Risk of appendiceal cancer in patients undergoing appendectomy for appendicitis in the era of increasing nonoperative management

Abstract

Background and Objectives Management practices for acute appendicitis are changing. In cases of nonoperative treatment, the risk of missed or delayed diagnosis of malignancy should be considered. We aimed to identify predictors associated with appendiceal cancer diagnosis after appendectomy for acute appendicitis. Materials and Methods This retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) appendectomy‐targeted data set from 2016 to 2017. A total of 21 069 patients with imaging‐confirmed or imaging indeterminate appendicitis who underwent appendectomy were included. Logistic regression was used to identify predictors of cancer diagnosis. Results Increasing age had an increasing monotonic relationship with the odds of pathologic cancer diagnosis after appendectomy (age 50‐59 odds ratio [OR], 2.08, 95% confidence interval [CI], 1.28‐3.39, P = .003; age 60‐69 OR, 2.89, 95% CI, 1.72‐4.83, P < .001; age 70‐79 OR, 3.85, 95% CI, 2.08‐7.12, P < .001; age >80 OR, 5.32, 95% CI, 2.38‐11.9, P < .001). Other significant predictors included obesity, morbid obesity, normal preoperative white blood cell count, and imaging indeterminate for appendicitis. Conclusions When counseling patients regarding operative vs nonoperative treatment options for management of acute appendicitis, the rising risk of a delayed or missed cancer diagnosis with increasing age must be discussed.

Appendiceal Adenocarcinoma Found by Surgery for Acute Appendicitis is Associated with Older Age – A Retrospective Cohort Study

“…These data concur with a similar NSQIP analysis performed by Lu, et al between 2016 and 2017. These results were in agreement with those established in prior reports that support a signi cant association between increased risk of malignancy and increasing age in patients who have undergone surgical appendectomy for presumed appendicitis (10). The rate of appendectomy at Jacobi Medical Center and North Central Bronx Hospital for acute appendicitis was 94%, which also matched the United States NSQIP rate of 95%.…”

“…To date, the only gold standard con rmatory test for appendiceal cancer is appendectomy that is usually performed for the presentation of acute appendicitis (21)(22)(23). In a recent prospective study of acute complex appendicitis, patients with complicated appendicitis who underwent either surveillance or interval appendectomy were found to have an exceedingly high rate of malignancy that even resulted in premature discontinuation of a prospective study (10,(24)(25)(26). Our ndings corroborate recent ndings in prospectively collected data, analyzed post-hoc, from the MUSTANG trial (27).…”

Continued increasing incidence of malignant appendiceal tumors in Canada and the United States: A population‐based study

“…Furthermore, although the majority of studies regarding nonoperative management for appendicitis have focused on short‐term or intermediate‐term complications and disease recurrence as their outcomes, the findings of the current study have suggested that the risk of malignancy should be considered as an outcome as well because nonoperative approaches may significantly delay diagnosis and treatment. Lu et al recently reported that predictors associated with the diagnosis of malignant appendiceal tumors after appendectomy for acute appendicitis included increasing age, obesity, a normal preoperative white blood cell count, and imaging that is indeterminate for appendicitis . Data such as these can help to stratify risk of malignancy and better inform decision making to include all important outcomes when selecting between treatment alternatives.…”

National trends in the presentation of surgically resected appendiceal adenocarcinoma over a decade

“…The reported incidence of appendiceal adenocarcinoma has increased over the past two decades 3 . Prior literature has demonstrated that older patients (>50 and >60 years of age, depending upon study) with atypical and/or complicated appendicitis are more likely to harbor appendiceal adenocarcinoma 3,8‐12 . Over the same time frame, increased adoption of nonoperative management for both uncomplicated and complicated appendicitis has occurred with a relative decrease in early operative management by approximately 0.1%/year from 1998 to 2014 19 .…”

“…While the current reported incidence of appendiceal adenocarcinoma in all appendectomy pathology specimens is low, ranging 0.08%–2%, the incidence of appendiceal adenocarcinoma has increased over the previous decade by 54% across all histologic subtypes, stages, and ages 3‐9 . Prior studies have shown that, among those presenting with appendicitis, appendiceal adenocarcinoma is more common among older patients, specifically those greater than 50 years of age, patients with greater comorbidities based on American Society of Anesthesiologists (ASA) classification, patients who have absence of traditional symptomatology (i.e., migratory right lower quadrant abdominal pain), and patients who present with phlegmonous findings on imaging; the sensitivity and specificity of these prognostic factors though has not been consistently reported 7‐12 …”