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

Appendiceal neoplasms in Saudi Arabia: prevalence and clinicopathological profile

BACKGROUND

The appendix is a small organ with no particular known function. Primary appendiceal neoplasms (ANs) are rare. While the prevalence is increasing worldwide over the past two decades, no apparent increase in the prevalence of ANs has been reported in the Arabian Gulf States. Recently, a significant decline in the age at diagnosis of some types of ANs has been reported worldwide, with a female predominance.

OBJECTIVES

Evaluate the prevalence and clinicopathological characteristics of ANs within our institution in Saudi Arabia and compare them to limited existing studies from different regions as well as the Arabian Gulf States.

DESIGN

Retrospective cohort.

SETTING

Tertiary care center in Riyadh.

PATIENTS AND METHODS

All patients who underwent appendectomy and had the appendix submitted for histopathological evaluation between May 2015 and June 2020 were included to allow for a follow-up of 5 years or more at the time of data collection.

MAIN OUTCOME MEASURES

Demographics, clinical presentations, surgical interventions, histopathological findings, complications, and recurrence rates.

SAMPLE SIZE

25 AN patients.

RESULTS

Of 1110 patients, 25 had ANs (13 female and 12 male participants) with a mean (standard deviation) age of 54.6 (14.1) years. Only 40% presented with acute appendicitis, 64% had comorbidities, and less than 50% underwent laparoscopic appendectomy. Histopathologically, 72% were low-grade appendiceal mucinous neoplasms (LAMNs). Complications were minimal grades (Clavien-Dindo classification), with 80% experiencing none. The mean hospital stay was 9.96 days. Local recurrence occurred in 8% of cases, and distant metastasis was documented in one adenocarcinoma case. However, the 5-year overall and disease-free survival rates were 88% and 80%, respectively.

CONCLUSIONS

The incidence of ANs is increasing in Saudi Arabia with the higher prevalence of LAMNs. The pathological examination of the resected appendix played a pivotal role in the diagnosis of ANs.

LIMITATIONS

Data collected retrospectively, a single institution, and a small population.

Anastomotic leakage following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal cancer: A clinical cohort study

BACKGROUND

Extended oncological resections for colorectal cancer surgery are associated with a high rate of complications, especially anastomotic leakage (AL). This study determines the incidence of risk factors for postoperative complications following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer (CRC).

METHODS

In this cohort study, the clinical data of all patients with CRC, treated with CRS and HIPEC, from 2011 to 2021 was analyzed. We considered patients' characteristics, tumor-specific features, postoperative complications, and hospital stay using Chi-Square-test or Fisher's exact test. The Mann-Whitney-U-test was used to measure the probability of differences between two sets of data.

RESULTS

Of 1089 HIPEC procedures performed in the study center, 185 patients with CRC and peritoneal metastasis were treated with CRS and HIPEC after formation of at least one anastomosis and therefore included in this study. This included synchronous and metachronous peritoneal metastasis with a mean peritoneal cancer index of 8.67 ± 5.22. In this cohort, AL occurred in 12 (6.5 %) patients. There was no correlation between the number of anastomoses and the occurrence of an AL (p = 0.401).

CONCLUSION

This study reports a low risk of AL after CRS with HIPEC for CRC, comparable to other published data. If a complete cytoreduction seems possible, the risk of anastomotic leakage should not negatively influence the decision to resect. Further studies on this subject are essential to validate our findings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Appendiceal diverticulosis: a harbinger of underlying primary appendiceal adenocarcinoma?

Diagnosis of primary appendiceal adenocarcinoma (PAA) is hindered by its rarity and largely asymptomatic nature. Appendiceal diverticulosis (AD) is equally rare. We report an unusual case of PAA presenting with perforated appendiceal diverticulitis, and discuss a review of the literature about its association, and its surgical and pathological implications. A middle-aged man was admitted with right iliac fossa (RIF) pain and a corresponding tender abdominal mass for 5 days. Computerised tomography (CT) scan demonstrated a thickened appendix with 3 cm abscess at its base. During laparoscopic appendicectomy, the appendiceal phlegmon was adhered to the surrounding bowel. Histology showed a perforated diverticulum near the appendiceal tip, and a primary appendiceal well-differentiated adenocarcinoma located proximal to it with clear margins. Up to 48% of ADs are associated with appendiceal neoplasms, but its coexistence with PAA is reported in fewer than ten instances worldwide. Obstructing appendiceal tumours, by raising intraluminal pressure, can predispose to AD formation. Intestinal-type PAA is often managed like its colorectal counterpart, although controversies about management of PAA in a perforated AD remain. Recognition of the association of AD and PAA is critical to ensure meticulous oncological resection and histological examination.

Clinical-epidemiological profile of acute appendicitis: retrospective analysis of 638 cases

OBJECTIVE

to describe the clinical and epidemiological profile of acute appendicitis (AA) of the patients treated at a referral center in the Juiz de Fora macro-region, Minas Gerais State, Brazil.

METHODS

we conducted a retrospective, observational study in the Dr. Mozart Geraldo TeixeiraEmergency Hospital. We selected 638 patients diagnosed with AA, and analyzed the variables gender, age, evolutionary phase, length of hospital stay, pathological diagnosis, use of antibiotics, use of drains, complications and mortality.

RESULTS

AA was more prevalent in young adults (19-44 years) and males (65.20%). The mean hospital stay was seven days and phase II was the most prevalent. We found the histopathological diagnosis of primary tumor of the appendix in six patients (0.94%), adenocarcinoma being the most common histologic type (66.7%). Regarding the use of antibiotics, 196 patients underwent antibiotic prophylaxis and 306 received antibiotic therapy. Eighty-one patients used some kind of drain, for an average of 4.8 days. Seventeen patients died (2.67%), predominantly males (70.59%), with mean age of 38.47 years.

CONCLUSION

AA has a higher prevalence in males and young adults. The length of stay is directly associated with the evolutionary phase. The most common complication is infection of the surgical site. Mortality in our service is still high when compared with developed centers.

OBJETIVO

avaliar a epidemiologia e os resultados do tratamento cirúrgico de doentes portadores de graus III e IV, mais avançados, da Síndrome de Mirizzi (SM) de acordo com a classificação de Csendes.

MÉTODOS

estudo retrospectivo, de corte transversal através da revisão de prontuários de 13 pacientes portadores de graus III e IV da SM operados de dezembro de 2001 a setembro de 2013, entre 3691 colecistectomias realizadas neste período.

RESULTADOS

a incidência da SM foi 0,6% (23 casos) e os graus III e IV perfizeram 0,35% deste número. Houve um predomínio de tipo IV (12 casos). O diagnóstico pré-operatório foi possível em 53,8% dos casos. A conduta preferencial foi derivação biliodigestiva (10 casos) e foi optado por drenagem com tubo "T" e sutura da via biliar em três ocasiões especiais. Três pacientes apresentaram fístula biliar resolvida com conduta expectante e um caso de coleperitônio necessitou reoperação. No seguimento ambulatorial dos pacientes que realizaram a anastomose biliodigestiva (oito), 50% estão assintomáticos, 25% apresentaram estenose da anastomose e 25% perderam seguimento. O tempo médio de acompanhamento foi 41,8 meses.

CONCLUSÃO

de incidência baixa e de diagnóstico pré-operatório em apenas metade dos casos, a SM em graus avançados tem na anastomose biliodigestiva sua melhor conduta, porém não isenta de morbimortalidade.

Neoplasms of the Appendix: Pictorial Review with Clinical and Pathologic Correlation

Appendiceal neoplasms are uncommon tumors of the gastrointestinal tract that may manifest with symptoms of appendicitis, right lower quadrant pain, or palpable mass, leading to imaging or surgical intervention. The majority of appendiceal masses consist of primary epithelial neoplasms and neuroendocrine tumors (NETs). Epithelial neoplasms-mucinous and nonmucinous types-are more often detected at imaging than NETs due to their larger size and propensity for peritoneal spread and metastatic disease. Epithelial mucinous neoplasms are defined by the presence of mucin, detected at radiologic and pathologic examination. A mucocele or pseudomyxoma peritonei from epithelial mucinous tumors are the two most common cross-sectional imaging findings of appendiceal mucinous neoplasms. Nonmucinous epithelial tumors are less common and manifest as masses similar to colonic-type malignancies. NETs are often discovered incidentally at appendectomy due to their small size and nonaggressive behavior. Imaging findings of primary appendiceal tumors may overlap with those of acute appendicitis. Additionally, an appendiceal mass may cause acute appendicitis, obscuring the underlying mass. Other neoplasms including lymphoma, sarcoma, mesenchymal and nerve sheath tumors, or secondary malignant involvement of the appendix are rare. Treatment depends on the histologic subtype and extent of disease. Detailed description of organ, nodal, and peritoneal involvement informs surgical management with the goal of complete cytoreduction. Novel treatments such as hyperthermic intraperitoneal chemotherapy have increased survival for patients with mucinous tumors. ^©RSNA, 2017.

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

Background

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

Case presentation

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

Conclusions

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

Clinical Significance of Metastatic Lymph Nodes in the Gut of Patients with Pure and Mixed Primary Appendiceal Carcinoids

BACKGROUND

Right hemicolectomy is indicated for primary appendiceal carcinoids with diameters greater than 2 cm because of an increased risk of metastasis to the lymph nodes of the gut. However, the natural history of positive nodes remains unknown.

OBJECTIVE

The aim of this study was to investigate the impact of metastatic lymph nodes on survival among patients with pure or mixed primary appendiceal carcinoids, while controlling for potential confounders such as age, sex, tumor size, surgical intervention, and lymph node rate (number of positive lymph nodes/lymph node yield).

DESIGN

This is a retrospective comparative study..

SETTINGS

Data were retrieved from the Surveillance, Epidemiology and End Results database.

PATIENTS

Patients undergoing colectomy for appendiceal carcinoids between 1998 and 2009 were selected.

MAIN OUTCOME MEASURES

The survival curves for the 2 groups were compared to evaluate differences in prognosis. Univariate and multivariate analyses were performed.

RESULTS

Lymph node rates did not significantly differ between the pure and mixed carcinoid groups (p = 0.768), although overall survival was poorer among patients with mixed carcinoids (p = 0.004; HR, 0.498; 95% CI, 0.310-0.800). For pure carcinoids, surgical intervention (p = 0.029; HR, 0.241; 95% CI, 0.067-0.867), age (p < 0.001; HR, 1.083; 95% CI, 1.051-1.116), and lymph node rate (p = 0.039; HR, 5.295; 95% CI, 1.089-25.754) were independent predictors of overall survival. For mixed carcinoids, surgical intervention (p = 0.019; HR, 1.675; 95% CI, 1.088-2.578), tumor size (p < 0.001; HR, 0.442; 95% CI, 0.286-0.683), age (p < 0.001; HR, 1.041; 95% CI, 1.026-1.056), and lymph node rate (p < 0.001; HR, 17.471; 95% CI, 10.047-0.382) were significant prognostic factors.

LIMITATIONS

The study is limited by its retrospective nature and by the shortcomings of the Surveillance, Epidemiology and End Results database related to the availability and quality of data.

CONCLUSION

Based on the data retrieved from the Surveillance, Epidemiology and End Results database and adjusted for potential confounding factors, the lymph node rate of metastasis strongly impacts overall survival among patients with pure or mixed carcinoids. Nodal metastasis thus appears to be a reliable clinical hallmark of tumor aggressiveness.

Association of type 2 diabetes mellitus and the risk of colorectal cancer: A meta-analysis and systematic review

AIM: To provide a quantitative assessment of the association between type 2 diabetes mellitus (T2DM) and the risk of colorectal cancer (CRC).

METHODS: Systematic review was conducted thorough MEDLINE, EMBASE, Cochrane Library, and ISI Web of knowledge databases till 31^st January 2014. This meta-analysis included the cohort studies that illustrated relative risk (RR) or odds ratio estimates with 95%CI for the predictive risk of CRC by T2DM. Summary relative risks with 95%CI were analyzed by using an effects summary ratio model. Heterogeneity among studies was assessed by the Cochran’s Q and I² statistics.

RESULTS: The meta analysis of 8 finally selected studies showed a positive correlation of T2DM with the risk of CRC as depicted by effects summary RR of 1.21 (95%CI: 1.02-1.42). Diabetic women showed greater risk of developing CRC as their effect summary RR of 1.22 (95%CI: 1.01-49) with significant overall Z test at 5% level of significance was higher than the effect summary RR of 1.17 (95%CI: 1.00-1.37) of men showing insignificant Z test. The effect summary RR of 1.19 with 95%CI of 1.07-1.33 indicate a positive relationship between DM and increased risk of CRC with significant heterogeneity (I² = 92% and P-value < 0.05).

CONCLUSION: Results from this systematic review and meta-analysis report that diabetic people have an increased risk of CRC as compared to non-diabetics.

Unusual histopathological findings in appendectomy specimens from patients with suspected acute appendicitis

AIM: To investigate the prevalence and implications of unusual histopathological findings in appendectomy specimens from patients with suspected acute appendicitis.

METHODS: The demographic and histopathological data of 1621 patients (≥ 16 years-old) who underwent appendectomy to treat an initial diagnosis of acute appendicitis between January 1999 and November 2011 were retrospectively assessed. Microscopic findings were used to classify the patients under six categories: appendix vermiformis, phlegmonous appendicitis, gangrenous appendicitis, perforated appendicitis, supurative appendicitis, and unusual histopathologic findings. The demographic and clinicopathologic characteristics of patients with unusual histopathologic findings were evaluated in detail, and re-analysis of archived resected appendix specimens was carried out.

RESULTS: A total of 912 males and 709 females, from 16 to 94 years old, were included in the study and comprised 789 cases of suppurative appendicitis, 370 cases of appendix vermiformis, 243 cases of perforated gangrenous appendicitis, 53 cases of flegmaneous appendicitis, 32 cases of gangrenous appendicitis, and 134 (8.3%) cases of unusual histopathological findings. The unusual histopathological findings included fibrous obliteration (n = 62), enterobius vermicularis (n = 31), eosinophilic infiltration (n = 10), mucinous cystadenoma (n = 8), carcinoid tumor (n = 6), granulomatous inflammation (n = 5), adenocarcinoma (n = 4; one of them mucinous), and mucocele (n = 3), adenomatous polyp (n = 1), taenia sup (n = 1), ascaris lumbricoides (n = 1), appendiceal diverticula (n = 1), and B cell non-hodgkin lymphoma (n = 1). None of the 11 patients with subsequent diagnosis of tumor were suspected of cancer prior to the appendectomy.

CONCLUSION: Even when the macroscopic appearance of appendectomy specimens is normal, histopathological assessment will allow early diagnosis of many unusual diseases.