When facing an appendiceal neoplasm, different controversies arise about their classification, treatment and prognosis.
These kinds of tumors are a very heterogeneous group of neoplasia, characterized by an extremely variable clinical behavior and prognosis, ranging from absolutely benign to highly aggressive with poor prognosis [Citation1]. In most instances they are incidentally discovered at routine appendectomy and recent data report their increasing incidence [Citation1, Citation2]. The main reason for the reported variable behavior is related to the histopathology of the appendiceal neoplasm; in fact, it is in this area where researchers are making the more extensive efforts [Citation1, Citation3, Citation4]. But then, established the diagnosis and having classified properly the histopathology of the appendiceal neoplasm, the question arises about the appropriateness of the appendectomy alone or, instead, the need of a more extensive surgical procedure. The question is still open although the literature is trying to give progressively answers to this problem. The article of Dan and coworkers [Citation5] expands previous research [Citation6, Citation7] and represents a valid contribution in this respect, trying to answer to the questions if and how to perform a more extended surgical procedure. Patient’s age, tumor histology, grading, size, T and M status are obviously prognostic factors, but when combined in a nomogram give a straight and useful indication concerning treatment.
So far, a cornerstone in the choice of surgical strategy has been the size of the neoplasm with the well-known cutoff size of two cm in diameter of the lesion. Recently this concept has been put into question [Citation1, Citation2].
Histopathology instead is becoming a guide-light for the choice of an extended surgical procedure beyond simple appendectomy. Detailed histopathologic and biologic classifications of appendiceal neoplasms are now available and this give a great contribution to the choice of appropriate surgical treatment [Citation1, Citation2]. Right colectomy, ovariectomy, extensive peritonectomy, intraperitoneal hyper-thermic chemotherapy, all have a defined space in the surgical treatment of appendiceal malignancy [Citation1–4].
Besides this, histological classification of the neoplasm gives us important prognostic indications and may suggest the use of systemic adjuvant treatments and/or an aggressive approach in follow-up.
Dan and coworkers recognized the limitation of their investigation due to the retrospective nature of data analyzed [Citation5], but for such an infrequent disease, the SEER database represents a valuable source of useful information. In fact, in spite of such limitations, previous paper in the literature analyzed successfully the SEER for appendiceal neoplasms [Citation6–9], obtaining interesting results and contributing to the discussion around the many open questions encountered on this topic.
Another weak point might be represented by the classification of appendiceal malignancies reported in the SEER, forcedly simplified and obsolete. The authors retrieved appendiceal neoplasia from the SEER classified as cystic, mucinous and serous, adenocarcinoma and adenoma, other. The modern histological classification is far more complex and even subjected to debate and in constant evolution [Citation1, Citation3, Citation4]. Just think to the newly discovered “adenocarcinoma ex goblet cells carcinoid”, a particular distinct entity from the classic mixed carcinoid, highly aggressive with bad prognosis [Citation4]. However, the idea of developing a nomogram to support in a friendly and simple manner the choice of further treatments in case of incidental neoplasm of the appendix is potentially useful and exciting. This instrument warrants further investigations and developments.
Disclosure statement
No potential conflict of interest was reported by the author(s).
References
- Galanopoulos M, Toumpanakis C. The problem of appendiceal carcinoids. Endocrinol Metab Clin N Am. 2018;47(3):661–669. doi:10.1016/j.ecl.2018.04.004.
- Marmor S, Portschy PR, Tuttle TM, Virnig BA. The rise in appendiceal cancer incidence: 2000-2009. J Gastrointest Surg. 2015;19(4):743–750. doi:10.1007/s11605-014-2726-7.
- Glasgow SC, Gaertner W, Stewart D. The American Society of Colon and Rectal Surgeons, Clinical Practice Guideline for the management of Appendiceal Neoplasms. Dis Colon Rectum. 2019;62:1425–1438.
- Reid MD, Basturk O, Shaib WL, et al. Adenocarcinoma ex-goblet cell carcinoid (appendiceal-type crypt cell adenocarcinoma) is a morphologically distinct entity with highly aggressive behaviour and frequent association with peritoneal/intra-abdominal dissemination: an analysis of 77 cases. Mod Pathol. 2016;29(10):1243–1253. doi:10.1038/modpathol.2016.105.
- Wang D, Liu C, Yan T, et al. A nomogram for predicting lymph nodal metastasis in patients with appendiceal cancer: an analysis of SEER database. J Invest Surg. 2021;34(8):924–930. doi:10.1080/08941939.2019.1711467.
- Yan Q, Zheng WJ, Chen QL, et al. Nomogram to predict overall survival and disease-specific survival with appendiceal mucinous adenocarcinoma. Medicine (Baltimore). 2019;98(40):1–11.
- Mosquera C, Fitzgerald TL, Vora H, Grzybowski M. Novel nomogram combining depth of invasion and size can accurately predict the risk for regional nodal metastases for appendiceal neuroendocrine tumors (A-NET). J Surg Oncol. 2017;116(6):651–657. doi:10.1002/jso.24714.
- Ciarrocchi A, Pietroletti R, Carlei F, Necozione S, Amicucci G. Propensity adjusted appraisal of the surgical strategy for appendiceal carcinoids. Tech Coloproctol. 2015;19(1):35–41. Jandoi:10.1007/s10151-014-1249-2.
- Ciarrocchi A, Pietroletti R, Carlei F, Amicucci G. Clinical Significance of Metastatic Lymph Nodes in the Gut of Patients with Pure and Mixed Primary Appendiceal Carcinoids. Dis Colon Rectum. 2016;59(6):508–512.