APENDİKS TÜMÖRLERİNİN CERRAHİ TEDAVİSİ: 15 YILLIK TEK MERKEZLİ BİR İNCELEME

Yıl 2022, Cilt: 85 Sayı: 3, 312 - 320, 06.07.2022

Safa Toprak , Recep Erçin Sönmez , Melek Büyük , Mehmet İlhan , Ali Fuat Kaan Gök , Mine Güllüoğlu Cemalettin Ertekin , Mustafa Kayıhan Günay

https://doi.org/10.26650/IUITFD.1094714

Öz

Amaç: Apendiksin primer neoplazmları, çoğu klinisyenin aşina olmadığı nadir bir durumdur. Seçilen yaklaşım apendektomiden sitoredüktif cerrahiye farklılık gösterebilir. Apendiks tümörlerinin cerrahi tedavisi ile ilgili klinik deneyimimizi sunmayı amaçladık.
Gereç ve Yöntem: Ocak 2006 ile Şubat 2021 arasında; apendektomi öyküsü olan 4450 hasta geriye dönük olarak incelendi. ‘Tırtıklı lezyon/polip, düşük/yüksek dereceli apendiks müsinöz neoplazm (LAMN/HAMN), müsinöz/müsinöz olmayan/goblet hücreli adenokarsinom, nöroendokrin tümör (NET)’ tanısı alan hastalar çalışmaya dahil edildi. Histolojik değerlendirmeler, cerrahi prosedürler, takip verileri ve sağkalım sonuçları değerlendirildi.
Bulgular: Apendiks tümörü tanısı konan 132 [K:87 (%65.9)] hastadan; 27’si (%20,5) benign (Grup A), 61’i (%46,2) borderline (Grup B) ve 44’ü (%33,3) malign (Grup C) grupta idi. Primer operasyon olarak sırasıyla 105 (%79,5) ve 27 (%20,5) hastaya apendektomi ve sağ hemikolektomi uygulandı. Daha önce apendektomi öyküsü olan 17 hastaya (%12.9) sağ hemikolektomi (n=9; cerrahi sınır pozitifliği nedeniyle) ve Hipertermik İntraperitoneal Kemoterapi (HIPEC) ile Sitoredüktif Cerrahi (CRS) (n=8; nüks nedeniyle) sekonder cerrahi olarak uygulandı. Takip süresi boyunca 88 (%66,6) hastaya sadece apendektomi uygulandı. Adenokarsinom, nükssüz sağkalım (RFS) için istatistiksel olarak anlamlı bir faktör olarak ortaya çıktı (HR=7.28, p=0.049). Malignite (HR=3.76, p=0.036) ve yaş (≥60) (HR=3.86, p=0.006) genel sağkalımın (OS) önemli faktörleriydi.
Sonuç: Apendektomi, işlemin düşük morbiditesi ve olumlu sağkalım sonuçları göz önüne alındığında, seçilmiş vakalarda apendiks tümörlerinin tedavisinde etkilidir. İleri evre tümörler için kemoterapi ile birlikte genişletilmiş rezeksiyonlar tercih edilen yaklaşım olmalıdır.

Anahtar Kelimeler

Apendiks tümörleri, Hipertermik intraperitoneal kemoterapi (HIPEC), nöroendokrin tümör, düşük dereceli apendiküler müsinöz neoplazi, tırtıklı lezyon, apendektomi

SURGICAL MANAGEMENT OF APPENDIX TUMORS: A SINGLE-CENTER REVIEW OF 15 YEARS

Öz

Objective: Primary neoplasms of the appendix are rare and most clinicians are unfamiliar with them. The selected approach may differ, ranging from appendectomy to cytoreductive surgery. We aimed to present our clinical experience with the surgical management of appendix tumors.
Materials and Methods: 4,450 patients with a history of appendectomy from January 2006 to February 2021 were analyzed retrospectively. Patients diagnosed with “serrated lesion/polyp, low/high-grade appendiceal mucinous neoplasm (LAMN/ HAMN), mucinous/non-mucinous/goblet cell adenocarcinoma, neuroendocrine tumor (NET)” were included in the study. Histological evaluations, surgical procedures, follow-up data, and survival outcomes were evaluated.
Results: Among 132 [F:87 (65.9%)] patients diagnosed with appendix tumors, 27 (20.5%) were in the benign group (Group A), 61 (46.2%) were in the borderline group (Group B), and 44 (33.3%) were in the malignant group (Group C). Appendectomy and right hemicolectomy were performed as the initial operations in 105 (79.5%) and 27 (20.5%) patients, respectively. Seventeen patients (12.9%) with a previous history of appendectomy received right hemicolectomy (n=9; due to surgical margin positivity) and Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) (n=8; due to recurrence) as redo surgery during the follow-up period. Appendectomy was sufficient for 88 (66.6%) patients. Adenocarcinoma was revealed as a statistically significant factor for recurrence-free survival (RFS) (HR=7.28, p=0.049). Malignancy (HR=3.76, p=0.036) and age (≥60) (HR=3.86, p=0.006) were significant factors of overall survival (OS). Conclusion: Appendectomy is efficient in the treatment of appendix tumors for selected cases considering low morbidity of the procedure and favorable survival outcomes. For advanced-stage tumors, extended resections combined with chemotherapy should be the preferred approach.

Anahtar Kelimeler

Appendix tumors, Hyperthermic intraperitoneal chemotherapy (HIPEC), neuroendocrine tumor, low-grade appendicular mucinous neoplasia, serrated lesion, appendectomy

Kaynakça

• 1. Marmor S, Portschy PR, Tuttle TM, Virnig BA. The rise in appendiceal cancer incidence: 2000-2009. J Gastrointest Surg 2015;19(4):743-50. [CrossRef] google scholar
• 2. Nagtegaal ID, Odze RD, Klimstra D, Paradis V, Rugge M, Schirmacher P, et al. The 2019 WHO classification of tumours of the digestive system. Histopathology 2020;76(2):182-8. [CrossRef] google scholar
• 3. Greene FL, Page DL, Fleming ID, Fritz AG, Balch CM, Haller DG, et al. Colon, and Rectum. In: AJCC Cancer Staging Manual 6th ed. Chicago: Springer 2002:113-24. [CrossRef] google scholar
• 4. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. Appendix. In: AJCC Cancer Staging Manual 7th ed. Chicago: Springer 2010:133-42. [CrossRef] google scholar
• 5. Glasgow SC, Gaertner W, Stewart D, Davids J, Alavi K, Paquette IM, et al. The American Society of Colon and Rectal Surgeons, Clinical Practice Guidelines for the Management of Appendiceal Neoplasms. Dis Colon Rectum 2019;62(12):1425-38. [CrossRef] google scholar
• 6. Pape UF, Perren A, Niederle B, Gross D, Gress T, Costa F, et al. ENETS Consensus Guidelines for the management of patients with neuroendocrine neoplasms from the jejuno-ileum and the appendix including goblet cell carcinomas. Neuroendocrinology 2012;95(2):135-56. [CrossRef] google scholar
• 7. Turner KM, Hanna NN, Zhu Y, Jain A, Kesmodel SB, Switzer RA, et al. Assessment of neoadjuvant chemotherapy on operative parameters and outcome in patients with peritoneal dissemination from high-grade appendiceal cancer. Ann Surg Oncol 2013;20(4):1068-73. [CrossRef] google scholar
• 8. Turaga KK, Pappas SG, Gamblin T. Importance of histologic subtype in the staging of appendiceal tumors. Ann Surg Oncol 2012;19(5):1379-85. [CrossRef] google scholar
• 9. Tajima T, Tajiri T, Mukai M, Sugiyama T, Hasegawa S, Yamamoto S, et al. Single-center analysis of appendiceal neoplasms. Oncol Lett 2018;15(5):6393-9. [CrossRef] google scholar
• 10. Hatch QM. Appendiceal Neoplasms. Dis Colon Rectum 2017;60(12):1235-8. [CrossRef] google scholar
• 11. Carr NJ, Cecil TD, Mohamed F, Sobin LH, Sugarbaker PH, Gonzâlez-Moreno S, et al. A Consensus for Classification and Pathologic Reporting of Pseudomyxoma Peritonei and Associated Appendiceal Neoplasia: The Results of the Peritoneal Surface Oncology Group International (PSOGI) Modified Delphi Process. Am J Surg Pathol 2016;40(1):14-26. [CrossRef] google scholar
• 12. Bariol C, Hawkins NJ, Turner JJ, Meagher AP, Williams DB, Ward RL. Histopathological and clinical evaluation of serrated adenomas of the colon and rectum. Mod Pathol 2003;16(5):417-23. [CrossRef] google scholar
• 13. Misdraji J. Mucinous epithelial neoplasms of the appendix and pseudomyxoma peritonei. Mod Pathol 2015;28(Suppl 1):S67-79. [CrossRef] google scholar
• 14. Chicago Consensus Working Group. The Chicago Consensus on Peritoneal Surface Malignancies: Management of Appendiceal Neoplasms. Ann Surg Oncol 2020;27(6):1753-60. [CrossRef] google scholar
• 15. Arnason T, Kamionek M, Yang M, Yantiss RK, Misdraji J. Significance of proximal margin involvement in low-grade appendiceal mucinous neoplasms. Arch Pathol Lab Med 2015;139(4):518-21. [CrossRef] google scholar
• 16. Cortina R, McCormick J, Kolm P, Perry RR. Management and prognosis of adenocarcinoma of the appendix. Dis Colon Rectum 1995;38(8):848-52. [CrossRef] google scholar
• 17. Gonzâlez-Moreno S, Sugarbaker PH. Right hemicolectomy does not confer a survival advantage in patients with mucinous carcinoma of the appendix and peritoneal seeding. Br J Surg 2004;91(3):304-11. [CrossRef] google scholar
• 18. Landry CS, Woodall C, Scoggins CR, McMasters KM, Martin RC 2nd. Analysis of 900 appendiceal carcinoid tumors for a proposed predictive staging system. Arch Surg 2008;143(7):664-70. [CrossRef] google scholar
• 19. Pape UF, Niederle B, Costa F, Gross D, Kelestimur F, Kianmanesh R, et al. ENETS Consensus Guidelines for Neuroendocrine Neoplasms of the Appendix (Excluding Goblet Cell Carcinomas). Neuroendocrinology 2016;103(2):144-52. [CrossRef] google scholar
• 20. Dube P, Sideris L, Law C, Mack L, Haase E, Giacomantonio C, et al. Guidelines on the use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy arising from colorectal or appendiceal neoplasms. Curr Oncol 2015;22(2): e100-12. [CrossRef] google scholar