Does a Positive Appendiceal Resection Margin in Low-Grade Appendiceal Mucinous Neoplasms, Warrant Additional Surgery? Our Institution Experience and Literature Review

Ibrahim, E.M.; Akrmah, Muhammad; Ligato, Saverio

doi:10.1245/s10434-023-13930-5

Cited by 5 publications

(6 citation statements)

References 20 publications

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“…Our AS approach for these patients is in accordance with a study by Ibrahim et al. [ 29 ], which supported conservative management in patients diagnosed with LAMN and presenting involvement of the appendectomy margin, but indicates some disregard for the Grade C recommendation of performing a cecectomy following incomplete LAMN resection [ 24 ].…”

Section: Discussionsupporting

confidence: 81%

Active surveillance for low-grade appendiceal mucinous neoplasm (LAMN)

Mouawad,

Bardier,

Wagner

et al. 2023

Pleura and Peritoneum

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Objectives Due to the scarcity of low-grade appendiceal mucinous neoplasm (LAMN), there is an absence of systematized guidelines concerning its management, especially after incidental finding on an appendiceal specimen. In this study, we evaluate the active surveillance (AS) strategy adopted for a series of patients diagnosed with LAMN on resection specimens who were considered to have a low risk of pseudomyxoma progression. Methods Thirty patients were included between April 2014 and July 2021, with a female majority and a median follow-up period of 3.1 years. The inclusion criteria were as follows: LAMN diagnosis on appendiceal specimens, confirmed in an expert center, limited extra-appendiceal mucin resected and localized around the appendix, normal biology (CEA, CA199, CA125) and normal abdominopelvic MRI. AS included physical exam (trocar scar), biology and MRI, 6 months postoperatively, then yearly for 10 years. Results As an initial surgery, 77 % had an appendectomy as their initial intervention, 17 % had a cecectomy, and 6 % had a right colectomy. After follow-up, 87 % of patients showed no sign of disease progression by MRI, while 13 % progressed to PMP. MRI performed in the first postoperative year predicted the disease prognosis in 97 % of patients. Conclusions The AS strategy, based on MRI, is a valid option after incidental LAMN diagnosis.

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Section: Discussionsupporting

confidence: 81%

Active surveillance for low-grade appendiceal mucinous neoplasm (LAMN)

Mouawad,

Bardier,

Wagner

et al. 2023

Pleura and Peritoneum

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“…If no gross peritoneal spread of disease or macroscopic extra-appendiceal mucin is noted on surgical exploration, appendectomy alone should be performed to a negative margin. [133][134][135] % Agreement: First round 97%, second round 98%…”

Section: Blockmentioning

confidence: 99%

“…In many cases surveillance will not be necessary; however, the risk of recurrence is never zero, as it is possible for an AMN to perforate and then re-seal, leading to a theoretical increased risk of peritoneal progression or recurrence. [134][135][136] % Agreement: First round 93%, second round 96%…”

Section: Blockmentioning

confidence: 99%

“…If final surgical margins are positive, with viable neoplastic epithelial cells at the margin (not acellular mucin alone) or there is concern for the same, repeat resection should be performed to a negative margin, although data suggests in some series that even gross resection may be adequate. [134][135][136] Historically, ileocecectomy or cecectomy have been performed, but the consensus recommendation is to perform the most conservative resection possible, such as cuff resection. Anastomosis should be avoided if possible.…”

Section: Blockmentioning

confidence: 99%

“…If final surgical margins are negative but microscopic perforation is noted, or there is microscopic extra-appendiceal mucin or neoplastic cells confined to the surface of the appendix, surveillance is indicated as described in block 11. [134][135][136] Microscopic extra-appendiceal mucin and neoplastic cells confined to the surface of the appendiceal specimen alone still constitute a negative margin. % Agreement: First round 94%, second round 98%…”

Section: Blockmentioning

confidence: 99%

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Consensus guideline for the management of patients with appendiceal tumors Part 1: Appendiceal tumors without peritoneal involvement

Turaga

2024

Preprint

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Background: Appendiceal tumors comprise a heterogeneous group of tumors which may be localized or disseminate throughout the peritoneum. Limited high quality clinical data exists and many practices have been extrapolated from colorectal cancer without validation in appendiceal cohorts. Many controversies exist regarding their treatment, and practices vary widely between centers and care settings. A national consensus update of best management practices for appendiceal malignancies was performed to better standardize care. Methods The 2018 Chicago consensus guideline was updated via modified Delphi consensus, performed over two rounds using nationally circulated surveys. Supporting evidence was evaluated using rapid systematic reviews. Key systemic therapy concepts were summarized by content experts. Results Most supporting literature consists of observational studies, but increasingly high-quality studies are becoming available to drive management. Two consensus-based pathways were generated for localized appendiceal tumors, one for epithelial mucinous neoplasms and another for appendiceal adenocarcinoma. Of 138 participants responding in the first round, 133 (96%) engaged in the second round. Over 90% consensus was achieved for all pathway blocks. Key points include minimizing intervention invasiveness where permitted by pathologic classification and margin status, and determining what margin and pathologic findings are indications for consideration of cytoreduction with or without intraperitoneal chemotherapy. Surveillance and systemic therapy recommendations are also presented. Conclusion With growing but still primarily observational evidence currently dictating care, these consensus recommendations provide expert guidance in the treatment of appendiceal tumors without peritoneal involvement.

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