Is routine appendectomy beneficial in the management of ovarian cancer?

Rate of Appendiceal Metastasis with Non-Serous Epithelial Ovarian Cancer in Manitoba

OBJECTIVE

This study sought to evaluate the rate of appendiceal involvement in non-serous mucinous and endometrioid-associated epithelial ovarian cancers.

METHODS

The Manitoba Cancer Registry and CancerCare database were used to find all women with non-serous epithelial ovarian, fallopian tube, or primary peritoneal cancer between 1995 and 2011. All patients with an appendectomy were then identified, and their final pathology findings were reviewed. Women who did not receive treatment or lacked follow-up were excluded.

RESULTS

We identified 338 patients from 1995-2011 with no prior appendectomy. Of these, 16.6% received an appendectomy, and 22.8% were clinically evaluated. Most cases within this cohort were mucinous (62%) and stage 1 (63%). Four appendiceal metastases were identified (7.2%), and one half appeared clinically normal at the time of surgery (3.6%). Within the mucinous histologic type, 32.7% of patients received an appendectomy, with a metastatic rate of 5.7%. Of the 127 endometrioid cases, only 10 patients received an appendectomy, and 2 were found to have metastases. No metastases were found in the 85 patients in the clear cell cohort, only 5 of whom received an appendectomy.

CONCLUSION

Routine appendectomy or clinical assessment of the appendix is valuable for all non-serous ovarian cancers. The rate of involvement for endometriosis-associated ovarian cancers may be significantly higher than expected, and further studies need to be conducted.

The role of appendectomy for mucinous ovarian neoplasms

OBJECTIVE

To determine how frequently the appendix harbors pathology in women having surgery for mucinous neoplasms of the ovary and assess the associated morbidity.

STUDY DESIGN

A retrospective chart review of patients operated on at our institution with the diagnosis of a mucinous neoplasm of the ovary or appendix.

RESULTS

A total of 327 cases were identified. Of the 309 women with mucinous ovarian neoplasms, 197 (64%) were benign, 68 (22%) low malignancy potential, and 44 (14%) were invasive. Of 155 appendectomies performed, only 1 metastatic low grade mucinous appendiceal tumor was found, but this appendix was grossly abnormal. There was no association between wound complications and appendectomy.

CONCLUSION

When a grossly normal appendix is removed during surgery for a mucinous ovarian neoplasm without evidence of pseudomyxoma peritonei, no primary or metastatic mucinous appendiceal tumors are found.

Occult metastasis in early ovarian cancers: risk factors and associated prognosis

OBJECTIVE

The purpose of this study was to define risk factors associated with the occult metastasis in early stage epithelial ovarian carcinoma (EOC), and to compare the survivals in respect to occult metastasis.

STUDY DESIGN

A retrospective review of 169 patients with clinically early stage EOC was performed.

RESULTS

Overall, 53 patients (53/169, 31.4%) were upstaged. The most common occult metastasis was the lymphatic involvement (22/53; 41.5%). Overall, 64.1% (34/53) of these upstaged patients had unrecognized disease in the upper abdomen or retroperitoneal space. Multivariable analysis revealed 3 factors to be associated with occult metastasis: Ca-125 levels > or = 500 U/mL (P = .04), positive peritoneal cytology (P = .001), and grade III disease (P = .04). Five-year survival rates were 61.83% and 88.25%, respectively, in patients with or without occult metastasis. Among the upstaged patients, omental or peritoneal metastasis revealed the worst prognosis.

CONCLUSION

Proper surgical staging is an important issue in early stage ovarian cancers, particularly in patients with high Ca-125 levels, positive cytology, and high grade tumor.

Routine Appendectomy in Epithelial Ovarian Carcinoma: Is It Necessary?

OBJECTIVE

To detect risk factors for the appendiceal metastasis and to define the role of routine appendectomy in patients with epithelial ovarian carcinoma.

METHODS

A total of 285 patients with epithelial ovarian carcinoma who had undergone primary cytoreductive surgery including appendectomy were retrospectively evaluated. Appendiceal involvement was divided into 2 groups: gross and microscopic. Clinicopathologic variables were evaluated for possible significance in terms of appendiceal metastasis. A second analysis was performed using the same variables to detect a possible relation with microscopic metastasis. In a subgroup analysis, we also analyzed the role of routine appendectomy in patients with clinically early stage disease.

RESULTS

One-hundred six patients were found to have appendiceal metastasis (37%). Univariate and multivariate analysis revealed stage of disease as the unique factor determining the appendiceal metastasis (P < .001). Five patients with apparently stage I-II disease were upstaged due to isolated appendiceal metastasis (4.9%). In the second analysis excluding the patients with gross involvement, ascites was an independent predictor of microscopic involvement (P < .01).

CONCLUSION

Routine appendectomy is indicated in all epithelial ovarian carcinoma patients as part of the initial surgical staging procedure because of a considerable rate of upstaging in early stage disease and optimal cytoreduction in advanced stages.

LEVEL OF EVIDENCE

II-3.

The surgical management of ovarian cancer

This article aims to cover current concepts and controversies in the surgical management of ovarian cancer. While there have been significant advances in the surgical management of vulval, cervical and even endometrial cancer there have been few developments in the surgical management of ovarian cancer. This situation is likely to continue until we get a clearer understanding of the natural history of this disease and better therapeutic options become available.

Surgical staging of early invasive epithelial ovarian tumors

Early stage epithelial ovarian carcinoma is defined pathologically as a tumor strictly limited to one or both ovaries without any extra-ovarian disease (i.e., Stage IA or B of the International Federation of Gynecology and Obstetrics (FIGO) classification). This diagnosis can be obtained only after an exhaustive surgical staging procedure, performed as soon as the diagnosis of epithelial invasive ovarian carcinoma is established. This staging surgery currently encompasses a peritoneal cytology, the thorough inspection of all the visceral and parietal peritoneal surfaces with biopsy of any abnormality, total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH + BSO), random peritoneal biopsies, omentectomy, appendectomy and bilateral pelvic and para-aortic lymphadenectomies, up to the left renal vein. The results of this staging procedure and its indications are discussed. In all of the cases, the radical removal of the pathologic adnexa is indicated, along with the complete peritoneal and retroperitoneal staging. While fertility-sparing surgery (avoiding hysterectomy and contralateral adnexectomy, if possible) seems to be safe for young women, a TAH + BSO is the rule for the others. Adjuvant chemotherapy can be omitted in well-differentiated tumors with a negative staging operation, but currently it remains indicated in all other cases. Indeed, the ultimate goal in early stage ovarian carcinoma is to not impair by inadequate management the high chance of a cure.

Isolated appendiceal metastasis in early ovarian carcinoma

The appendix was identified as the only site of extrapelvic metastatic ovarian carcinoma at the time of primary surgical staging. Isolated appendiceal metastasis has not been previously reported in comprehensively staged early stage ovarian carcinoma. Routine appendectomy during surgical staging of ovarian carcinoma should be considered.

Appendectomy in the surgical staging of ovarian carcinoma

OBJECTIVES

Extensive debulking is accepted as the primary method of operative management for carcinoma of the ovary. However, there is no consensus regarding the role of appendectomy in primary surgical treatment. The aim of this study was to assess the role of appendectomy in the surgical staging and cytoreduction of ovarian carcinoma.

METHODS

The study was a retrospective review of 90 primary malignant ovarian carcinoma patients who had an appendectomy in addition to primary cytoreductive surgery.

RESULTS

Out of 90 patients, 10 (11.1%) had metastasis to the appendix. The rate of metastasis to the appendix was 11.5% (9/78) in malignant epithelial ovarian carcinomas and 8.3% (1/12) in non-epithelial ovarian tumors. Of the patients with metastasis in the appendix, malignant epithelial ovarian tumors were identified in 90% (serous: 70%; clear cell: 20%), and non-epithelial malignant ovarian tumor were disclosed in 10% (granulosa cell carcinoma). There were no metastases to the appendix in the other histological types. Although metastasis to the appendix was not observed in early stage ovarian carcinomas, it was detected in 21.4% (9/42) of stage III and 50% (1/2) of stage IV. Macroscopic tumor metastasis in the abdomen was noted in all patients with metastasis to the appendix.

CONCLUSION

Appendectomy for stage I and II patients was not beneficial and did not affect final staging. As a result, for the proper staging of ovarian carcinoma there is no advantage to the addition of routine appendectomy to primary cytoreductive surgery in early stage (stage I and II) malignant epithelial ovarian tumors. Appendectomy would contribute to the cytoreduction of advanced stage disease if it is macroscopically involved.