results between centers and tumor registries. Serrated polyps are the most common benign polyp in the appendix. They need to be distinguished from low-grade appendiceal mucinous neoplasm, which can also mimic other benign conditions. Goblet cell adenocarcinomas are a distinctive type of appendiceal neoplasm.

Combined Endoscopic Mucosal Resection and Extended Laparoscopic Appendectomy for the Treatment of Periappendiceal, Cecal, and Appendiceal Adenomas

BACKGROUND

Surgical resection is the gold standard in the treatment of neoplasia involving the appendiceal orifice (Ao). Endoscopic mucosal resection (EMR) of adenomas involving the Ao can be challenging because of the risk of appendicitis, perforation, or incomplete resection. Surgical resection of Ao lesions is limited by the difficulty of ensuring a negative lateral margin without compromising the ileocecal valve and usually necessitates ileocecal resection. Although combined endoscopic and laparoscopic surgery has become more widely accepted for a variety of conditions, a structured approach to lesions involving the Ao has yet to be described. We describe a novel approach to the treatment of periappendiceal, cecal, and appendiceal adenomas-and present an algorithm to guide decision-making regarding the application of these techniques.

METHODS

All patients referred to our therapeutic endoscopy practice with tumors involving the Ao between August 2013 and July 2017 were included. Based on tumor size and involvement of the os, patients were either referred for extended laparoscopic appendectomy (ELA), EMR, or a combined approach.

RESULTS

In total, 47 patients were included; 25 patients underwent EMR only, 13 patients underwent ELA only, and nine patients underwent combined resection. Two patients undergoing EMR had postpolypectomy syndrome. One EMR-only patient with a positive lateral margin was referred for appendectomy, but declined. No patient required ileocecectomy. Pathologic examination revealed a high rate of sessile serrated adenoma (SSA; 36%).

CONCLUSIONS

Our results introduce a decision algorithm and suggest that EMR combined with ELA is a safe and curative technique for the treatment of large cecal adenomas involving the Ao.

Management and prognostic prediction of appendiceal mucinous adenocarcinoma with peritoneal metastasis: a single center study in China

Background

To investigate the clinical and pathological characteristics of appendiceal mucinous adenocarcinoma with peritoneal metastasis and analyze the prognostic factors.

Methods

A retrospective analyses of clinicopathological features of 50 patients with appendiceal mucinous adenocarcinoma with peritoneal metastasis from January, 2013 to December, 2017 in Aerospace Central Hospital, Beijing, China. Survival data calculation and comparison were respectively performed with the Kaplan-Meier method and the log-rank test. The Cox proportional hazards regression method was used for multivariate survival analyses.

Results

Cytoreduction for appendiceal mucinous adenocarcinoma was conducted on 50 patients (24 males and 26 females), with a median age of 52.5 years at the time of surgery (range 31–71 years). The median overall survival (OS) time was 24 months, with 2-,3- and 5-year survival rates of 53, 24 and 8%, respectively. At the last follow-up in December 2018, 13 patients were still alive. Multivariate analysis revealed that patients who had low Ki-67 expression (less than 50%) and CCR (completeness of cytoreduction) 0/1/2 score had significantly better OS rate than their respective counterparts.

Conclusions

Ki-67 expression statue and CCR score could be employed as the prognosis prediction in patients with appendiceal mucinous adenocarcinoma.

Survival outcomes of appendiceal mucinous neoplasms by histological type and stage: Analysis of 266 cases in a multicenter collaborative retrospective clinical study

AIM

Appendiceal mucinous neoplasms are rare, and thus the literature is sparse with regard to histological types, staging, and prognosis. In particular, it is unclear how long-term outcome may differ between mucinous adenocarcinomas and other adenocarcinomas. In the present study, we aimed to investigate the histological types and stages of appendiceal neoplasms, and to evaluate the prognostic impacts of these factors in patients with mucinous adenocarcinomas and non-mucinous adenocarcinomas.

METHODS

Patients with appendiceal tumors diagnosed between 2007 and 2016 were retrospectively identified from the databases of 19 institutions in the Clinical Study Group of Osaka University, Colorectal Group.

RESULTS

A total of 266 patients with appendiceal tumors were identified, of whom 130 had pathologically diagnosed adenocarcinomas, including 57 with mucinous adenocarcinomas and 73 with non-mucinous adenocarcinomas. Five-year overall survival (OS) rates were 64.5% for mucinous adenocarcinomas, and 49.0% for non-mucinous adenocarcinomas. OS was significantly shorter among patients with non-mucinous adenocarcinomas compared to mucinous adenocarcinomas. Among patients with mucinous adenocarcinomas, 5-year OS rates were 53.6% for stage 0/I, 82.6% for II/III, and 48.4% for IV. Among patients with non-mucinous adenocarcinomas, 5-year OS rates were 90.9% for stage 0/I, 68.8% for II/III, and 7.1% for IV. Analysis of patients with stage IV disease revealed significantly shorter OS among patients with non-mucinous adenocarcinomas compared to mucinous adenocarcinomas.

CONCLUSION

Our present findings showed a better prognosis in patients with mucinous adenocarcinomas compared to non-mucinous adenocarcinomas. In this setting, Union for International Cancer Control staging was associated with prognosis for non-mucinous adenocarcinomas, but not for mucinous adenocarcinomas.

A diagnostic dilemma of appendicular mass in an elderly patient: a case report and literature review

Primary appendicular adenocarcinoma is a rare tumor, mucinous variety, being most common. The case presentation highlights the unusual appearance and diagnostic dilemma of an appendicular adenocarcinoma. Our elderly patient presented with an ill-defined tender lump which later was diagnosed as a perforated appendicular adenocarcinoma, responsive to single-staged surgery and adjunct chemotherapy. We considered the single-staged surgery since the appendix was perforated and right colectomy would not aid the prognosis. High index of clinical suspicion for malignancy should be kept in mind for elderly patients presenting with an appendicular lump. Every effort should be made during the elective surgery to remove the mass during the single-staged surgery.

Nationwide overview of survival and management of appendiceal tumors in children

INTRODUCTION

There remains a paucity of literature on survival related to pediatric appendiceal tumors. The purpose of this study was to determine the incidence, surgical management, and survival outcomes of appendiceal tumors in pediatric patients.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) Registry was analyzed for pediatric appendiceal tumors from 1973 to 2011. Parameters analyzed were: tumor type, surgical management (appendectomy vs. extensive resection), tumor size, and lymph node sampling. Chi-square analysis for categorical and Student's t test for continuous data were used.

RESULTS

Overall, 209 patients had an appendiceal tumor, including carcinoid (72%), appendiceal adenocarcinoma (16%), and lymphoma (12%). Patients undergoing appendectomy vs. extensive resection had similar 15-year survival rates (98% vs. 97%; p=0.875). Appendectomy vs. extensive resection conferred no 15-year survival advantage when patients were stratified by tumor type, including adenocarcinoma (87% vs. 89%; p=0.791), carcinoid (100% vs. 100%; p=0.863), and lymphoma (94% vs. 100%; p=0.639). There was no significant difference in 15-year survival between tumor size groups ≥2 and <2cm (both 100%) and presence or absence of lymph node sampling (96% and 97%; p=0.833) for all patients with a carcinoid tumor.

CONCLUSION

Appendectomy may be adequate for pediatric appendiceal tumors. Extensive resection may be of limited utility for optimizing patient survival, placing patient at greater operative risk.

TYPE OF STUDY

Retrospective Prognostic Study.

LEVEL OF EVIDENCE

III.

Survival after resection of appendiceal carcinoma by hemicolectomy and less radical than hemicolectomy: a population-based propensity score matched analysis

AIM

The operative treatment for non-metastatic appendiceal carcinoma is controversial despite the recommendation of right hemicolectomy (RH) by many researchers. The aim of this population-based study was to compare outcomes after RH and less radical resection than right hemicolectomy (LRH).

METHOD

A total of 1144 patients who underwent resection with additional lymphadenectomy of Stages I-III appendiceal carcinoma from 2004 to 2012 were identified in the Surveillance, Epidemiology and End Results database. Overall survival (OS) and cancer-specific survival (CSS) after RH and LRH were assessed by unadjusted and risk-adjusted Cox regression analysis and by propensity score matched analysis.

RESULTS

A total of 855 (74.7%) patients underwent RH and 289 (25.3%) underwent LRH. In an unadjusted analysis, survival after LRH and RH did not differ in OS [hazard ratio (HR) 0.95, 95% CI 0.71-1.26, P = 0.707] and CSS (HR 0.95, 95% CI 0.69-1.32, P = 0.762). The 5-year OS and CSS in patients who underwent RH were 71.6% (95% CI 67.8-75.6%) and 76.4% (95% CI 72.8-80.3) compared with 73.8% (95% CI 67.9-80.2) and 78.7% (95% CI 73.2-84.7) in patients with LRH, respectively. No relevant difference in survival between LRH and RH could be observed in a multivariable analysis (OS, HR 0.90, 95% CI 0.65-1.25, P = 0.493; CSS, HR 0.87, 95% CI 0.60-1.26, P = 0.420) and after propensity score adjusted analysis (OS, HR 0.87, 95% CI 0.62-1.22, P = 0.442; CSS, HR 0.97, 95% CI 0.67-1.40, P = 0.883).

CONCLUSIONS

In this retrospective analysis, survival after RH for non-metastatic appendiceal carcinoma was not statistically significantly superior to LRH. Hence, LRH with lymphadenectomy might be sufficient for treatment of non-metastatic appendiceal carcinoma.

Acute appendicitis, inflammatory appendiceal mass and the risk of a hidden malignant tumor: a systematic review of the literature

Introduction

Acute appendicitis is significantly common. Despite the increased use of computed tomography, the number of perforated cases has been stable in the past three decades. Between 2% and 6% of patients with acute appendicitis present appendiceal mass, often described as inflammatory phlegmon or abscess. Malignant tumors are confirmed by pathological analysis in 0.9–1.4% of all appendectomies performed to treat acute appendicitis. However, recent series demonstrate an elevated incidence of malignancies, ranging from 5.9 to 12%, in patients with inflammatory appendiceal mass.

Methods

The analysis was based on a systematic review of the literature. The articles were searched in PubMed for the period from 1987 to 2016. Articles presenting the incidence of the hidden malignancy among patients with appendiceal inflammatory mass were selected. Variables as age, interval appendectomy rate, the incidence of neoplasm, time to surgery, minimally invasive assessment, histology, right colectomy rate and morbidity were analyzed.

Results

A total of 13.244 patients were described as presenting acute appendicitis. Appendiceal tumor is present in approximately 1% of the appendectomies, while the rate of neoplasm varies from 10 to 29% in patients presenting appendiceal inflammatory mass. Interval appendectomies, despite been the minority of the procedures, disregard the higher morbidity associated with right sided colectomies. The review of literature also describes oncologic, histologic and clinical aspects of patients presenting appendiceal neoplasm, describing the most frequent histologic subtypes of this illness.

Conclusion

Hidden appendiceal neoplasm in acute appendicitis are rare, fortunately. However, its incidence is much higher in patients presenting appendiceal inflammatory mass. Hence, interval appendectomy should be considered in this subgroup of patients.

The Management and Prognostic Prediction of Adenocarcinoma of Appendix

Malignant tumours of the appendix are quite rare, especially appendiceal adenocarcinomas, which may be difficult to detect preoperatively or intraoperatively. We collected data for 1404 patients with adenocarcinoma of the appendix from the Surveillance, Epidemiology, and End Results Program (SEER) database to explore the potential associations between clinicopathological factors and overall survival. Furthermore, a novel nomogram for predicting prognosis was developed based on our analysis of the SEER data. The nomogram prediction model included seven prognostic factors derived based on different clinical estimates. When compared with the traditional tumour-node-metastasis (TNM) staging system, the nomogram prediction model showed superior discriminatory power (Harrell’s C-index, 0.741 vs. 0.686) and a greater degree of similarity to actual 5-year overall survival after calibration (Akaike Information Criterion index, 5270.781 vs. 5430.141). Finally, we provide recommendations for the management of patients with adenocarcinoma of the appendix. Notably, we found the depth of adenocarcinoma invasion may be used as an indicator to determine the optimal surgical approach. For mucinous adenocarcinomas of the appendix, because these tumours are characterized by unique biological behaviour, intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) is recommended. However, whether systematic chemotherapy should be administered to patients with adenocarcinoma of the appendix requires further investigation.

Adenocarcinoma mimicking appendicular lump: a diagnostic dilemma-a case report

Background

Primary appendiceal adenocarcinoma is a rare tumor, mucinous variety being common. This case is reported to highlight the unusual presentation and diagnostic difficulty of appendiceal adenocarcinoma.

Case presentation

Patient presented with acute appendicitis with ill-defined tender lump which responded to conservative management.

Conclusions

High index of suspicion should be kept in mind for elderly patients presenting with appendicular lump. Every effort should be made during elective appendectomy to remove stump in case of sloughed out appendix.

Impact of Mucinous Histology on the Prognosis of Stage I-III Adenocarcinomas of the Appendix: a Population-Based, Propensity Score-Matched Analysis

BACKGROUND

Whereas the poor prognosis of signet ring cell adenocarcinomas of the appendix is well known, the significance of mucinous histology remains unclear. The aim of this population-based study was to evaluate if mucinous histology is an independent prognostic factor in appendiceal adenocarcinomas.

METHODS

Patients with stage I-III adenocarcinoma of the appendix who underwent surgery between 2004 and 2012 were identified in the Surveillance, Epidemiology, and End Results database. Overall survival (OS) and cancer-specific survival (CSS) were assessed using risk-adjusted Cox proportional hazards regression models and propensity score methods.

RESULTS

Overall, 980 patients with appendix cancer were included, of which 449 (45.8 %) had a mucinous histology. In an unadjusted analysis, the 5-year OS and CSS in patients with a mucinous adenocarcinoma (MC) was 76.8 % (95 % confidence interval (95 %CI): 72.1-81.7 %) and 81.0 % (95 %CI: 76.6-85.6 %), respectively, compared with 70.0 % (95 %CI: 65.1-75.3 %) and 76.2 % (95 %CI: 71.5-81.2 %) in patients with non-mucinous adenocarcinoma (NMC) (P = 0.082 and P = 0.368). In multivariable analysis, no impact on survival was observed for OS (HR = 1.22, 95 %CI: 0.89-1.68, P = 0.208) and CSS (HR = 1.21, 95 %CI: 0.84-1.74, P = 0.296). After propensity score matching, nearly identical survival rates were observed (OS: HR = 1.03, 95 %CI: 0.71-1.49, P = 0.881 and CSS: HR = 1.05, 95 %CI: 0.70-1.59, P = 0.803).

CONCLUSIONS

The present population-based, propensity score matched analysis shows that mucinous histology does not affect survival in stage I-III appendiceal adenocarcinoma patients. Therefore, the same treatment strategies can be applied for patients with NMC and MC of the appendix.

Appendix adenocarcinoma in an elderly patient from a nursing home

Appendiceal malignancies are rare clinic entities. The clinical presentation of appendiceal malignancies is often atypical. Acute abdominal pain and acute appendicitis, which requires early surgical intervention, are the most common clinical presentations of appendiceal malignancies. In this case report, an adenocarcinoma of the appendix in a 64-year-old male from a nursing home has been presented. He had right lower quadrant pain for the last 5 days. On physical examination, he had significant guarding. Intravenous contrast-enhanced abdominopelvic tomography revealed no pathological features. Laparotomy under general anesthesia was scheduled. During exploration, a perforated appendicitis was observed. Formal appendectomy was performed. The patient was lost due to pneumonia and septic shock 5 days after surgical intervention. In addition, the natural history of the disease and its basic diagnostic and therapeutic aspects are discussed. Preoperative or intraoperative diagnosis may not be available for some patients. Thus, routine histopathological examination is essential for adequate diagnosis and treatment.

Appendicular mucocele: two case reports and literature review

The classification of mucinous tumors of the vermiform appendix is quite controversial, and includes a spectrum of neoplastic lesions ranging from benign proliferations, intraluminal, to invasive adenocarcinomas. Among the complications of appendicular mucinous neoplasms we should mention the "pseudomyxoma peritonei", a condition caused by cancerous cells (mucinous adenocarcinoma) that produce abundant mucin or gelationous ascites. Mucinous neoplasms of the appendix are rare diseases of unknown etiology. The diagnosis is difficult because of poorly specific clinical, biochemical and imaging parameters, and their detection can be occasional. Most of the reported cases involving women of reproductive age (with a history of endometriosis, abdominal surgery or pelvic inflammatory disease). The definitive diagnosis requires histology and immunohistochemistry. Cytoredutive surgery combined with hyperthermic intraperitoneal chemoterapy (HIPEC) is now considered the best treatment for this disease. We present two cases treated with surgery and HIPEC.

Clinicopathologic and Prognostic Features in Patients with Peritoneal Metastasis from Mucinous Adenocarcinoma, Adenocarcinoma with Signet Ring Cells, and Adenocarcinoid of the Appendix Treated with Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy

BACKGROUND

Tumors that show a signet ring or adenocarcinoid histomorphology have been associated with a poor prognosis. This study aimed to analyze the clinicopathologic and prognostic features in patients with peritoneal metastasis from mucinous adenocarcinoma (PMCA), adenocarcinoma with signet ring cell (PMCA-S), or adenocarcinoid (PMCA-A) of the appendix treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy.

METHODS

Retrospective analysis of a prospectively maintained database for all patients treated for appendiceal adenocarcinoma from 1989 to 2012 was performed.

RESULTS

The study cohort consisted of 494 patients including 361 patients with PMCA (73.1 %), 80 patients with PMCA-S (16.2 %), and 53 patients with PMCA-A (10.7 %). The patients comprised 273 men (55.3 %) and 221 women (44.7 %) with a mean age at presentation of 50.7 years for the PMCA-S patients, 47.3 years for the PMCA patients, and 47.5 years for the PMCA-A patients (p < 0.03). The 3- and 5-year survival rates were respectively 51 and 38 % for PMCA compared with 30 and 22 % for PMCA-S and 26 and 15 % for PMCA-A. The median survival time was 45.4 months for PMCA compared with 18.9 months for PMCA-S and 26.8 months for PMCA-A (p < 0.000). The groups did not differ significantly in the completeness of cytoreduction achieved, with 53.5 % of the PMCA patients having a CC0/1 compared with 46.2 % of the PMCA-S patients and 41.6 % of the PMCA-A patients (p < 0.20). In the multivariate analysis, the independent predictors of a reduced survival were incompleteness of cytoreduction, histomorphology of PMCA-S or PMCA-A, and distant metastasis.

CONCLUSION

The findings showed that PMCA-S or PMCA-A histomorphology contributes to the poor prognosis associated with peritoneal metastasis from appendiceal adenocarcinoma. The independent predictors for a poor overall survival included incompleteness of cytoreduction, PMCA-S and PMCA-A histomorphology, and distant metastasis.

The impact of stage, grade, and mucinous histology on the efficacy of systemic chemotherapy in adenocarcinomas of the appendix: Analysis of the National Cancer Data Base

BACKGROUND

Adenocarcinomas of the appendix represent a heterogeneous disease depending on the presence of mucinous histology, histologic grade, and stage. In the current study, the authors sought to explore the interplay of these factors with systemic chemotherapy in a large population data set.

METHODS

Patients in the National Cancer Data Base (NCDB) who were diagnosed with mucinous, nonmucinous, and signet ring cell-type appendiceal neoplasms from 1985 through 2006 were selected. Multivariable Cox proportional hazards regression models were developed.

RESULTS

A total of 11,871 patients met the inclusion criteria for the current study: 50.3% had mucinous neoplasms, 40.5% had nonmucinous neoplasms, and 9.2% had signet ring cell-type neoplasms. The 5-year overall survival (OS) stratified by grade was similar among patients with American Joint Committee on Cancer stage I to stage III disease but not for those with stage IV disease. The median OS for patients with stage IV mucinous and nonmucinous tumors was 6.4 years and 2.3 years, respectively, for those with well differentiated histology (P<.0001) and was 1.5 years and 0.8 years, respectively, for those with poorly differentiated histology (P<.0001). In multivariable modeling for stage I to III disease, adjuvant chemotherapy improved OS for both mucinous and nonmucinous histologies, with hazard ratios (HRs) of 0.78 (95% confidence interval [95% CI], 0.68-0.89 [P = .0002]) and 0.83 (95% CI, 0.74-0.94 [P = .002]), respectively. For patients with stage IV disease, systemic chemotherapy significantly improved OS for those with nonmucinous (HR, 0.72; 95% CI, 0.64-0.82 [P<.0001]) but not mucinous (HR, 0.95; 95% CI, 0.86-1.04 [P = .2) histologies, although this was grade-dependent. The median OS for chemotherapy versus no chemotherapy was 6.4 years versus 6.5 years (P value not significant) for patients with mucinous, well-differentiated tumors and 1.6 years versus 1.0 years (P = .0007) for patients with mucinous, poorly differentiated tumors.

CONCLUSIONS

Adjuvant chemotherapy demonstrated a significant OS benefit regardless of histology. However, for patients with stage IV disease, the benefit of systemic chemotherapy varied by tumor histology and grade, with patients with well-differentiated, mucinous, appendiceal adenocarcinomas deriving no survival benefit from systemic chemotherapy. Cancer 2016;122:213-221. © 2015 American Cancer Society.

Mucinous epithelial neoplasms of the appendix and pseudomyxoma peritonei

The classification of appendiceal mucinous neoplasms has been controversial, largely focused on a particular subset of low-grade mucinous tumors that, despite their innocuous appearance, can disseminate to the peritoneal cavity as pseudomyxoma peritonei (PMP). Recent WHO classification of these tumors as low-grade appendiceal mucinous neoplasms acknowledges their unique morphologic appearance and biologic behavior. Still, debate about the use of this term and its parameters continues to impede the adoption of consensus classification for appendiceal mucinous neoplasms. The classification of PMP has also been the subject of debate, with international authorities advocating for the use of malignant terminology to describe all grades of PMP, even though some authorities consider low-grade PMP to be dissemination of adenomatous epithelium in the peritoneum. Recent data also emphasize the importance of histologic grade of the peritoneal tumors in defining prognosis of these patients.

Improving the AJCC/TNM staging for adenocarcinomas of the appendix: the prognostic impact of histological grade

PURPOSE

Though histological grade is known to have a major prognostic impact in metastatic mucinous appendiceal adenocarcinomas, the prognostic impact of grade in localized disease, and the validity of the American Joint Committee on Cancer AJCC Staging Manual 7th edition's decision to combine moderately and poorly differentiated mucinous adenocarcinomas into a single mucinous high-grade category, is not known.

METHODS

Patients with adenocarcinoma of the appendix diagnosed between 1988 and 2007 were identified from the SEER database. Cancer-specific survival (CSS) stratified by histological subtype, stage, and grade was calculated, and Cox proportional hazards regression analyses were performed.

RESULTS

We analyzed a total of 2469 appendiceal adenocarcinomas, of which 1375 had mucinous histology and 860 had nonmucinous histology. Though overall CSS was similar for mucinous and nonmucinous subtypes, differences in stage distribution and stage-stratified CSS were seen. Female sex, stage IV disease, and well-differentiated histology were more common for mucinous adenocarcinomas. Histological grade had a strong prognostic impact, especially in patients with stage IV mucinous adenocarcinoma. The adjusted hazard ratios for stage IV moderately and poorly differentiated histological grade were 1.63 [95% confidence interval (CI): 1.14-2.34] and 4.94 (95% CI: 3.32-7.35) for mucinous histology, in comparison with 1.44 (95% CI: 0.82-2.52) and 1.90 (95% CI: 0.95-3.80) for nonmucinous histology, respectively.

CONCLUSIONS

The strong prognostic impact of histological grade for mucinous adenocarcinomas is primarily restricted to stage IV disease. Stage IV moderately and poorly differentiated mucinous adenocarcinomas have distinctly different CSS and these data do not support the combination of these 2 histological grades in the recent AJCC Staging Manual 7th edition.

Primary mucinous adenocarcinoma of the vermiform appendix with high grade microsatellite instability

Primary adenocarcinoma of the vermiform appendix is a rare entity and is frequently discovered by the pathologist following appendectomy for suspected appendicitis.We present a 42-year-old male with primary mucinous adenocarcinoma of the appendix initially presenting symptoms of acute appendicitis. Histological investigation of the appendectomy specimen showed a mucinous adenocarcinoma and the patient was treated by secondary right hemicolectomy giving the final histopathological classification of an UICC IIIC tumor. Since the patient fulfills the revised Bethesda criteria analysis of immunoreactivity of DNA mismatch repair proteins was performed showing loss of MLH1 and MSH2 expression associated with high microsatellite instability (MSI-H), not yet reported for primary mucinous appendiceal carcinoma. Further genetic analysis for DNA mismatch repair gene mutations were negative. The patient received intensified adjuvant chemotherapy according to the FOLFOX-4-scheme, since MSI-H colorectal carcinomas might show lower response rates following standard 5-FU-based adjuvant chemotherapy.

Clinicopathological features and the outcome of surgical management for adenocarcinoma of the appendix

AIM: To present a comprehensive analysis of incidence, clinicopathological features, appropriateness of surgical procedures, and survival for adenocarcinoma of the appendix.

METHODS: A retrospective case analysis was conducted for the 10-year period 1998-2008. All patients diagnosed with adenocarcinoma of the appendix were analyzed for their demographics details, clinical features, tumor incidence and characteristics, tumor stage, surgical procedures performed, and their survival.

RESULTS: Nine thousand three hundred and twenty-three patients underwent appendectomies during the study period, and of these, 10 (0.1%: 8 men and 2 women with a mean age of 53.1 years, age range 21-83 years) were found to have primary adenocarcinoma of the appendix. Appendicular neoplasia was not suspected pre-operatively in any of the patients. Six (60%) patients underwent secondary right hemicolectomy. Four (40%) cases had appendectomy alone, and two of them died, whereas all those who underwent right hemicolectomy are alive and disease free. Five (50%) were reported to have grade 1 disease, three (30%) grade 2, and two (20%) grade 3 with mean survival of 34, 48, and 22 mo, respectively. Six (60%) patients presented with advanced disease (Duke’s C and D). At the end of follow up (mean period: 37.9 mo), eight patients are alive and disease free at the end of follow up. Overall mean survival was 36.3 mo (confidence interval; 16%-56%) with 41.3 and 16 mo for men and women, respectively. Mean survival for those with and without lymph node involvement was 33.6 and 40.2 mo, respectively. Right hemicolectomy gave better results than appendectomy alone, although the difference was not statistically significant due to the small number of cases.

CONCLUSION: Adenocarcinoma of the appendix is extremely rare neoplasm with varied presentations, and is usually advanced when diagnosed. Right hemicolectomy is the treatment of choice for such tumors.

Appendiceal mucinous adenocarcinoma presenting as an enterocutaneous fistula in an incisional hernia

A 68-year-old woman with a history of bone-graft harvesting from the right iliac crest presented with an incisional hernia and abscess at the graft donor site. Following incision and drainage of the abscess, CT demonstrated an enterocutaneous fistula between the appendix and bone-graft incision with appendicitis assumed to be the original cause of the abscess. At laparoscopy, the appendix was adherent to the hernia sac with mucinous material at the superficial orifice of the fistula site but not in the peritoneal cavity. Laparoscopic appendicectomy with fistula track excision was performed. Histological evaluation confirmed a well-to-moderately differentiated mucinous adenocarcinoma arising on a background of dysplastic villous adenoma. Tumour extended along the fistula track to involve the surface skin. A laparoscopic right hemicolectomy, lymph node dissection and wide local excision of the fistula track were carried out at a second procedure. Final histology confirmed pT4N1 tumour with clear resection margins.

Primary appendiceal carcinoma--epidemiology, surgery and survival: results of a German multi-center study

BACKGROUND

While carcinoma of the colon is a common malignancy, primary carcinoma of the appendix is rare. Many retrospective reviews outlined experience from different centers on appendiceal neoplasms. However, the study population is often small because it is so rare. The aim of this study was to analyze the type of surgery and survival of patients with appendiceal malignancies using data from a German multi-center observational study (31 341 patients).

METHODS

During a five-year period, 196 consecutive patients with malignant appendiceal tumors were distributed into four groups: appendiceal carcinoids, adenocarcinoma, mucinous adenocarcinoma and adenosquamous carcinoma. The following parameters were analyzed: demographics, clinical presentation, comorbidities, type and appropriateness of surgery, final pathology and survival.

RESULTS

Adenocarcinoma had the highest incidence (50.5%). The most common presentation was that of acute appendicitis. Mean age at presentation was youngest for carcinoid tumors. Carcinoid tumors had lowest tumor size and localized disease was present in 72.9%. Metastatic spread at presentation was highest for adenosquamous and mucinous adenocarcinoma and each had a distinct pattern. Right hemicolectomy was performed in 71.4%, limited resection in 11.7%. Overall 5-year survival was 83.1% for carcinoid vs. 49.2% for non-carcinoid tumors. Histological subtype and tumor stage significantly affected survival.

CONCLUSIONS

Long-term outcome of carcinoid tumors is superior to non-carcinoid neoplasms. Among all appendiceal neoplasms, adenosquamous carcinoma is the rarest histological subtype which is most commonly associated with advanced tumor stage and worst prognosis. Appropriate oncologic resection is being performed in a significant percentage of cases in Germany. However, the high rate of right hemicolectomy in patients with small carcinoid tumors needs to be critically discussed.

Primary appendiceal mucinous adenocarcinoma alongside with situs inversus totalis: a unique clinical case

INTRODUCTION

Mucinous adenocarcinoma is a rare neoplasm of the gastrointestinal tract and one of the three major histological subtypes of the primary appendiceal adenocarcinoma. The most common type of presentation is that of acute appendicitis and the diagnosis is usually occurred after appendectomy. The accurate preoperative diagnosis and management of the above condition represents a real challenge when uncommon anatomic anomalies such intestinal malrotation and situs inversus take place. Situs inversus totalis with an incidence of 0.01% is an uncommon condition caused by a single autosomal recessive gene of incomplete penetration in which the major visceral organs are mirrored from their normal positions.

CASE PRESENTATION

We present an unusual case of a 59 years old, previously healthy man presented with a left lower quadrant abdominal pain, accompanied with low fever, leukocytosis, anorexia and constipation. A chest radiograph demonstrated dextrocardia with a right side positioned stomach bubble. Both preoperative US and CT scan of the abdomen and pelvis declared situs inversus, with a characteristic thickening in its wall, appendix situated in the left lower quadrant of the abdomen. These findings reached to the diagnosis of acute appendicitis with situs inversus and a standard appendicectomy was performed. Pathologic evaluation established primary mucinous adenocarcinoma of the appendix and three months afterwards the patient underwent a subsequent extended left hemicolectomy.

CONCLUSION

In conclusion, the occurrence of primary appendiceal mucinous adenocarcinoma along with situs inversus, definitely accounts as a unique clinical case. Even synchronous manifestation of primary mucinous adenocarcinoma of the appendix and situs inversus totalis represents an unusual anatomo-pathological entity, all physicians should be familiar having the knowledge to make an appropriate and accurate diagnosis that will lead to prompt and correct treatment.

Adenocarcinoma of the appendix with a fistula to the urinary bladder

Adenocarcinoma of the vermiform appendix is a rare disease that constitutes less than 0.5% of all gastrointestinal malignancies. A patient was admitted with abdominal discomfort and urinary frequency but no symptoms suggestive of enterovesical fistula, e.g. pneumaturia or urinary tract infection. She was diagnosed with adenocarcinoma of the appendix with a fistula to the urinary bladder.

Mucinous adenocarcinoma of the appendix presenting with atypical symptomatology and presence of pseudomyxoma peritonei: a case report

Introduction

Primary tumors of the appendix are unusual and most of them are carcinoids. Their main presentation is that of an acute appendicitis or as a palpable mass, mainly in the right lower quadrant.

Case presentation

A female patient with mucous adenocarcinoma of the appendix, which primarily presented as atypical abdominal pain. Diagnosis of the disease was made after appendicectomy and histopathological analysis of the specimen. The patient finally underwent a complementary right hemicolectomy.

Conclusion

Mucin producing adenocarcinomas of the appendix are a category of rare cancers of the gastrointestinal tract. Although at present they are a well studied pathologic entity, the crucial issue of their preoperative diagnosis remains unsolved.

Treatment of Appendiceal Adenocarcinoma in the United States: Penetration and Outcomes of Current Guidelines

Current treatment guidelines for appendiceal adenocarcinoma specify that right hemicolectomy should be performed. This study evaluates appendiceal cancer outcomes in the United States and treatment guideline compliance. Data for patients diagnosed with appendiceal adenocarcinoma in the Surveillance, Epidemiology, and End Results database (1988 to 2003) were analyzed. The 2511 patients with appendiceal adenocarcinoma had an average age of 59.3 years, average tumor size of 4.05 cm, and 5-year survival rate of 57 per cent. The 5-year survival rate by stage was statistically different (P < 0.001): Stage 0, 95.7 per cent; Stage I, 88 per cent; Stage II, 75.2 per cent; Stage III, 37.1 per cent; and Stage IV, 25.6 per cent. Appendectomy was performed in 33.4 per cent, which does not follow the current guidelines. In this group, 5-year survival was significantly less for patients with Stage III and IV disease (48% vs 38.2%, P = 0.03; 46% vs 26.4%, P = 0.04, respectively). Patients with Stage I and II disease had similar 5-year survival for appendectomy and colectomy (90.2% vs 90.1%, P = 0.7; 78.3% vs 76%, P = 0.6, respectively). One-third of patients with adenocarcinoma did not undergo current surgical guideline therapy. However, it appears hemicolectomy only improved survival for patients with later-stage disease. The current data raise the question of whether Stage I and II appendiceal cancer can be adequately treated with simple appendectomy.

Primary signet ring cell carcinoma of the appendix: A rare case report and our 18-year experience

Primary adenocarcinoma of the appendix is a rare malignancy that constitutes < 0.5% of all gastrointestinal neoplasms. Moreover, primary signet ring cell carcinoma of the appendix is an exceedingly rare entity. We have encountered 15 cases of primary appendiceal cancer among 3389 patients who underwent appendectomy over the past 18 years. In the present report, we describe a rare case of primary signet ring cell carcinoma of the appendix with ovarian metastases and unresectable peritoneal dissemination occurring in a 67-year-old female patient. She underwent appendectomy and bilateral salpingo-oophorectomy with a laparoscopy procedure. She then received palliative systemic chemotherapy with 12 cycles of oxaliplatin, 5-fluorouracil, and leucovorin (FOLFOX-4). The patient currently is well without progression of disease 12 mo after beginning chemotherapy.

Definitive diagnosis of primary adenocarcinoma of the appendix by laparoscopic appendectomy

We report a 62-year-old woman with a primary adenocarcinoma of the appendix mimicking ovarian tumor. We had diagnosed it definitively by laparoscopic appendectomy, and additional surgery was required in this case. However, the present case suggests that, in some cases, if cancer of the appendix can be diagnosed early, laparotomy can be avoided and the cancer treated with minimally invasive laparoscopic surgery alone.

Peritoneal pseudomyxoma associated with synchronic malignant mucinous neoplasias of the cecum, appendix and rectum. Case report and review of the literature

Peritoneal pseudomyxoma is a pathological condition that compromises the peritoneum, characterized by the production of large quantities of mucinous liquid, which progressively fills the peritoneal cavity, originating in general from mucinous appendicular or ovarian tumors. We report a peritoneal pseudomyxoma associated with mucinous adenocarcinoma of the appendix synchronic with adenocarcinoma of the rectum in a 44 year old patient, where the initial diagnosis was rectal adenocarcinoma. Tumour of the appendix and peritoneal pseudomyxoma were incidental and found intraoperatively. We focus the histological patterns of the lesions, diagnosis and the treatment, with revision of the literature.

Malignant neoplasms of the appendix

BACKGROUND

Appendiceal neoplasms, first described in 1882, are still rare, with pre-operative diagnosis invariably difficult. We present our 10-year experience of these lesions with a review of current epidemiology, pathology and treatment modalities.

MATERIALS AND METHODS

A retrospective histopathological review of all appendicectomy specimens was completed between April 1994 and December 2003 to identify patients diagnosed with malignant neoplasms. Patient demographics, operative details, histopathology and clinical outcomes were obtained from case notes. A literature search of the PubMed database was then performed using the medical search headings; appendix, tumour, neoplasm and malignancy.

RESULTS

Twenty-two patients (eight men) were identified during the study period, with no age difference between gender (mean age in women 58, range 14-83 vs mean age in men 55, range 16-78). Eleven patients were found to have carcinoid-type tumours, eight patients with adenocarcinomas and three patients with lymphomas. Other appendiceal pathologies were identified after appendicectomies, hemicolectomy and oophorectomy. Mean follow-up was 41 months (range 1-125 months). Fourteen patients were alive at the end of follow-up. Patients with classical carcinoid tumours (CCT) had better outcomes than patients with the goblet cell carcinoid, adenocarcinoma and lymphoma.

CONCLUSIONS

From our own experience and a subsequent review of the literature, we recommend right hemicolectomy as the treatment of choice for all malignant appendiceal neoplasms, except for small CCT less than 2 cm in diameter at the tip of the appendix, with a low proliferative index, without angiolymphatic or mesoappendiceal extension. Further adjuvant therapy should be considered after oncological assessment.

The value of routine histopathological examination of appendicectomy specimens

Background

Appendicectomy specimens removed from patients with suspected acute appendicitis often appear macroscopically normal but histopathological analysis of these cases may reveal a more sinister underlying pathology. We evaluated histopathological reports of 1225 appendicectomy specimens at the Norfolk and Norwich University Hospital (NNUH) over the past three years.

Methods

Histopathology reports for all appendices analysed at the NNUH between March 2003 and March 2006 were reviewed by examination of the case notes. The analysis focussed on the confirmation of acute appendicitis, incidental unexpected incidental findings other than inflammation, whether these abnormalities were suspected on gross examination at the time of surgery, and the effect on patient management and prognosis.

Results

The histopathology reports disclosed a variety of abnormal incidental lesions. Of the 1225 specimens, 46 (3.75%) revealed abnormal diagnoses other than inflammatory changes. Twenty-four (1.96%) of these were clinically significant and affected further patient management. Only two of these (0.16%) were suspected on macroscopic examination intra-operatively.

Conclusion

Twenty-four of the 1225 specimens (1.96%) had an impact on patient management or outcome and were not suspected on macroscopic examination at the time of surgery. These would have been missed had the specimens not been examined microscopically. The intra-operative diagnosis of the surgeon is therefore unreliable in detecting abnormalities of the appendix. This study supports the sending of all appendicectomy specimens for routine histopathological examination.

Appendiceal adenocarcinoma presenting with bilateral Krukenberg tumors

Primary appendiceal malignancy metastatic to the ovaries is a condition that may mimic advanced stage ovarian cancer. This condition is rarely diagnosed preoperatively. A 52-year-old woman referred to our institution for presumed advanced stage of ovarian cancer was found to have primary appendiceal adenocarcinoma metastatic to ovaries at laparotomy. We describe the clinical course of the patient. It is important for the gynecologist-oncologist to include tumors of the appendix into the differential diagnosis of any case of ovarian tumor.

Surgical treatment of malignant carcinoid tumours of the appendix

Since their first description in 1882, malignant neoplasms of the appendix still remain rare. Malignant carcinoid tumours are the most common accounting for 85% of all appendiceal neoplasms. Preoperative diagnosis is invariably difficult, and precise treatment protocols for these neoplasms remain unclear. We reviewed our experience and searched published evidence to produce management guidelines. A retrospective review of all malignant carcinoid tumours diagnosed in our hospital between April 1994 and December 2003 was performed. Patient demographics, operative details, histological types and clinical outcomes were retrieved from case notes supplemented by a questionnaire to the patient's General Practitioner. A literature search was then performed. Nine patients were identified with classical carcinoid tumours (CCT); (M = 3 and F = 6, mean age: 43, range 14-81) and two patients with goblet-cell morphology (F = 2, age 46 and 76). Mean follow-up was 63 months (range 1-125 months). Nine patients were alive at the end of follow-up. Appendicectomy was performed for acute appendicitis. Other appendiceal pathologies were identified following hemicolectomy and oophorectomy. CCT are the most common tumours and have the better prognosis. From our experience and subsequent review of the literature, we recommend right hemicolectomy as the treatment of choice for malignant carcinoid tumours. However, small CCTs less than 2 cm in diameter at the tip of the appendix, with a low proliferative index, without angiolymphatic or mesoappendiceal extension can be treated by appendicectomy. Following oncological assessment, further adjuvant therapy should be considered for patients with advanced disease.

Primary appendiceal malignancy: a clinicopathologic study

Primary appendiceal cancer is a rare neoplasm. We analyzed the clinicopathologic characteristics and clinical outcomes of patients with primary appendiceal cancer treated at Buddhist Tzu Chi General Hospital in Eastern Taiwan. We reviewed the medical records of patients who had appendectomy at our hospital over a 10-year period and studied those who had histologically proven malignant appendiceal neoplasms. We treated eight such patients: seven males and one female. Their median age was 66 years (range, 59-78 years). There were three mucinous adenocarcinomas, two colonic type adenocarcinomas, and three adenocarcinoids. No patient was diagnosed correctly before surgery, and five (62.5%) had a preoperative diagnosis of acute appendicitis. Operative procedures included right hemicolectomy or partial colectomy in four, debulking and right hemicolectomy in three, and appendectomy only in one. With a mean follow-up of 64 months (range, 3-132), patients with adenocarcinoid lesions had better prognosis than those with adenocarcinomas. The important prognostic factors of primary appendiceal cancer included histologic subtypes and the extent of dissemination. In our series, palliative resection for disseminated lesions with or without additional chemotherapy resulted in long-term survival.