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Marks VA, Kerekes D, Butensky S, Ahuja N, Johnson C, Turaga K, Khan SA. Role of colectomy in the management of appendiceal tumors: a retrospective cohort study. BMC Gastroenterol 2023; 23:398. [PMID: 37978348 PMCID: PMC10655451 DOI: 10.1186/s12876-023-03019-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/29/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Appendiceal tumors represent a range of histologies that vary in behavior. Recommendations for treatment with appendectomy versus right hemicolectomy (RHC) for different tumor types are evolving and sometimes conflicting. This study sought to characterize variation in the United States around surgical treatment of major appendiceal tumor types over time and describe differences in outcomes based on procedure. METHODS Patients diagnosed with appendiceal goblet cell adenocarcinoma (GCA), mucinous adenocarcinoma, neuroendocrine neoplasm (NEN), or non-mucinous adenocarcinoma from 2004-2017 were identified in the National Cancer Database. Trends in RHC over time and predictors of RHC were identified. Surgical outcomes for each histologic type and stage were compared. RESULTS Of 18,216 patients, 11% had GCAs, 34% mucinous adenocarcinoma, 31% NENs, and 24% non-mucinous adenocarcinoma. Rate of RHC for NEN decreased from 68% in 2004 to 40% in 2017 (p = 0.008) but remained constant around 60-75% for other tumor types. Higher stage was associated with increased odds of RHC for all tumor types. RHC was associated with higher rate of unplanned readmission (5% vs. 3%, p < 0.001) and longer postoperative hospital stay (median 5 days vs. 3 days, p < 0.001). On risk-adjusted analysis, RHC was significantly associated with increased survival versus appendectomy for stage 2 disease of all tumor types (HRs 0.43 to 0.63) and for stage 1 non-mucinous adenocarcinoma (HR = 0.56). CONCLUSIONS Most patients with appendiceal tumors undergo RHC, which is associated with increased readmission, longer length of stay, and improved survival for stage 2 disease of all types. RHC should be offered selectively for appendiceal tumors.
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Affiliation(s)
- Victoria A Marks
- Department of Surgical Oncology, Yale School of Medicine, Yale University School of Medicine, 330 Cedar Street, FMB130, New Haven, CT, 06520, USA
| | - Daniel Kerekes
- Department of Surgical Oncology, Yale School of Medicine, Yale University School of Medicine, 330 Cedar Street, FMB130, New Haven, CT, 06520, USA
| | - Samuel Butensky
- Department of Surgical Oncology, Yale School of Medicine, Yale University School of Medicine, 330 Cedar Street, FMB130, New Haven, CT, 06520, USA
| | - Nita Ahuja
- Department of Surgical Oncology, Yale School of Medicine, Yale University School of Medicine, 330 Cedar Street, FMB130, New Haven, CT, 06520, USA
| | - Caroline Johnson
- Yale School of Public Health, 60 College St, New Haven, CT, 06510, USA
| | - Kiran Turaga
- Department of Surgical Oncology, Yale School of Medicine, Yale University School of Medicine, 330 Cedar Street, FMB130, New Haven, CT, 06520, USA
| | - Sajid A Khan
- Department of Surgical Oncology, Yale School of Medicine, Yale University School of Medicine, 330 Cedar Street, FMB130, New Haven, CT, 06520, USA.
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Zeineddin S, Aldrink JH, Bering J, Hoyt DW, Kastenberg ZJ, Brungardt J, Dasgupta R, Rinehardt HN, Malek MM, Ziogas IA, Roach JP, Craig BT, Rothstein DH, Lautz TB. Multi-institutional assessment of the prevalence of neuroendocrine tumors in children undergoing laparoscopic appendectomy for acute appendicitis in the United States. Pediatr Blood Cancer 2023; 70:e30620. [PMID: 37555297 DOI: 10.1002/pbc.30620] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/30/2023] [Accepted: 07/24/2023] [Indexed: 08/10/2023]
Abstract
As non-operative management of acute appendicitis in children has become more common, missed incidental appendiceal pathology can be an unintended consequence. We assessed the prevalence of neuroendocrine tumors in appendectomy specimens from eight US children's hospitals from 2012 to 2021. The prevalence of neuroendocrine tumors (NET) was found to be 1:271, with a median age of 14 years and 62% female. Most tumors were small (median 6 mm; interquartile range [IQR]: 3-10), and no recurrence was noted during the follow-up period (median 22.5 months; IQR: 3-53). The possibility of delayed diagnosis of these tumors should be part of the discussion for non-operative management of pediatric acute appendicitis.
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Affiliation(s)
- Suhail Zeineddin
- Division of Pediatric Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Jakob Bering
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - David W Hoyt
- Division of Pediatric Surgery, Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Zachary J Kastenberg
- Division of Pediatric Surgery, Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Joseph Brungardt
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Hannah N Rinehardt
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Marcus M Malek
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ioannis A Ziogas
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jonathan P Roach
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Brian T Craig
- Division of Pediatric Surgery, Department of Surgery, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David H Rothstein
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Timothy B Lautz
- Division of Pediatric Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois, USA
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3
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Zhao B, Wang J, Ye H, Cheng X, Meng K, Yang T. Mixed adenoneuroendocrine carcinoma originating from the appendix and colorectum: a comparative analysis of a large population-based database. Tech Coloproctol 2023; 27:1017-1024. [PMID: 36995458 DOI: 10.1007/s10151-023-02786-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 03/14/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE As a rare gastrointestinal neoplasm, the demographic, clinicopathological, and prognostic characteristics of mixed adenoneuroendocrine carcinoma (MANEC) remain unclear. The purpose of this study was to evaluate its biological features, survival outcome, and prognostic factors. METHODS From the Surveillance, Epidemiology, and End Results (SEER) database, we retrospectively reviewed clinicopathological and survival data of 513 patients who were histopathologically diagnosed with MANEC of the appendix and colorectum bettween 2004 and 2015. The clinicopathological features and survival outcomes of MANEC located at different anatomical locations were compared, and predictive factors for cancer-specific survival (CSS) and overall survival (OS) were assessed. RESULTS In terms of anatomical distribution of MANEC, the appendix (64.5%, 331/513) was more frequently involved, followed by colon (28.1%, 144/513) and rectum (7.4%, 38/513). The MANEC at different anatomical locations had a distinct clinicopathological characteristic, and colorectal MANEC was significantly associated with more aggressive biological features. The survival outcomes of appendiceal MANEC were significantly better than that of colorectal MANEC (3-year CSS rate 73.8% vs 59.4%, P = 0.010; 3-year OS 69.2% vs 48.3%, P < 0.001). In addition, hemicolectomy had a better survival benefit than appendicectomy for patients with appendiceal MANEC, regardless of lymph node metastasis (P < 0.05). Tumor location, histology grade III, tumor size > 2 cm, T3-T4 stage, lymph node metastasis, and distant metastasis were independent prognostic factors for patients with MANEC. CONCLUSIONS Tumor location had an important prognostic significance for MANEC. As an uncommon clinical entity, colorectal MANEC had more aggressive biological features and worse prognosis than its appendiceal counterpart. The standard surgical procedure and clinical management strategy for MANEC need to be established.
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Affiliation(s)
- Bochao Zhao
- Department of Gastrointestinal Surgery, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300190, People's Republic of China.
| | - Jingchao Wang
- Department of Gastrointestinal Surgery, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300190, People's Republic of China
| | - Haikun Ye
- Department of Gastrointestinal Surgery, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300190, People's Republic of China
| | - Xinghao Cheng
- Department of Gastrointestinal Surgery, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300190, People's Republic of China
| | - Kewei Meng
- Department of Gastrointestinal Surgery, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300190, People's Republic of China
| | - Tao Yang
- Department of Gastrointestinal Surgery, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300190, People's Republic of China.
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Gopakumar H, Jahagirdar V, Koyi J, Dahiya DS, Goyal H, Sharma NR, Perisetti A. Role of Advanced Gastrointestinal Endoscopy in the Comprehensive Management of Neuroendocrine Neoplasms. Cancers (Basel) 2023; 15:4175. [PMID: 37627203 PMCID: PMC10453187 DOI: 10.3390/cancers15164175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/15/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Neuroendocrine neoplasms (NENs), also called neuroendocrine tumors (NETs), are relatively uncommon, heterogenous tumors primarily originating in the gastrointestinal tract. With the improvement in technology and increasing use of cross-sectional imaging and endoscopy, they are being discovered with increasing frequency. Although traditionally considered indolent tumors with good prognoses, some NENs exhibit aggressive behavior. Timely diagnosis, risk stratification, and management can often be a challenge. In general, small NENs without local invasion or lymphovascular involvement can often be managed using minimally invasive advanced endoscopic techniques, while larger lesions and those with evidence of lymphovascular invasion require surgery, systemic therapy, or a combination thereof. Ideal management requires a comprehensive and accurate understanding of the stage and grade of the tumor. With the recent advancements, a therapeutic advanced endoscopist can play a pivotal role in diagnosing, staging, and managing this rare condition. High-definition white light imaging and digital image enhancing technologies like narrow band imaging (NBI) in the newer endoscopes have improved the diagnostic accuracy of traditional endoscopy. The refinement of endoscopic ultrasound (EUS) over the past decade has revolutionized the role of endoscopy in diagnosing and managing various pathologies, including NENs. In addition to EUS-directed diagnostic biopsies, it also offers the ability to precisely assess the depth of invasion and lymphovascular involvement and thus stage NENs accurately. EUS-directed locoregional ablative therapies are increasingly recognized as highly effective, minimally invasive treatment modalities for NENs, particularly pancreatic NENs. Advanced endoscopic resection techniques like endoscopic submucosal dissection (ESD), endoscopic submucosal resection (EMR), and endoscopic full-thickness resection (EFTR) have been increasingly used over the past decade with excellent results in achieving curative resection of various early-stage gastrointestinal luminal lesions including NENs. In this article, we aim to delineate NENs of the different segments of the gastrointestinal (GI) tract (esophagus, gastric, pancreatic, and small and large intestine) and their management with emphasis on the endoscopic management of these tumors.
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Affiliation(s)
- Harishankar Gopakumar
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL 61605, USA;
| | - Vinay Jahagirdar
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64110, USA; (V.J.); (J.K.)
| | - Jagadish Koyi
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64110, USA; (V.J.); (J.K.)
| | - Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology & Motility, The University of Kansas School of Medicine, Kansas City, KS 66160, USA;
| | - Hemant Goyal
- Department of Surgery, Center for Interventional Gastroenterology at UT (iGUT), The University of Texas Health Science Center, Houston, TX 77054, USA;
| | - Neil R. Sharma
- Advanced Interventional Endoscopy & Endoscopic Oncology (IOSE) Division, GI Oncology Tumor Site Team, Parkview Cancer Institute, 11104 Parkview Circle, Suite 310, Fort Wayne, IN 46845, USA;
| | - Abhilash Perisetti
- Division of Gastroenterology and Hepatology, Kansas City Veteran Affairs, Kansas City, MO 64128, USA
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Andrini E, Lamberti G, Alberici L, Ricci C, Campana D. An Update on Appendiceal Neuroendocrine Tumors. Curr Treat Options Oncol 2023; 24:742-756. [PMID: 37140773 PMCID: PMC10271885 DOI: 10.1007/s11864-023-01093-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- Elisa Andrini
- Department of Experimental, Diagnostic & Specialty Medicine (DIMES), University of Bologna, 40138, Bologna, Italy
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via P. Albertoni, 15, 40138, Bologna, Italy
| | - Giuseppe Lamberti
- Department of Experimental, Diagnostic & Specialty Medicine (DIMES), University of Bologna, 40138, Bologna, Italy
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via P. Albertoni, 15, 40138, Bologna, Italy
| | - Laura Alberici
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, S. Orsola-Malpighi Hospital, University of Bologna, Policlinico S. Orsola-Malpighi Via Massarenti N. 9, 40138, Bologna, Italy
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria Di Bologna, 40138, Bologna, Italy
| | - Claudio Ricci
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, S. Orsola-Malpighi Hospital, University of Bologna, Policlinico S. Orsola-Malpighi Via Massarenti N. 9, 40138, Bologna, Italy
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria Di Bologna, 40138, Bologna, Italy
| | - Davide Campana
- Department of Experimental, Diagnostic & Specialty Medicine (DIMES), University of Bologna, 40138, Bologna, Italy.
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via P. Albertoni, 15, 40138, Bologna, Italy.
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6
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Muñoz de Nova JL, Hernando J, Sampedro Núñez M, Vázquez Benítez GT, Triviño Ibáñez EM, del Olmo García MI, Barriuso J, Capdevila J, Martín-Pérez E. Management of incidentally discovered appendiceal neuroendocrine tumors after an appendicectomy. World J Gastroenterol 2022; 28:1304-1314. [PMID: 35645544 PMCID: PMC9099182 DOI: 10.3748/wjg.v28.i13.1304] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/09/2022] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
Appendiceal neuroendocrine tumors (aNETs) are an uncommon neoplasm that is relatively indolent in most cases. They are typically diagnosed in younger patients than other neuroendocrine tumors and are often an incidental finding after an appendectomy. Although there are numerous clinical practice guidelines on management of aNETs, there is continues to be a dearth of evidence on optimal treatment. Management of these tumors is stratified according to risk of locoregional and distant metastasis. However, there is a lack of consensus regarding tumors that measure 1-2 cm. In these cases, some histopathological features such as size, tumor grade, presence of lymphovascular invasion, or mesoappendix infiltration must also be considered. Computed tomography or magnetic resonance imaging scans are recommended for evaluating the presence of additional disease, except in the case of tumors smaller than 1 cm without additional risk factors. Somatostatin receptor scintigraphy or positron emission tomography with computed tomography should be considered in cases with suspected residual or distant disease. The main point of controversy is the indication for performing a completion right hemicolectomy after an initial appendectomy, based on the risk of lymph node metastases. The main factor considered is tumor size and 2 cm is the most common threshold for indicating a colectomy. Other factors such as mesoappendix infiltration, lymphovascular invasion, or tumor grade may also be considered. On the other hand, potential complications, and decreased quality of life after a hemicolectomy as well as the lack of evidence on benefits in terms of survival must be taken into consideration. In this review, we present data regarding the current indications, outcomes, and benefits of a colectomy.
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Affiliation(s)
- José Luis Muñoz de Nova
- Department of General and Digestive Surgery, Hospital Universitario de La Princesa, Madrid 28006, Spain
- Department of Surgery, Universidad Autónoma de Madrid, Madrid 28029, Spain
| | - Jorge Hernando
- Gastrointestinal and Endocrine Tumor Unit, Medical Oncology Department, Vall d´Hebron University Hospital, Vall d´Hebron Institute of Oncology, Barcelona 08035, Spain
| | - Miguel Sampedro Núñez
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Madrid 28006, Spain
| | - Greissy Tibisay Vázquez Benítez
- Department of Pathology, Hospital Universitario Puerta de Hierro, Madrid 28222, Spain
- Department of Pathology, Universidad Autónoma de Madrid, Madrid 28029, Spain
| | | | | | - Jorge Barriuso
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, United Kingdom
| | - Jaume Capdevila
- Gastrointestinal and Endocrine Tumor Unit, Medical Oncology Department, Vall d´Hebron University Hospital, Vall d´Hebron Institute of Oncology, Barcelona 08035, Spain
| | - Elena Martín-Pérez
- Department of General and Digestive Surgery, Hospital Universitario de La Princesa, Madrid 28006, Spain
- Department of Surgery, Universidad Autónoma de Madrid, Madrid 28029, Spain
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Noor M, Huber AR, Cates JMM, Gonzalez RS. Risk factors for progression of appendiceal neuroendocrine tumours: low-stage tumours <5 mm appear to be overwhelmingly indolent and may merit a separate designation. Histopathology 2021; 79:416-426. [PMID: 33754384 DOI: 10.1111/his.14369] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/04/2021] [Accepted: 03/20/2021] [Indexed: 12/15/2022]
Abstract
AIMS Appendiceal well-differentiated neuroendocrine tumours (NETs) are usually incidental and clinically benign. Several studies have reported different risk factors for nodal metastasis. The aim of this study was to investigate our appendiceal NETs (App-NETs) to determine the factors associated with malignant behaviour. METHODS AND RESULTS For 120 App-NETs, we reviewed the clinical presentation and follow-up, including serum chromogranin A (CgA) levels, and compiled several microscopic variables. Pathological factors were compared with nodal status and time to biochemical recurrence (elevated serum CgA level) by the use of Cox regression. We also reviewed similar App-NET data in the Surveillance, Epidemiology, and End Results (SEER) Programme. Among our 120 cases, seven patients had positive lymph nodes, and nine developed subsequent elevation of CgA levels; none developed distant metastases or died of disease. Only three patients had grade 2 NETs; none had nodal disease, and one developed an elevated CgA level. Increasing tumour size was associated with an increased risk of nodal disease [odds ratio (OR) 4.99, P = 0.0055). All seven node-positive cases were ≥13 mm. Factors associated with elevated CgA levels included age (OR 1.04, P = 0.041), pT4 disease (OR 10.22, P = 0.033), and nodal disease (OR 24.0, P = 0.012), but not size (OR 2.13, P = 0.072). Of the 1492 reported App-NETs in the SEER database with data on tumour size, 137 (9%) were pN1; only five of these (4%) were coded as being <5 mm. CONCLUSIONS Small (<5 mm) App-NETs that do not invade the serosa or mesoappendix appear to be overwhelmingly benign and low-grade, requiring neither Ki67 staining nor synoptic reporting. Given their indolent behaviour, different nomenclature or staging may be more appropriate for these NETs.
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Affiliation(s)
- Mushal Noor
- Department of Pathology, University of Rochester Medical Center, Rochester, NY, USA
| | - Aaron R Huber
- Department of Pathology, University of Rochester Medical Center, Rochester, NY, USA
| | - Justin M M Cates
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Raul S Gonzalez
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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8
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Skancke M, Sharp SP, Maron DJ, Wexner SD. Elevated prevalence of nodal positivity in carcinoid tumours of the appendix smaller than 2 cm has a negative impact on overall survival. Colorectal Dis 2020; 22:1958-1964. [PMID: 33463877 DOI: 10.1111/codi.15287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/20/2020] [Indexed: 02/08/2023]
Abstract
AIM The current standard of care for clinically node-negative carcinoid tumours of the appendix < 2.0 cm in size is appendectomy alone. The aim of this analysis was to evaluate the prevalence of pathological nodal positivity in clinically node-negative appendiceal tumour specimens < 2.0 cm and quantify the impact of occult pathological nodal positivity on overall survival following resection. METHOD A retrospective database review of the 2019 US National Cancer Database for appendiceal cancer identified 2007 cases of clinically node-negative appendiceal carcinoid tumours based on SEER histology codes 8240, 8241, 8242, 8243, 8243, 8244, 8245, 8246 and 8249. Kaplan-Meier with log-rank testing and multivariate Cox regression analysis evaluated the impact of occult nodal positivity on overall survival following resection for clinically node-negative appendiceal carcinoma. RESULTS The prevalence of occult nodal positivity increased from 1.9% for sub-centimetre tumours to 7% for tumours between 1.0 and 1.5 cm, 16.5% for tumours between 1.5 and 2.0 cm and to >29.5% for tumours > 2.0 cm. Rates of metastatic spread were similar for tumours < 2.0 cm but increased for larger tumours. Over two-thirds of patients received a segmental colectomy as definitive surgical therapy. After controlling for differences in cohorts, multivariate analysis showed an increased hazard ratio for mortality of 162% (HR 2.62, CI 1.884-3.541) for patients with pathological node-positive disease. CONCLUSION Clinically node-negative carcinoid tumours of the appendix bigger than 1.5 cm have an increased rate of occult nodal spread which has a negative impact on overall survival.
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Affiliation(s)
- M Skancke
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S P Sharp
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - D J Maron
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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9
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Abstract
Incidence of neuroendocrine tumors (NETs) is increasing, including those of the gastroenteropancreatic tract. A proper understanding of the management of this disease has become necessary for the general surgeon. This article addresses current guidelines for diagnosis and localization of NETs, including somatostatin receptor PET. Updated treatment and outcomes of NETs by primary tumor site are discussed as well as those metastatic to the liver.
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Affiliation(s)
- Morgan Bonds
- Section of General, Vascular, and Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, CS-G6, Seattle, WA 98101, USA
| | - Flavio G Rocha
- Section of General, Vascular, and Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, CS-G6, Seattle, WA 98101, USA; University of Washington, Seattle, WA, USA.
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10
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Sugarbaker PH, Ben-Yaacov A, Hazzan D, Nissan A. Synchronous primary neuroendocrine and mucinous epithelial tumors present in the same appendix. Case report of 2 patients. Int J Surg Case Rep 2020; 67:76-79. [PMID: 32035310 PMCID: PMC7010995 DOI: 10.1016/j.ijscr.2020.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/13/2020] [Accepted: 01/20/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Although uncommon, neoplasms of the appendix do exist. The two most common types are neuroendocrine tumors and mucinous appendiceal neoplasms. METHODS In two patients unusual gross and microscopic findings in an appendectomy specimen were recorded. Special immunocytochemistry studies were used to determine the histologic type of the tumors in the appendix. RESULTS The clinical features and histopathology of two patients who had both a neuroendocrine tumor and a low grade appendiceal mucinous neoplasm in the same appendectomy specimen were described. Possibilities for the causation and treatment of this unusual condition were discussed. The incidence of this double malignancy was estimated at 2.5 in 1000 appendectomy specimens. CONCLUSION Although extremely unusual, a neuroendocrine tumor and a mucinous appendiceal neoplasm can exist in the same appendix. This condition is reported in two young patients.
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Affiliation(s)
- Paul H Sugarbaker
- Program in Peritoneal Surface Malignancies, MedStar Washington Hospital Center, Washington, DC, USA.
| | - Almog Ben-Yaacov
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - David Hazzan
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Aviram Nissan
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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Abstract
PURPOSE OF REVIEW To synthesize the current knowledge and guidelines on the management of appendiceal neuroendocrine neoplasms (ANENs). RECENT FINDINGS Most recent guidelines are essentially based on heterogeneous retrospective series. With the advent of a more precise classification of neuroendocrine neoplasms, this heterogeneity is rightly criticized and many 'grey areas' are now debated in expert literature. The only way to solve these issues is through the conduct of large prospective multicentre studies, but this seems somewhat utopian, given the rarity of this disease. SUMMARY ANENs are rare tumours with a favourable prognosis, and mainly diagnosed in young patients. They are predominantly localized, and diagnosed incidentally on appendectomy. This procedure is curative for the vast majority of patients but ANENs can relapse even a significant time after the first diagnosis. Identifying the risks for recurrence is challenging, with some factors thought to be predictive of nodal involvement. The presence of one or more of these factors justifies an oncological radicalization of the surgical procedure (right hemicolectomy with lymphadenectomy). However, the beneficial impact of this surgical procedure on survival is still unproven.
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Ricci C, Ingaldi C, Alberici L, Brighi N, Santini D, Mosconi C, Ambrosini V, Campana D, Minni F, Casadei R. Histopathological diagnosis of appendiceal neuroendocrine neoplasms: when to perform a right hemicolectomy? A systematic review and meta-analysis. Endocrine 2019; 66:460-466. [PMID: 31227991 DOI: 10.1007/s12020-019-01984-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/12/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE The European Neuroendocrine Tumor Society (ENETS) guidelines advocate a right hemicolectomy (RHC) only in patients with appendiceal neuroendocrine neoplasms (aNENs) at risk for N+(node positive). The risk is defined using site, size, and grading of tumor as well as mesoappendiceal or lymphovascular invasion. METHODS A systematic review and meta-analysis was carried out. The data were reported using risk difference (RD) to define the risk of N+. The number needed to treat/harm (NNT/NNH) and the likelihood of being helped or harmed (LHH) were calculated using RD. Two strategies were considered: "to treat all" versus "to treat only patients having aNENs with risk stigmata". The aim was to evaluate the harm/benefit ratio related to the use of the ENETS lymph-nodal metastases (N+) risk factors. RESULTS Six studies were included involving a total of 261 patients. The RD (-0.30; P < 0.001) of N+ was significantly lower in aNENs ≤ 20 mm as compared to those >20 mm. One unnecessary RHC every five patients (NNT = 5) could be avoided while 1 patient with N+ every six patients (NNH = 6) remained untreated. The risk was lower than the benefits (LHH = 1.2). The RD NNT, NNH, and LHH values suggested that only a 15 mm cutoff and the presence of lymphovascular invasion could be considered useful. CONCLUSIONS An RHC should be performed in patients with aNENs >20 mm. The use of a 15 mm cutoff criterion had a similar outcome to that of a 20 mm cutoff. Lymphovascular invasion should only be considered a minor criterion. Selection based on other parameters should be avoided.
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Affiliation(s)
- Claudio Ricci
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy.
- NET Team Bologna-ENETS Center of Excellence, S.Orsola-Malpighi Hospital, Bologna, Italy.
| | - Carlo Ingaldi
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- NET Team Bologna-ENETS Center of Excellence, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Laura Alberici
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- NET Team Bologna-ENETS Center of Excellence, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Nicole Brighi
- NET Team Bologna-ENETS Center of Excellence, S.Orsola-Malpighi Hospital, Bologna, Italy
- Department of Specialized Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Donatella Santini
- NET Team Bologna-ENETS Center of Excellence, S.Orsola-Malpighi Hospital, Bologna, Italy
- Histopathological Unit, Department of Diagnostic & Preventive Medicine, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Cristina Mosconi
- NET Team Bologna-ENETS Center of Excellence, S.Orsola-Malpighi Hospital, Bologna, Italy
- Radiology Unit, Department of Diagnostic & Preventive Medicine, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Valentina Ambrosini
- NET Team Bologna-ENETS Center of Excellence, S.Orsola-Malpighi Hospital, Bologna, Italy
- Department of Specialized Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Davide Campana
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- NET Team Bologna-ENETS Center of Excellence, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Francesco Minni
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- NET Team Bologna-ENETS Center of Excellence, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Riccardo Casadei
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- NET Team Bologna-ENETS Center of Excellence, S.Orsola-Malpighi Hospital, Bologna, Italy
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Lymph Node Status: In Reply to Carr. J Am Coll Surg 2019; 229:516-517. [PMID: 31655706 DOI: 10.1016/j.jamcollsurg.2019.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 07/15/2019] [Indexed: 11/21/2022]
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Carr JA. Tumor Size and Lymph Node Metastasis of Appendiceal Carcinoid Tumors. J Am Coll Surg 2019; 229:516. [PMID: 31655707 DOI: 10.1016/j.jamcollsurg.2019.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 07/15/2019] [Indexed: 11/30/2022]
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Sugarbaker PH. Management of Appendiceal Malignancy. J Am Coll Surg 2019; 229:517-519. [PMID: 31655708 DOI: 10.1016/j.jamcollsurg.2019.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/15/2019] [Indexed: 11/29/2022]
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Appendiceal Carcinoid Tumors: In Reply to Sugarbaker. J Am Coll Surg 2019; 229:519. [PMID: 31655709 DOI: 10.1016/j.jamcollsurg.2019.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 07/15/2019] [Indexed: 11/21/2022]
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