Malignancies of the appendix: beyond case series reports

Goblet cell carcinoid of the appendix: Six case reports

BACKGROUND

Goblet cell carcinoid (GCC) of the appendix is a rare tumor characterized by neuroendocrine and adenocarcinoma features. Accurate preoperative diagnosis is very difficult, with most patients complaining mainly of abdominal pain. Computed tomography shows swelling of the appendix, so diagnosis is usually made incidentally after appendectomy based on a preoperative diagnosis of appendicitis. Even if a patient undergoes preoperative colonoscopy, accurate endoscopic diagnosis is very difficult because GCC shows a submucosal growth pattern with invasion of the appendiceal wall.

CASE SUMMARY

Between 2017 and 2022, 6 patients with GCC were treated in our hospital. The presenting complaint for 5 of these 6 patients was abdominal pain. All 5 patients underwent appendectomy, including 4 for a preoperative diagnosis of appendicitis and the other for diagnosis and treatment of an appendiceal tumor. The sixth patient presented with vomiting and underwent ileocecal resection for GCC diagnosed from preoperative biopsy. Although 2 patients with GCC underwent colonoscopy, no neoplastic changes were identified. Two of the six patients showed lymph node metastasis on pathological examination. As of the last follow-up (median: 15 mo), all cases remained alive without recurrence.

CONCLUSION

As preoperative diagnosis of GCC is difficult, this possibility must be considered during surgical treatments for presumptive appendicitis.

Bowel pseudo-obstruction caused by goblet cell adenocarcinoma of the appendix: A case report

INTRODUCTION

Goblet cell adenocarcinoma of the appendix is a rare diagnosis with features of both adenocarcinomas and carcinoid tumors. Commonly presenting with chronic abdominal pain, appendicitis, or abdominal distention, it can also be incidentally discovered during appendectomies.

CASE PRESENTATION

A 50-year-old man with right lower abdominal pain was admitted to our hospital, which is a critical care center. A computed tomography(CT) scan showed ileal narrowing, but endoscopy found no strictures. He was admitted with suspected bowel obstruction and improved with an ileal tube. Laparoscopic surgery revealed a tumor of the appendix. Histologically, he was diagnosed goblet cell adenocarcinoma, suggesting tumor infiltration of nerve fibers impairing peristalsis.

DISCUSSION

Goblet cell adenocarcinoma of the appendix has unique histology and a poor prognosis. Treatment typically involves surgery and chemotherapy. This case highlights challenges in preoperative diagnosis, with the tumor causing bowel pseudo-obstruction by invading the intestinal wall and nerve plexus. Extensive infiltration of Auerbach's plexus was observed, consistent with the length of intestinal stenosis.

CONCLUSION

This case describes goblet cell adenocarcinoma of the appendix leading to bowel pseudo-obstruction due to ileal end stenosis. It emphasizes the importance of considering this diagnosis in cases of bowel obstruction without an obvious mass.

Incidental appendiceal neoplasms: Single-centre results

BACKGROUND

Histopathological examination of appendectomy specimens may reveal malignancies. Based on these results, either appendectomy is sufficient or sometimes a further treatment protocol can be needed. In this study, malignancy-diagnosed cases on appendectomy specimen were examined.

METHODS

Patients who underwent appendectomy between January 2013 and December 2018 with a pre-diagnosis of acute appendicitis were evaluated retrospectively and those cases with malignancy were included in the study. Patients' age, sex, tumor type, tumor diameter, tumor grade, tumor localization, surgical margin, Ki-67 index, state of lymphovascular invasion, state of peri-neural invasion, and follow-up period duration were recorded.

RESULTS

On examination of 2336 appendectomy specimens, 16 patients (0.7%) were found to have neuroendocrine tumors (NET), 11 patients (0.5%) were found to have low-grade mucinous neoplasm (LAMN), and five patients (0.2%) were found to have primary appendix carcinomas. Appendix tumors usually present with acute appendicitis symptoms. Despite re-operation with right hemicolectomy (RHC) being required in the treatment of adenocarcinoma cases, appendectomy provides adequate treatment in most cases with NET and LAMN. With these tumors, which usually have a benign prognosis, it is important to perform the necessary screening in the postoperative period and not to interrupt follow-up.

Clinical benefits of FOLFOXIRI combined with bevacizumab for advanced-stage primary signet ring cell carcinoma of the appendix: A case report

RATIONALE

Signet-ring cell carcinoma, which is an infrequent type of colorectal cancer. Abdominal pain is the primary presenting complaint of patients with acute appendicitis. It is difficult to diagnose patients with appendiceal carcinomas accompanying with symptoms of acute appendicitis.

PATIENT CONCERNS

A 33-year-old female patient was admitted to our hospital, with chief complaints of "bilateral pelvic space-occupying lesions for 1 month, aggravated abdominal distension, and she accompanied with diarrhea for 3 days."

DIAGNOSIS

The patient was with primary signet ring cell carcinoma of the appendix, presented with acute appendicitis, as well as bilateral ovarian metastasis and peritoneal implantation metastasis.

INTERVENTIONS

She was then treated with irinotecan, oxaliplatin, calcium folinate, 5-FU combined with bevacizumab, surgical treatment, and postoperative adjuvant treatment with oxaliplatin, capecitabine regimen to consolidate the efficacy.

OUTCOMES

The patient is in good conditions, and postoperative adjuvant chemotherapy is in progress as well.

CONCLUSION

The outcomes highlighted the importance of strict histopathologic assessment for appendiceal adenocarcinoma, and provided new ideas for the diagnosis and treatment of advanced-stage signet ring cell carcinoma of the appendix.

The Promise of Epigenetics Research in the Treatment of Appendiceal Neoplasms

Appendiceal cancers (AC) are a rare and heterogeneous group of malignancies. Historically, appendiceal neoplasms have been grouped with colorectal cancers (CRC), and treatment strategies have been modeled after CRC management guidelines due to their structural similarities and anatomical proximity. However, the two have marked differences in biological behavior and treatment response, and evidence suggests significant discrepancies in their respective genetic profiles. In addition, while the WHO classification for appendiceal cancers is currently based on traditional histopathological criteria, studies have demonstrated that histomorphology does not correlate with survival or treatment response in AC. Due to their rarity, appendiceal cancers have not been studied as extensively as other gastrointestinal cancers. However, their incidence has been increasing steadily over the past decade, making it crucial to identify new and more effective strategies for detection and treatment. Recent efforts to map and understand the molecular landscape of appendiceal cancers have unearthed a wealth of information that has made it evident that appendiceal cancers possess a unique molecular profile, distinct from other gastrointestinal cancers. This review focuses on the epigenetic landscape of epithelial appendiceal cancers and aims to provide a comprehensive overview of the current state of knowledge of epigenetic changes across different appendiceal cancer subtypes, highlighting the challenges as well as the promise of employing epigenetics in the quest for the detection of biomarkers, therapeutic targets, surveillance markers, and predictors of treatment response and survival in epithelial appendiceal neoplasms.

Appendiceal Signet Ring Cell Carcinoma: An Atypical Cause of Acute Appendicitis-A Case Study and Review of Current Knowledge

Appendiceal signet ring cell carcinoma (ASRCC) is a rare and aggressive form of appendiceal cancer, often presenting with nonspecific symptoms that overlap with acute appendicitis. Early diagnosis and appropriate management are crucial for improving patient outcomes in these rare malignancies. This case report and literature review aims to raise awareness among clinicians about ASRCC of the appendix as a cause of acute appendicitis and highlight the importance of considering this diagnosis in patients with atypical presentations or unexpected histopathological findings. We present a 65-year-old female patient with ASRCC who underwent successful surgical treatment and remains disease-free at the one-year follow-up. It also highlights the necessity of early detection and appropriate treatment in order to improve patient outcomes. In addition, a comprehensive literature review is provided, discussing the clinical presentation, histopathological characteristics, potential pathogenesis, treatment options, and prognosis of ASRCC.

An Update on Appendiceal Neuroendocrine Tumors

The mainstay of appendiceal neuroendocrine neoplasm (aNEN) treatment is surgery, based on simple appendectomy or right-sided hemicolectomy with lymphadenectomy (RHC). The majority of aNENs are adequately treated with appendectomy, but current guidelines have poor accuracy in terms of selecting patients requiring RHC, especially in aNENs 1-2 cm in size. Simple appendectomy is curative for appendiceal NETs (G1-G2) < 1 cm (if the resection status is R0), whereas RHC with lymph node dissection is recommended in tumors ≥ 2 cm in diameter, based on the high risk of nodal metastases in these cases. The clinical management of aNENs 1-2 cm in size is more controversial because lymph node or distant metastases are uncommon but possible. In our opinion, patients with tumor size > 15 mm or with grading G2 (according to WHO 2010) and/or lympho-vascular invasion should be referred for radicalization with RHC. However, decision-making in these cases should include discussion within a multidisciplinary tumor board at referral centers with the aim of offering each patient a tailored treatment, also considering that relatively young patients with long-life expectancy represent the majority of cases.

Goblet cell adenocarcinoma of the anal canal with perianal Paget disease: A rare case report with literature review

INTRODUCTION

AS an uncommon neoplasm, goblet cell adenocarcinoma (GCA) is characterized by mixed endocrine-exocrine features. It is almost exclusively found in the appendix. Primary GCA of the anal canal is extremely rare.

CASE PRESENTATION

Herein we describe a novel rare case of 74-year-old Chinese female who is diagnosed with GCA in the anal canal with perianal Paget disease, including a brief review of the literature. In the lesion of anal canal, the tumor was composed of signet-ring-like cells on confluent growth model and copious mucin was produced as well. Simultaneously, the results of immunohistochemistry showed signet-ring-like cells were positive for CK20, CDX2, synaptophysin (Syn), CD56, carcinoembryonic antigen (CEA) and Villin. Meanwhile, the Ki67-labeling index reached 40%. In the lesion of perianal Paget disease, the small groups of atypical neoplastic cells were present in the epidermis. Immunohistochemically, the neoplastic cells were positive for CK20, CDX2 and epithelial membrane antigen, but negative for CK7, GCDFP15, S100, HMB45, and P63. The Ki67-labeling index reached 60% in the most concentrated spot.

CONCLUSIONS

Extra-appendiceal GCA was rare and easily under-recognizable. The diagnosis of GCA was seldom made preoperatively. Occasionally, GCA could occur in the anal canal accompanied by perianal Paget disease. So careful rectal examination was important in the patient with perianal Paget disease for avoid missing diagnosis of GCA on anal canal. GCA may show aggressive clinical behavior compared with typical well-differentiated neuroendocrine tumors. Therefore, we should pay more attention on the recognization of this rare disease.

Appendiceal Carcinoid Tumor in a 16-Year-Old Patient

Carcinoid tumor is the most common neoplasm of the appendix. There is no specific preoperative clinical presentation for appendiceal carcinoids. The usual presentation is as a classic acute appendicitis, but it can also be asymptomatic. Rarely are there symptoms of carcinoid syndrome, which may include diarrhea, flushing, bronchoconstriction, and cardiac valve diseases, especially if there is liver metastasis. Carcinoid tumors are commonly diagnosed retrospectively after histological examination of the resected appendix. Appendiceal carcinoids usually behave as benign tumors, and appendectomy alone is a sufficient treatment in the majority of cases, while for larger lesions, a right hemicolectomy should be performed. The prognosis of patients with local appendiceal carcinoids is excellent. The present study reports the case of a 16-year-old female patient that presented with severe right lower quadrant pain for 2 days. The patient underwent a successful appendectomy and recovered 2 days later. Subsequently, an appendiceal carcinoid tumor located at the proximal half towards the base of the appendix was diagnosed by histopathological examination. A follow-up examination 2 weeks after surgery revealed that the patient was well, with no discomfort. This report aims to determine the prevalence of appendiceal carcinoids in young patients and the definitive management.

Goblet cell adenocarcinoma of the appendix: an update and practical approach to diagnosis and grading

Goblet cell adenocarcinoma is a rare appendiceal tumour with amphicrine differentiation that has distinct morphologic and clinical features compared to carcinomas seen elsewhere in the gastrointestinal tract. These tumors have engendered considerable confusion in the literature regarding their classification, and they have been described under several different names including goblet cell carcinoid, adenocarcinoid, and adenocarcinoma, among others. In the recent fifth edition of the World Health Organization Classification of Digestive System Tumors, goblet cell adenocarcinoma is the preferred diagnosis because of the increasing recognition of a frequent co-existing high-grade adenocarcinoma component. This review will present the clinicopathologic, molecular, and immunohistochemical features of goblet cell adenocarcinoma and discuss the current challenges in diagnosis, grading, and clinical management.

Management of Appendix Neuroendocrine Neoplasms: Insights on the Current Guidelines

Appendiceal neuroendocrine neoplasms (ANENs) usually present as incidental findings at the time of appendectomy for acute appendicitis. They are rare, accounting for only 0.5-1% of intestinal neoplasms; they are found in 0.3-0.9% of all appendectomy specimens. They are usually sporadic tumors. There are several histological types including well-differentiated neuroendocrine tumors (NETs), poorly differentiated neuroendocrine carcinomas (NECs), and mixed neuroendocrine-non-neuroendocrine neoplasms (MiNENs). Histologic differentiation and the grade of well-differentiated NETs correlate with clinical behavior and prognosis. Management varies based on differentiation, aggressiveness, and metastatic potential. There is debate about the optimal surgical management for localized appendiceal NETs that are impacted by many factors including the tumor size, the extent of mesoappendiceal spread, lymphovascular invasion and perineural involvement. In addition, the data to guide therapy in metastatic disease are limited due to the paucity of these tumors. Here, we review the current advances in the management of ANENs within the context of a multidisciplinary approach to these tumors.

Prognostic impact of number of examined lymph nodes on survival of patients with appendiceal neuroendocrine tumors

BACKGROUND

The prognosis of patients with appendiceal neuroendocrine tumors (ANETs) is related to lymph node (LN) metastasis and other factors. However, it is unclear how the number of examined LNs (ELNs) impact on survival.

AIM

To determine the factors affecting the cancer-specific survival (CSS) of patients with ANET and to evaluate the impact of the number of ELNs on survival.

METHODS

A total of 4583 ANET patients were analyzed in the Surveillance, Epidemiology, and End Results database. Univariate survival analysis was used to identify factors related to survival and the optimal number of ELNs and lymph node ratio (LNR) were determined by the Kaplan–Meier method. The survival difference was determined by CSS.

RESULTS

Except for sex, the other factors, such as age, year, race, grade, histological type, stage, tumor size, ELNs, LNR, and surgery type, were associated with prognosis. The 3-, 5-, and 10-year CSS rates of ANET patients were 91.2%, 87.5, and 81.7%, respectively (median follow-up period of 31 mo and range of 0-499 mo). There was no survival difference between the two surgery types, namely, local resection and colectomy or greater, in both stratifications of tumor size ≥ 2 cm (P = 0.523) and < 2 cm (P = 0.068). In contrast to patients with a tumor size < 2 cm, those with a tumor size ≥ 2 cm were more likely to have LN metastasis (χ² = 378.16, P < 0.001). The optimal number of ELNs was more than 11, 7, and 18 for all patients, node-negative patients, and node-positive patients, respectively. CSS rates of patients with a larger number of ELNs were significantly improved (≤ 10 vs ≥ 11, χ² = 20.303, P < 0.001; ≤ 6 vs ≥ 7, χ² = 11.569, P < 0.001; ≤ 17 vs ≥ 18, χ² = 21.990, P < 0.001; respectively). ANET patients with an LNR value ≤ 0.16 were more likely to have better survival than those with values of 0.17-0.48 (χ² = 48.243, P < 0.001) and 0.49-1 (χ² = 168.485, P < 0.001).

CONCLUSION

ANET ≥ 2 cm are more likely to develop LN metastasis. At least 11 ELNs are required to better evaluate the prognosis. For patients with positive LN metastasis, 18 or more LNs need to be detected and lower LNR values (LNR ≤ 0.16) indicate a better survival prognosis.

Signet-ring cell carcinoma of the appendix with ganglioneuromatosis: a case report

Background

Primary cancer of the appendix, especially signet-ring cell carcinoma, is an uncommon disease, and it is rarely suspected before surgery. Diffuse intestinal ganglioneuromatosis that is not associated with neurofibromatosis-1 or multiple endocrine neoplasia 2b is also rare. The most frequent symptoms caused by it are changes in bowel habits, abdominal pain, and occlusive episodes.

Case presentation

The patient was a 48-year-old woman who had a month-long history of chronic abdominal pain, fullness, constipation, and diarrhoea. Enhanced computed tomography showed a 100-mm irregular swelling in the appendix and thickening of the appendiceal wall with cystic dilatation. Based on a preoperative diagnosis of appendiceal cancer, the patient underwent laparoscopic ileocecal resection with D3 lymph node dissection. Pathological diagnosis revealed a signet-ring cell carcinoma of the appendix with ganglioneuromatosis. The patient completed four courses of capecitabine plus oxaliplatin (CAPEOX) as postoperative adjuvant chemotherapy, and 23-month postoperative outcome was noneventful without recurrence.

Conclusion

We report a signet-ring cell carcinoma of the appendix that was detected early because of its presence with ganglioneuromatosis.

Goblet Cell Adenocarcinoma of the Appendix: A Systematic Review and Incidence and Survival of 1,225 Cases From an English Cancer Registry

Background

Goblet cell adenocarcinoma (GCA) of the appendix is a rare and aggressive tumour with varying nomenclature and classification systems. This has led to heterogeneity in published data, and there is a lack of consensus on incidence, survival, and management.

Methods

We provide an overview of GCA with a comprehensive systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and a retrospective analysis of all cases recorded in the English National Cancer Registration and Analysis Service database between 1995 and 2018. The Kaplan–Meier estimator was used to calculate overall survival, and Cox proportional hazards regression was used to identify prognostic factors.

Results

The systematic review demonstrated an incidence of 0.05–0.3 per 100,000 per year among North American registry studies. The 1-, 3-, and 5-year survival rate was 95.5%, 85.9%–87.6%, and 76.0%–80.6%, respectively. Age, stage, and grade were identified as prognostic factors for survival. Our analysis included 1,225 cases. Age-standardised incidence was 0.0335 per year in 1995 and gradually rose to 0.158 per year in 2018. The 1-, 3-, and 5-year survival rate was 90.0% [95% confidence interval (95% CI): 85.4–94.0], 76.0% (95% CI: 73.8–80.9), and 68.6% (95% CI: 65.9–72.2), respectively. On univariate Cox regression analyses, female sex, stage, and grade were associated with worse overall survival. On multivariate analysis, only stage remained a statistically significant prognostic factor.

Conclusions

GCA of the appendix is rare, but incidence is increasing. We report a lower incidence and survival than North American registry studies. Higher stage was associated with decreased survival. Further prospective studies are required to establish optimal management.

The association between appendicitis severity and patient age with appendiceal neoplasm histology-a population-based study

PURPOSE

Recent studies have reported alarming appendiceal tumor rates associated with complicated acute appendicitis, especially in patients presenting with a periappendicular abscess. However, the data on histology of appendiceal tumors among acute appendicitis patients is limited, especially in patient cohorts differentiating between uncomplicated and complicated acute appendicitis. We have previously reported the association of increased appendiceal tumor prevalence with complicated acute appendicitis in this population-based study. The objective of this secondary analysis was to evaluate the association of both appendicitis severity and patient age with appendiceal tumor histology.

METHODS

This nationwide population-based registry study (The Finnish Cancer Registry) was conducted from 2007 to 2013. All appendiceal tumors (n = 840) and available medical reports (n = 504) of these patients at eight study hospitals were previously evaluated, identifying altogether 250 patients with both acute appendicitis and appendiceal tumor.

RESULTS

The severity of acute appendicitis was significantly associated with more malignant tumor histology. The risk of adenocarcinoma or pseudomyxoma was significantly higher among patients with periappendicular abscess (OR 15.05, CI 95% 6.98-32.49, p < 0.001) and patients presenting with perforated acute appendicitis (OR 4.09, CI 95% 1.69-9.90, p = 0.0018) compared to patients with uncomplicated acute appendicitis. Similarly, patient age over 40 years was significantly associated with the risk of adenocarcinoma and pseudomyxoma (OR 26.46, Cl 95% 7.95-88.09, p < 0.001). Patient sex was not associated with a more malignant appendiceal tumor histology (p = 0.67).

CONCLUSION

More malignant appendiceal tumor histology of adenocarcinoma or pseudomyxoma was significantly associated with patient age over 40 years and complicated acute appendicitis, especially periappendicular abscess.

Systemic chemotherapy combined with anti-epidermal growth factor receptor antibody therapy for RAS wild-type appendiceal signet-ring cell carcinoma: a series of three cases

The effect of anti-epidermal growth factor receptor (EGFR) antibody-containing chemotherapy on appendiceal signet-ring cell carcinoma (SRCC) remains unknown. Herein, we report three patients, diagnosed as having synchronous metastases, who underwent this treatment for unresectable appendiceal SRCC with RAS wild type. Cases 1, 2, and 3 received FOLFOX with panitumumab, FOLFOX with cetuximab, and FOLFIRI with cetuximab, respectively, and their progression-free survival were 6.2, 7.2, and 18.7 months, respectively. The subsequent anti-vascular endothelial growth factor antibody-containing therapy was ineffective, and their overall survival was 8.2, 11.4, and 22.9 months, respectively. The anti-EGFR antibody-containing chemotherapy showed moderate efficacy for appendiceal SRCC. Further studies including molecular analysis should be needed.

MRI features of signet ring rectal cancer

PURPOSE

Signet Ring Rectal Cancer (SRRC) of rectum is rare high-grade subtype with poor prognosis and characteristic histopathology. We evaluated its imaging appearance and correlated its outcomes.

MATERIALS AND METHODS

We conducted a retrospective review of the rectal MRIs of 97 patients with rectal SRRC, evaluating tumor morphology, T2 signal, length, location, pattern of tumor growth, nodal status and location, EMVI (extramural vascular invasion), site of metastases, and response to chemotherapy. The tumor signal on T2W images was categorized into intermediate, T2 hyperintense, and fluid/mucin bright. Imaging findings were correlated with risk of metastatic/ recurrent disease, disease-free survival, and overall survival.

RESULTS

The median age of patients of SRRC in our study was 35 years and more frequently found in male patients. The common imaging features of SRRC were T2-hyperintense signal (63%), infiltrative growth pattern (76%), positive MR CRM (Circumferential Resection Margin on MRI) (84%), presence of EMVI (51%), and advanced T and N stage (97% and 84%, respectively). Peritoneum and nodes were the most common sites of metastases. Raised serum CEA (Carcino-embryonic Antigen) levels, positive MR CRM status, extramesorectal adenopathy, and advanced N stage had statistically significant predictive value for recurrence or metastases. Elevated serum CEA levels (p = 0.019) and intermediate T2 signal (p = 0.012) demonstrated significant independent association with poor overall survival, while advanced N stage (p = 0.033) demonstrated significant independent association with worse disease-free survival in multivariate analysis.

CONCLUSION

SRRC affected young patients and demonstrated T2-hyperintense signal and subepithelial spread in an infiltrative pattern. Elevated CEA levels and T2-intermediate signal intensity are independent predictors for worse overall survival and advanced nodal stage is independent prognostic factor of poor disease-free survival. MRI rectum can pinpoint the pathology given the distinct MRI morphology and age of presentation.

Appendiceal goblet cell carcinomas have poor survival despite completion surgery

PURPOSE

Appendiceal goblet cell carcinomas (aGCCs) are rare but aggressive tumours associated with significant mortality. We retrospectively reviewed the outcomes of aGCC patients treated at our tertiary referral centre.

METHODS

We analysed aGCC patients, diagnosed between 1990-2016, assessing the impact of completion surgery and tumour factors on survival. Survival was assessed using Kaplan-Meier analysis.

RESULTS

We identified 41 patients (23 F, 18 M); median age 61 (range 27-79) years. Mean tumour size was 10.5 (range 0.5-50) mm; most tumours were located in the appendiceal tip (n = 18, 45%). Appendicectomy was the index surgery in 32 patients, 24 of whom subsequently underwent completion surgery at median 3 (range 1.3-13.3) months later. Histology from completion surgery showed residual disease in 8 patients: nodal disease (n = 2) or residual tumour (n = 6). Index surgery for the rest was either colectomy (n = 7) or cytoreductive surgery plus intraperitoneal chemotherapy (CRS-HIPEC) (n = 1). Index and completion surgery had 0% mortality and 2.5% morbidity. Overall and recurrence-free survival were not significantly affected by tumour grade or completion surgery. Disease recurred in 9 patients after a median follow-up of 57.0 (4.6-114.9) months; 7 of these patients died during follow-up. Recurrences were treated with CRS-HIPEC (n = 1), palliative chemotherapy (n = 3) or supportive care (n = 5). Five- and ten- year overall survival were 85.3% and 62.3% respectively; 5-year and 10-year recurrence-free survival were 73.6% and 50.6%.

CONCLUSION

The prognosis of aGCCs remains relatively poor. Completion surgery did not prevent recurrence or improve survival, but this needs to be verified with a larger patient cohort. The high mortality associated with tumour recurrence questions current treatment recommendations.

Omission of Right Hemicolectomy May be Safe for Some Appendiceal Goblet Cell Adenocarcinomas: A Survival Analysis of the National Cancer Database

BACKGROUND

Appendiceal goblet cell adenocarcinomas (GCC) are rare tumors with clinical behavior between classic carcinoids and adenocarcinomas. Current guidelines recommend right hemicolectomy for all GCCs.

PATIENTS AND METHODS

The National Cancer Database was retrospectively queried for appendiceal GCCs undergoing appendectomy or right hemicolectomy between 2004 and 2016. Demographics, tumor characteristics, and post-operative outcomes were collected. The primary outcome was overall survival, which was examined by surgical type and tumor T stage. Multivariate logistic regression was utilized to identify predictors of survival.

RESULTS

In total, 1083 GCCs were included, and 81.8% underwent right hemicolectomy. Mean age was 57 years, and 89% were White. Patients undergoing hemicolectomy had higher T-stage tumors (66.6%/14.4% T3/T4 vs. 55.8%/8.1%, p < 0.001). Lymph node positivity increased with T stage (1.1%, 2.1%, 9.9%, and 29.1% for T1-T4). GCCs undergoing colectomy were more frequently moderately or poorly differentiated (16.7%/9.0% vs. 12.2%/6.6%, p = 0.011). Appendectomy surgical margins were positive in 17.3% (3.4% hemicolectomy, p < 0.001). In T3/T4 tumors, a significant survival benefit at 5 years was observed in patients undergoing colectomy as compared with appendectomy (85.4% vs. 82.0%, p = 0.028). On multivariate analysis, lymph node positivity markedly decreased survival overall for the entire cohort (HR 7.58, p < 0.001) and for T3/T4 tumors (HR 7.63, p < 0.001). In patients with T3/T4 tumors, there was a trend towards improved survival with right hemicolectomy (HR 0.42, p = 0.068).

CONCLUSION

Omitting right hemicolectomy can be considered for select T1/T2 appendiceal GCCs with negative appendectomy margins, given low rates of lymph node metastases and lack of survival benefit with right hemicolectomy.

Defining stage in mucinous tumours of the appendix with peritoneal dissemination: the importance of grading terminology: systematic review

Background

Mucinous appendiceal neoplasms with peritoneal dissemination (PD) show a wide spectrum of clinical behaviour. Histological grade has been correlated with prognosis, but no universally accepted histological grading has been established. The aim of this systematic review was to provide historical insight to understand current grading classifications, basic histopathological features of each category, and to define which classification correlates best with prognosis.

Methods

MEDLINE and the Cochrane Library were searched for studies that reported survival across different pathological grades in patients with mucinous neoplasm of the appendix with PD treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. PRISMA guidelines were followed.

Results

Thirty-eight studies were included. Ronnett’s classification was the most common (9 studies). Classifications proposed by the Peritoneal Surface Oncology Group International (PSOGI) (6 studies) and the seventh or eighth edition of the AJCC (7 studies) are gaining in popularity. Nine studies supported a two-tier, 12 a three-tier, and two a four-tier classification system. Three studies demonstrated that acellular mucin had a better prognosis than low-grade pseudomyxoma peritonei in the PSOGI classification or M1bG1 in the eighth edition of the AJCC classification. Four studies demonstrated that the presence of signet ring cells was associated with a worse outcome than high-grade pseudomyxoma peritonei in the PSOGI classification and M1bG2 in the eighth edition of the AJCC.

Conclusion

There is a great need for a common language in describing mucinous neoplasms of the appendix with PD. Evolution in terminology as a result of pathological insight turns the four-tiered PSOGI classification system into a coherent classification option.

Frequency and Risk Factors for Metastasis in Newly Diagnosed Appendiceal Carcinoma

Background

Appendiceal carcinoma has an insidious clinical presentation, and these tumors are rarely suspected prior to surgery, potentially leading to late diagnosis. The aim of this study is to investigate the prevalence of metastatic disease at initial presentation and potentially associated sociodemographic characteristics.

Methods

Patients were identified from the Surveillance, Epidemiology, and End Results (SEER) program using the International Classification of Diseases for Oncology-3 (ICD-O-3) histology/behavior codes between 2010 and 2015. Firth logistic regression was performed to determine the association of metastasis at presentation with tumor subtype, adjusted for age, race, sex, insurance and marital status, tumor grade, and tumor and nodal stage using the 7th edition of the American Joint Committee on Cancer (AJCC) staging system.

Results

We identified a total of 3,447 patients with known metastatic status. A total of 38.4% had metastatic disease at diagnosis. Compared to colonic-type adenocarcinoma (CA), mucinous adenocarcinoma (MA) and signet ring cell carcinoma (SC) were more likely to present with metastasis at diagnosis (OR: 2.34; 95% CI [1.80- 3.06]; OR: 1.93 [1.29-2.89], respectively), however, goblet cell carcinoma (GC) was less likely (OR: 0.59 [0.36-0.93]). Compared to tumors invading the submucosa (T1 stage), tumors invading deeper through the visceral peritoneum or nearby organs (T4 stage) were significantly more likely to present with metastatic disease (OR: 3.46 [2.24-5.51]). Tumors invading the muscularis propria (T2 stage) or deeper into the subserosa, or the mesoappendix (T3 stage) were less likely to present with metastatic disease (OR: 0.34 [0.16-0.71]); OR: 0.55 [0.34-0.91], respectively). Compared to no regional lymph node spread, four or more regional lymph node involvement (N2 stage) was more likely to present with metastatic disease (OR: 2.19 [1.53-3.16]). Men were less likely to present with metastatic disease (OR: 0.60 [0.48-0.73]). A total of 90.1% of CA, 84.2% of GC, 42.2% of MA, and 78.5% of SC patients with metastasis at diagnosis had extraperitoneal distant metastasis (M1b).

Conclusions

A significant proportion of patients with newly diagnosed appendiceal carcinoma presented with metastatic disease, concerning substantial diagnostic delay and potentiating the need for aggressive treatments. Predictors of metastatic disease included female sex, histologic subtype, and significant regional lymph node involvement. Future research should focus on earlier detection and explore tumor biology.

Lessons learned about appendiceal neuroendocrine neoplasms from data analysis of the Belgian Cancer Registry 2010-2015

BACKGROUND AND STUDY AIMS

Appendiceal neuroendocrine neo-plasms (aNENs) are a diverse group of malignant neoplasms of varying biological behavior for which information about manage-ment and outcome is sparse, with the majority of available studies being retrospective, including only a limited number of patients, and therefore not necessarily reflecting the reality in the community. In the present study clinical, epidemiological and pathological data of appendiceal neuroendocrine neoplasms in Belgium is provided and compared with current literature.

METHODS

A population-based study was conducted by linking data of the Belgian Cancer Registry with medical procedures in the Belgian Health Insurance database for patients diagnosed with aNEN between 2010 and 2015.

RESULTS

We found an aNEN incidence of 0.97/100.000 person years in Belgium. Neuroendocrine carcinoma of the appendix are rare. Most appendiceal neuroendocrine tumors (aNETs) are small G1 tumors. Positive lymph nodes are often found in tumors larger than 2cm, especially aNET G2.

CONCLUSION

A rapid uptake of changing classifications was seen in the community. However, systematic reporting of risk factors for small aNEN can still be improved and should be stimulated. In 9% of cases, reclassifications had to be made, pointing out that in a retrospective analysis, original pathological reports should be checked for specific parameters, before reliable conclusions can be drawn.

Appendiceal globet cell adenocarcinoma: a rare cause of acute appendicitis

We present the case of a 70-year-old man who consulted for abdominal pain, vomiting, fever, and signs of peritoneal irritation. Histopathology showed goblet-like cells organized in nests, without tubules, with transmural infiltration. Immunohistochemistry revealed positivity for synaptophysin and chromogranin, diagnosing grade 3 goblet cell adenocarcinoma (GCA).

Lymph node positivity and association with long-term survival for different histologies of appendiceal cancer

BACKGROUND

Appendiceal cancers represent a diverse group of malignancies with varying biological behavior. The significance of lymph node metastases in relation to long-term survival and chemotherapy response is poorly defined.

METHODS

The National Cancer Database was queried to find patients diagnosed with appendiceal cancer from 1998 to 2012. Kaplan-Meier curves and multivariable Cox regression analyses were used to study the association between lymph node status and overall survival. Stage IV patients were excluded.

RESULTS

The rate of nodal positivity of the 9841 patients with known node status was: signet ring 47.4%, carcinoid 42.3%, nonmucinous adenocarcinoma 28.8%, goblet cell 21.9%, and mucinous adenocarcinoma 20.4%. Node-positive patients had worse long-term survival for all subtypes with the exception of carcinoid tumors (p < 0.001). The strongest association was for signet cell and goblet cell. Adjuvant chemotherapy in node-positive patients improved survival for mucinous, nonmucinous, and signet ring cell histology (p < 0.01), but not for goblet cell.

CONCLUSIONS

Nodal involvement in patients with appendiceal cancer varies in incidence, association with adverse survival, and response to systemic therapy. Individualized treatment algorithms for the management of the subtypes of appendiceal cancer are needed.

Appendiceal Goblet Cell Adenocarcinoma Case Report and Review of the Literature

Acute appendicitis is a common presentation to the emergency department. The common pathogenesis thereof relates to obstruction of the appendiceal lumen by an appendicolith, which leads to an increase in intraluminal and intramural pressure. This is followed by distension of the appendix, subsequent small vessel occlusion and lymphatic stasis, and appendiceal wall ischemia and necrosis, eventually leading to rupture if not treated. Occasionally tumors at the base of the appendix can lead to appendicitis via the same process as an appendicolith. Goblet cell adenocarcinoma (alternatively named goblet cell carcinoid) is amongst the most rare appendiceal tumors, with a reported incidence rate of 0.05 cases per 100,000 population per year in the United States. These tumors contain features of both neuroendocrine tumors as well as adenocarcinomas, but behave more similarly to adenocarcinomas. Consensus regarding management of these tumors is lacking, likely due to the rarity of the disease. In this paper, we present a case of appendiceal goblet cell adenocarcinoma causing appendicitis and review the literature regarding these rare epithelial tumors.

Appendiceal neoplasm incidence and mortality rates are on the rise in Australia

OBJECTIVES

The study aimed to examine the incidence and mortality rates of appendiceal neoplasms (ANs) in Australia.

METHODS

A retrospective analysis was performed on national data obtained from the Australian Institute of Health and Welfare (AIHW) from 1982 to 2013. Changes to the incidence, and the cancer-specific mortality following the diagnosis of ANs were analyzed over this time period, with stratification performed for histological subtype, gender, and age groups (<50y and ≥50y).

RESULTS

Incidence and mortality rates of ANs increased significantly across both genders and age groups. Incidence rates increased by 415%, from 0.40/100 000 population in 1982 to 2.06/100 000 in 2013. Overall mortality rates increased by 130%, from 0.057/100 000 during 1982-1985 to 0.131/100 000 during 2010-2013. Controlling for age group and gender, the incidence rates increased by 20% every four years (Incidence rate ratio (IRR) = 1.20, 95% confidence interval (CI): 1.17, 1.23, global P value<0.0001), and controlling for age, the mortality rates increased by 8% every four years (IRR = 1.08, 95% CI: 1.00, 1.17, global P-value = 0.0401).

CONCLUSION

The increasing use of CT scanning, improvements in pathological assessment of the appendix, and the growing aging population may have contributed in part to the apparent rise in the incidence of ANs.

Management of Low-Grade Appendiceal Mucinous Neoplasms (LAMN): An International Survey of Surgeons Performing CRS and HIPEC

BACKGROUND

Low-grade appendiceal mucinous neoplasms (LAMN) are commonly managed by community surgeons at diagnosis. There is variability in the treatment of LAMN, both by community and specialist providers. We assessed current management practices for LAMN across surgeons with expertise in peritoneal surface malignancies (PSM).

METHODS

An online survey was sent to 106 international surgeons specializing in PSM. The survey assessed demographics, favored pre-referral management, and definitive management practices for LAMN.

RESULTS

The response rate was 40% (67% USA, 33% international). Respondents had performed a median of 18 (interquartile range [IQR] 7.75-29) HIPEC cases in the last year, of which 10 (IQR 4-20) were for LAMN. Ninety-three percent reported more than half of LAMN referrals had already undergone surgery-an estimated 50% appendectomy and 20% right hemicolectomy (RH). No surgeon respondents supported performing right hemicolectomy before referral. For LAMN confined to the appendix, 86% of respondents would definitively treat with appendectomy. In the presence of mucinous implants, 24% would observe after appendectomy and 76% would proceed with HIPEC. All would perform HIPEC if implants contained tumor cells. When LAMN involved the appendiceal base, 67% of respondents would proceed with partial cecectomy, while 33% favored RH.

CONCLUSIONS

Pre-referral management of LAMN is not standardized and 20% of patients were referred to a surgeon who performs CRS/HIPEC after a right hemicolectomy that would not have been recommended. Management of LAMN by surgeons who treat PSM is also variable. Long-term data and identification of prognostic features are necessary to generate consensus on the optimal management of these complex patients.

Invasive Mucinous Neoplasm of the Appendix Masquerading as Recurrent Urinary Tract Infections: a Case Report

We report on a case of a healthy male patient who was referred to Urology for recurrent persistent urinary tract infections. Investigation revealed a large intraabdominal inflammatory collection abutting the cecum and bladder suspicious for ruptured appendicitis and colovesical fistula. He was taken to the operating room for exploratory laparotomy with General Surgery and Urology and found to have a ruptured appendix secondary to mucinous appendiceal neoplasm with invasion into the cecum and the bladder wall. He then underwent systemic chemotherapy followed by hyperthermic intraperitoneal chemotherapy. He is well with stable right lower quadrant inflammatory collection and without evidence of metastatic disease 22 months following initial surgery. This case presents a rare presentation of a rare disease process that is easy to misdiagnose or be delayed in diagnosis because of its vague and often varied presentation.

Is adjuvant chemotherapy beneficial for stage II-III goblet cell carcinoid/goblet cell adenocarcinoma of the appendix?

BACKGROUND

Goblet cell carcinoma (GCC), formerly known as goblet cell carcinoid, of the appendix constitutes less than 14% of all primary appendiceal neoplasms. Surgical resection is the main treatment and the role of adjuvant chemotherapy (AC) is not established. This study aims to evaluate the impact of AC in stage II-III appendiceal GCC.

METHODS

Patients with pathological stage II and III GCC who underwent surgical resection between 2006 and 2015 were identified from the National Cancer Database (NCDB) using ICD-O-3 morphology and topography codes: 8243/3 (goblet cell carcinoid) and C18.1. Patients treated with neoadjuvant systemic and/or radiation therapy and adjuvant radiation were excluded. Univariate and multivariable analyses were conducted, and Kaplan-Meier Curves were used to compare overall survival (OS) based on treatment received with Log-rank test.

RESULTS

A total of 619 patients were identified. 54.4% males and 89.0% Caucasian; median age 56 (range, 23-90) years. Distribution across pathological stages II-III was 82.7% (N = 512) and 17.3% (N = 107) respectively. AC was administered in 9.4% (N = 48) of stage II and 47.7% (N = 51) of stage III patients. For stage II patients, AC was not associated with better OS in univariate (HR 0.32; 95% CI 0.04-2.34; p = 0.261) or multivariable analyses (HR 0.29; 95% CI 0.04-2.12; p = 0.221). By contrast, in stage III patients, AC was associated with better OS in univariate (HR 0.35; 95% CI 0.17-0.71; p = 0.004) and multivariable analyses (HR 0.25; 95% CI 0.07-0.88; p = 0.031). In the entire cohort 5-year OS for patients that received AC was 85.5% (74.0%, 92.1%) versus 82.7% (77.5%, 86.8%) (p = 0.801) with no AC. For stage II patients, 5-year OS was 96.9% with AC vs. 89.1% with no AC (p = 0.236). For stage III patients, 5-year OS was 77.1% with AC vs. 42.8% with no AC (p = 0.003).

CONCLUSION

AC was associated with improved OS in patients with pathological stage III GCC of the appendix, but not with pathological stage II.

The Role of Adjuvant Chemotherapy in Non-Metastatic Goblet Cell Carcinoid of the Appendix: An 11-Year Experience from the National Cancer Database

BACKGROUND

Goblet cell carcinoids (GCC) are an aggressive, albeit rare, subtype of appendiceal tumors that exhibit distinct histologic features and lack clear treatment guidelines. We aimed to ascertain the impact of adjuvant chemotherapy (AC) for GCC in a national cohort of patients.

METHODS

Patients who underwent a right hemicolectomy for stage I-III GCC of the appendix between 2006 and 2016 were selected from the National Cancer Database (NCDB). Stratification based on AC receipt was performed. Kaplan-Meier survival estimates and Cox proportional hazard regression were used to identify predictors of overall survival (OS).

RESULTS

A total of 867 patients were identified, of whom 124 (14%) received AC. Patients in the AC group were significantly younger (54 vs. 57 years; p = 0.006) and were predominantly of male sex (60 vs. 48%; p = 0.012). On histopathology, patients in the AC group had a higher proportion of poorly/undifferentiated grade (27 vs. 5%; p < 0.001), T4 disease (35 vs. 11%; p < 0.001), and lymph node-positive disease (45 vs. 7%; p < 0.001) than patients who did not receive AC. After excluding patients diagnosed in 2016 due to a lack of follow-up data (n = 162), a survival advantage for the AC group was detected only after stratification for lymph node-positive disease (p = 0.007). On Cox proportional hazard regression, AC demonstrated an independent association with improved OS (hazard ratio 0.24, 95% confidence interval 0.084-0.683; p = 0.007).

CONCLUSION

The current analysis from the NCDB supports the role of AC for GCC of the appendix, chiefly for patients with lymph node metastatic disease.

Synchronous primary adenocarcinoma of the appendix and colon: Case report and literature review

•

Primary adenocarcinoma of appendix is rare pathology that is discovered usually on histopathologic examination of resected appendix.

•

It is important to report all pathologic reports to the primary physician in order to confirm primary diagnosis and discuss it with their patients.

•

If a diagnosis of PAA is reported, a surveillance lifelong colonoscopy screening is mandatory to rule out synchronous or metachronous occurrence of colonic malignances.

Introduction

Primary adenocarcinoma of the appendix (PAA) is rare with fewer than 300 cases reported from 1882 Up to 2004. Synchronous occurrence of PAA with a second primary colonic carcinoma is even more unusual. Literature review shows a total of 40 reported synchronous cases in the English literature from the first case reported in1947 up to 2017. Hereby, an additional case is presented, which is the first case reported in Jordan.

Presentation of case

A 39-year-old woman presented in October 2016 with persistent right lower quadrant abdominal pain diagnosed clinically as acute appendicitis. Abdominal computed tomography showed an oval shaped 3 × 3.4 cm mass at the sub-hepatic region, associated with increased attenuation of surrounding mesenteric fat and multiple enlarged lymph nodes. Three days later, a right hemicolectomy was carried out. A diagnosis of invasive primary adenocarcinoma of the ascending colon with an incidental, microscopic primary adenocarcinoma of the distal part of the appendix was reported.

Discussion

Primary appendiceal adenocarcinoma is rare pathology with an incidence ranges from 0.01% to 0.3% that is characterized by presence of adenocarcinomatous cells originating in the appendix that are in direct continuity with the normal appendiceal mucosa. Even it is less common, synchronous primary adenocarcinoma of the appendix and the colon has been reported in literature, with less than 37 cases being reported in literature so far. PAA are seldom suspected in preoperative phase or even intraoperatively, and it is diagnosed based on histopathologic examination of the resected appendix. Once PAA is diagnosed, a lifelong surveillance with colonoscopy is mandatory to detect synchronous or metachronous colonic malignancies.

Conclusions

Once a diagnosis of primary appendiceal adenocarcinoma is proved histologically, it is it is warranted to perform surveillance for synchronous or metachronous tumors because of the increased risk of a second primary malignancy in the gastrointestinal tract.

Vesico-appendiceal fistula secondary to adenocarcinoma of the appendix: a case report and literature review

A 50-year-old woman presented with a 5-month history of recurrent urinary tract infections. She had no complaints of any intestinal symptoms. She had been treated previously with oral antibiotics. The episodes became more frequent and she started with pain in the lower abdomen and fetid urine. Complete study lead to diagnosis of adenocarcinoma of the appendix with bladder fistula. The lesion was removed by laparoscopic right hemicolectomy and en bloc partial cystectomy. Pathological examination revealed a mucinous adenocarcinoma that had originated in the appendix and extended into the bladder wall. Six years after the operation, the patient remains asymptomatic with no evidence of recurrent or metastatic disease. Appendiceal carcinoma extending to the bladder is extremely rare and approximately 40 cases have been described. Management of recurrent urinary tract infections should not limit to empiric antibiotic therapy before the exclusion of possible organic causes. Appendiceal carcinoma may invade the bladder without intestinal symptoms but with urinary symptoms only, because of its anatomical position. The recommended treatment for non-carcinoid appendiceal tumours is right hemicolectomy and for T4 tumours en bloc resection of the involved structures. Further study is needed to determine adjuvant therapy. A literature review was made.

Gastro-entero-pancreatic neuroendocrine neoplasia: The rules for non-operative management

Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) with favorable pathological and clinical features may be considered as indolent lesions, and therefore be amenable to conservative management. According to the primary tumor site, different non-aggressive approaches, based on endoscopic resection or simple active surveillance, can be proposed to selected patients fulfilling specific criteria. Tumor size, Ki67 proliferative index and depth of invasion are markers that can be used in order to identify these subjects. Patients with type I gastric NENs <1 cm as well as those with non-ampullary duodenal NENs <1 cm with no associated syndrome can be safely managed by endoscopic resection. On the other hand, an active surveillance approach is preferred over surgery for patients with asymptomatic, non-functioning pancreatic NENs ≤2 cm without dilation of the main pancreatic duct or bile duct. As far as NENs of the appendix are concerned, appendectomy should be considered as curative when a R0 resection has been achieved in the presence of a tumor ≤1.5 cm, graded as G1 and without lymphovascular invasion. Finally, G1 rectal NENs ≤1 cm without invasion of the muscular layer can be safely treated by endoscopic resection. Therefore, surgeons should be aware of the existence of indolent GEP-NENs, in order to avoid unnecessary operations with associated postoperative complications.

Lights and darks of neuroendocrine tumors of the appendix

INTRODUCTION

Neuroendocrine tumors of the appendix are a relatively frequent type of neuroendocrine tumor, usually detected incidentally after appendectomy. Almost all small slow-growing G1 tumors with no risk factors are cured with appendectomy while the rare and aggressive G3 carcinomas may represent a challenge in terms of management and often lead to a poor outcome. In the middle of the spectrum, a number of tumors present with in-between features and sometimes no clear-cut guidance emerges from the literature for directing the management and follow-up of these patients.

EVIDENCE ACQUISITION

A meticulous review of the literature on neuroendocrine tumors of the appendix, including the recommendations published by the relevant international societies.

EVIDENCE SYNTHESIS

The literature on the neuroendocrine tumors of the appendix appears to be inhomogeneous. Likely this occurs as a consequence of a number of factors, including the mostly retrospective nature of the available data, the heterogeneous records of the same, and some peculiar aspects of the appendiceal neuroendocrine tumors, with evidence of considerable biological and clinical differences in terms of epidemiology, management, and prognosis from the less aggressive tumors to the most aggressive cancers. In particular, some situations concerning tumors in the middle of the biological and clinical spectrum are still poorly defined.

CONCLUSIONS

There are some persisting "grey areas" with regard to the characterization and the clinical management of neuroendocrine tumors of the appendix. An increasing awareness of the biological and clinical aspects of this disease and new, ideally prospective, focused studies might help and clarify some relevant issues that are not fully elucidated yet and could increase the solidity of the guidance for the management and the follow-up of the patients.

Management of Appendiceal Neuroendocrine Tumors: Metastatic Potential of Small Tumors

BACKGROUND

Appendiceal neuroendocrine tumors (ANETs) are rare neoplasms usually discovered incidentally during appendectomy. ANETs < 2 cm were thought to have no metastatic potential, and this dogma has driven management. Our aim is to evaluate the metastatic potential of ANETs < 2 cm.

PATIENTS AND METHODS

A retrospective review was performed in a series of patients with ANETs who presented to our tertiary referral center from 1998 to 2019. Demographics, tumor characteristics, treatment, and clinical outcomes were evaluated.

RESULTS

In total, 114 patients were included. Median follow-up was 3.3 years (range, 21 days-15 years). At last follow-up, 34 (30%) patients had positive regional lymph nodes and 20 (18%) patients had metastatic disease. Of the 20 patients with metastatic disease, 11 (55%) had primary ANETs < 2 cm. Patient age > 40 years at diagnosis and ANETs with serosal invasion, lymphovascular invasion, intermediate tumor grade, or positive lymph nodes were features significantly more likely to present with metastatic disease. We found no difference in the rate of lymph node positivity, metastatic disease, or overall survival when patients were stratified by tumor size or type of resection (appendectomy vs. right hemicolectomy). On multivariate analysis, patients with metastatic disease at diagnosis had worse overall survival (HR = 24.4, p = 0.008).

CONCLUSIONS

In our cohort, tumor size was not a significant risk factor for metastatic disease or worse outcome as many patients with ANETs < 2 cm developed metastatic disease. Appendectomy alone was sufficient surgical management for most ANETs. Patients with risk factors for metastatic disease, regardless of primary ANET size, should be evaluated thoroughly and counseled for further management and surveillance.

Preoperative Factors Associated with Appendiceal Tumors in Nonelective Appendectomy

Background: The rates of incidental appendiceal neoplasms after appendectomy performed for acute appendicitis is <2%. To date, no large studies have investigated the preoperative risk factors or imaging findings associated with incidental appendiceal tumors that present as appendicitis. Our study aims to identify preoperative factors that are associated with an increased risk of appendiceal tumors in patients who present with signs and symptoms of acute appendicitis. Materials and Methods: Using the targeted appendectomy American College of Surgeons National Surgical Quality Improvement Program database, we identified patients who underwent nonelective appendectomy for acute appendicitis in 2016. Patients with final pathology consistent with a tumor were compared with those with only appendicitis. A nonmatched case/control method was used to pull a random sample from the appendicitis cohort using a 1:4 ratio (tumor: acute appendicitis) to obtain adequate power for comparison. Preoperative patient variables and imaging findings were investigated using stepwise logistic regression to identify variables associated with appendiceal tumor. Results: Following multivariate analysis, preoperative imaging read of "indeterminate" and "not consistent with appendicitis," female gender, increased age, and lower preoperative white blood cell (WBC) count were significant predictors of tumor causing symptoms of appendicitis. The odds of having tumor pathology were significantly increased in patients with preoperative imaging of "indeterminate" and "not consistent with appendicitis." The odds of having tumor pathology were 82% higher for females than for males, increased by 2% for every 1-year increase in age, and increased by 3% for every one-unit decrease in WBC count. Conclusion: While incidental appendiceal tumors can present as acute appendicitis, 3 patient variables and one imaging finding were identified that may increase suspicion for appendiceal tumors. Consideration should be given to patients with these associated risk factors for additional preoperative consultation in addition to the potential for intraoperative pathology consultation.

Clinicopathologic and prognostic features in appendiceal malignancies: does tumor invasiveness matter?

Objectives

To evaluate the survival rates of appendiceal tumors and prognostic factors affecting survival.

Material and Methods

Demographic features, tumor characteristics and pre- and post-operative outcomes of the patients were analyzed retrospectively. The study was performed according to the Helsinki declaration.

Results

Twenty-three of the 2840 specimens were investigated prospectively. Median age of the patients was 28 (range: 1-89) years, with a male (n= 1730, 60.9%) to female (n= 1110, 39.1%) ratio of 1.55. Pediatric group did not present appendiceal malignancy. Carcinoid tumors were reported in 17 (0.59%) and adenocarcinoma was reported in 6 (0.20%) patients. Multivariate analyses of the subtypes showed serosal invasion as an independent risk factor for mucinous and non-mucinous adenocarcinoma (HR: -2.70, 95% CI: 0.006-0.755, p= 0.029). Median follow-up time was 48 months (range: 28-61 months) and disease specific survival rates of carcinoid tumors, mucinous- and non-mucinous adenocarcinomas were 36(95% CI 32-40), 30 (95% CI 13-46), 43 (95% CI 30-55) months, respectively (p= 0.749). Factors affecting survival in the univariate analyses were advanced tumor stage, serosal invasion and tumor invasion depth. In multivariate analyses, tumor invasion depth was the only independent prognostic factor with poor survival rates in all subtypes of appendiceal malignancies (HR= 1.31 (95% CI: 1.01-13.5), p= 0.047).

Conclusion

Tumor subtype and tumor invasiveness are important risk factors for survival. Besides other treatment modalities, appendectomy still remains the survival benefit with better clinical outcomes.

Proposed Classification of Pseudomyxoma Peritonei: Influence of Signet Ring Cells on Survival

The nomenclature and classification of pseudomyxoma peritonei (PMP) is confusing and controversial. Numerous classification systems have been proposed, none of which are easily reproducible or a useful guide for treatment. Patients with PMP of appendiceal origin were identified from our institution's database. Kaplan-Meier analyses were performed based on a proposed new PMP classification, a three-tiered grading system designated PMP1, PMP2, and PMP3. These results were compared with the established schemes by Ronnett and Bradley et al. There were 211 patients included in the analysis with a mean age of 51 ± 12 years at diagnosis. For PMP1, 86 patients (40.8%) included cases with abundant extracellular mucin and columnar non-stratified epithelium without dysplasia or atypia. For PMP3, 50 patients (23.7%) consisted of PMP with any percentage of signet ring cells (SRCs), For PMP2, 75 patients (35.5%) included all other patients. The mean age (± standard deviation) for PMP 1, 2, and 3 were 51 ± 12, 51 ± 12, and 51 ± 10 years, respectively ( P = 0.90). The three groups had similar sex distribution ( P = 0.24) and resection status ( P = 0.47). Kaplan-Meier analyses showed median survivals of 120, 88, and 40 months and 5-year survival rates of 85.7, 63.05, and 32.2 per cent ( P < 0.0001) for PMP 1, 2, and 3, respectively. Three distinct categories, PMP1, 2, and 3, were identified, which provide better stratification in terms of overall survival and represent differences in tumor biology that may impact treatment recommendations.

Clinicopathologic Features and Survival Outcomes of Signet Ring Cell Carcinoma of the Appendix: An Analysis of the Surveillance, Epidemiology, and End Results Database

Background and objective

Signet ring cell carcinoma of the appendix (SRCCA) is an exceedingly rare tumor, and very limited data are available regarding its characteristics and survival probabilities. Our objective in this study was to utilize the Surveillance, Epidemiology, and End Results (SEER) database to explore the patient and tumor characteristics and to characterize the three- and five-year cancer-specific survival (CSS) probabilities of SRCCA.

Methods

Patients with SRCCA diagnosed between 2000 and 2015 were analyzed using the SEER database. The three- and five-year CSS probabilities were estimated by the Kaplan-Meier method, and the groups were compared using log-rank comparisons and multivariable Cox hazard regression analysis.

Results 

A total of 527 patients were identified. The median age of the participants at diagnosis was 56 years, with a majority of them being female and white. Histologically, 60% of the tumors were high grade, and 61.3 % of the tumors were found to be metastatic on presentation. Three- and five-year CSS probabilities were 39% and 18.4%, respectively, and median survival was 26 months. Best survival outcomes were noted in males (five-year CSS: 25.4%, p=0.027), unmarried patients (five-year CSS: 19.1%, p=0.042), tumors <2 cm in size (five-year CSS: 50.5%, p<0.001), and low-grade tumors (five-year CSS: 44.8%, p<0.001). Subtotal colectomy yielded better three- and five-year CSS probabilities compared to no surgery and partial colectomy (48.5% and 26.5%, respectively, p<0.001). On the multivariate analysis, it was found that age and stages T4, N1, and M1 were associated with an increased risk of mortality, while surgery, regardless of the extent, was a protective factor.

Conclusion 

SRCCA is a rare tumor with a high prevalence among old-aged white females. This tumor is usually diagnosed in an advanced stage and has a dismal prognosis. Surgical intervention, regardless of the extent, showed better survival probabilities compared to no surgery.

Endometrium-Limited Metastasis of Extragenital Malignancies: A Challenge in the Diagnosis of Endometrial Curettage Specimens

Malignancies of extragenital origin very rarely metastasize to the uterine body. Endometrium-limited metastases may pose diagnostic challenges in endometrial curettage specimens as they may be misdiagnosed as primary endometrial tumors. We investigated the clinicopathological characteristics of seven cases with endometrial-limited metastases from carcinomas of the nasopharynx (n = 1), breast (n = 2), colon (n = 2), stomach (n = 1), and appendix (n = 1). The patients' ages ranged from 36 to 71 (mean: 55.4) years. None of the patients had a remarkable gynecological history, and the presenting sign in all cases was abnormal uterine bleeding. Although myometrial involvement was absent, multiple metastases were already present in extrauterine locations such as the lung, liver, bone, abdominopelvic peritoneum, and omentum. All patients underwent ultrasonographic examination prior to endometrial curettage. The histologies of the endometrial metastases identified from the curettage specimens were identical to those of the corresponding primary tumors. Ancillary tests including immunostaining and Epstein-Barr virus-encoded RNA in situ hybridization confirmed the extragenital origin. Endometrium-limited metastases from extragenital malignancies are extremely rare. They present with abnormal vaginal bleeding and mimic endometrial carcinomas of endometrioid or poorly differentiated types. Since their clinical presentations and histological features are similar to those of primary endometrial tumors, pathologists should consider the possibility of metastases while evaluating endometrial curettage specimens obtained from patients with a history of extragenital malignancies.

Management of acute appendicitis in adults: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Acute appendicitis (AA) has been considered one of the most common acute surgical conditions in the world. Recent studies, however, have suggested that nonoperative management (NOM) with a course of antibiotics (ABX) may be as effective as surgery in treating appendicitis. As there are evolving perspectives regarding the optimal therapy for appendicitis, we sought to provide recommendations regarding the role of NOM with the administration of antibiotics (antibiotics-first approach) in uncomplicated AA as well as the need for routine interval appendectomy (RIA) in those presenting with appendiceal abscess or phlegmon (AAP) initially managed without appendectomy.

METHODS

A writing group from the Guidelines Committee of the Eastern Association for the Surgery of Trauma (EAST) performed a systematic review and meta-analysis of the current literature regarding appendicitis in adult populations. The Grading of Recommendations Assessment, Development and Evaluation methodology was applied and meta-analyses and evidence profiles generated.

RESULTS

When comparing antibiotics-first therapy to surgery for uncomplicated AA in adult populations, we found that perforation and recurrence of disease were the only outcomes consistently represented in the literature. For perforation, we were unable to make a definitive conclusion based on the degree of heterogeneity among the six randomized controlled trials reviewed. The risk of recurrence at 1 year with antibiotics-first treatment was 15.8% (95% confidence interval, 12.05-118.63). Critical outcomes could not be evaluated with the current literature. In NOM patients for AAP, the risk of recurrence was 24.3% if RIA was not performed (95% confidence interval, 2.74-73.11).

CONCLUSION

Based on the completed meta-analysis and Grading of Recommendations Assessment, Development and Evaluation profiles, we were unable to make a recommendation for or against the antibiotics-first approach as primary treatment for uncomplicated AA. For NOM with AAP, we conditionally recommend against RIA in an otherwise asymptomatic patient. This review reveals multiple limitations of the published literature, leaving ample opportunities for additional research on this topic.

LEVEL OF EVIDENCE

Systematic review, level II.

Appendicular neoplasms and consequences in patients undergoing surgery for suspected acute appendicitis

INTRODUCTION

In patients treated with an appendectomy for acute appendicitis, the specimen is generally sent for histological evaluation. In an era of increasing non-operative treatment for acute appendicitis, it is important to know the incidence, the diagnostic accuracy, and treatment consequences of appendicular neoplasms that are found in acute appendicitis. We hypothesize that pre- and intra-operative parameters might predict an appendicular neoplasm.

METHODS

Data was used from our previous prospective observational cohort study. All patients undergoing surgery for suspected acute appendicitis were included. The primary outcome was the incidence of appendicular neoplasms in patients operated for acute appendicitis. Secondary outcomes were pre-operative diagnostics and imaging outcomes, intra-operative surgical judgment, and postoperative management and outcome. Possible predictors of an appendicular neoplasm were identified and used in multivariable logistic regression. Patients with an appendicular neoplasm were followed for 3 years after initial appendectomy.

RESULTS

A total of 1975 patients underwent surgery for suspected acute appendicitis and in 98.3% (1941/1975) the appendix was removed. In 1.5% (30/1941) of these patients, an appendicular neoplasm was found. Among the malignant neoplasms, the majority were grade 1 neuroendocrine tumors (NET) in 65% (13/20). On pre-operative imaging, there was no suspicion of malignancy. In three cases, there was an intra-operative suspicion of malignancy. Multivariable analysis showed only age as an independent predictor for appendicular neoplasms. No recurrent or new malignancy was found during follow-up.

DISCUSSION

The incidence of appendicular neoplasm in patients undergoing an acute appendectomy is very low and clinical risk factors could not be identified.