Lymph Node Positivity in Appendiceal Adenocarcinoma: Should Size Matter? - 06/10/17

Doi : 10.1016/j.jamcollsurg.2017.01.056

John V. Gahagan, MD ^a,^⁎ , Matthew D. Whealon, MD ^a, Michael J. Phelan, PhD ^b, Steven Mills, MD, FACS ^a, Alessio Pigazzi, MD, PhD, FACS ^a, Michael J. Stamos, MD, FACS ^a, Ninh T. Nguyen, MD, FACS ^a, Joseph C. Carmichael, MD, FACS ^a
^a Department of Surgery, University of California Irvine, Irvine, CA
^b Department of Statistics, University of California Irvine, Irvine, CA

^∗Correspondence address: John V Gahagan, MD, Department of Surgery, University of California, Irvine, 333 City Blvd W, Suite 1600, Orange, CA 92868.Department of SurgeryUniversity of California, Irvine333 City Blvd WSuite 1600OrangeCA92868

Abstract

Background

The management algorithm for appendiceal adenocarcinoma is not well defined. This study sought to determine whether tumor size or depth of invasion better correlates with the presence of lymph node metastases in appendiceal adenocarcinoma, and to compare these rates with colon adenocarcinoma.

Study Design

A retrospective review of the National Cancer Database was performed to identify patients with appendiceal or colonic adenocarcinoma from 2004 to 2013 who underwent surgical resection. Cases were categorized by tumor size and by T stage. Rates of lymph node metastases were examined as a function of size and T stage.

Results

A total of 3,402 appendiceal and 314,864 colonic cases were identified. For appendiceal adenocarcinoma, larger tumor size was associated with higher T stage: Pearson correlation of 0.41 (95% CI 0.408 to 0.414; p < 0.001). Lymph node metastases were present in 19.1%, 27.8%, 39.6%, 39.4%, 42.4% and 39.1% for tumor sizes <1 cm, >1 to 2 cm, >2 to 3 cm, >3 to 4 cm, >4 to 5 cm, and >5 cm, respectively. Lymph node metastases were present in 0%, 11.2%, 12.3%, 35.5%, and 40.0% for in situ, T1, T2, T3, and T4 tumors, respectively. There was no difference in the rates of lymph node metastases between appendiceal and colonic adenocarcinoma for tumor sizes <3 cm, or for in situ and T1 tumors. Rates of lymph node metastases are higher in colonic adenocarcinoma for tumor sizes >3 cm and for T2, T3, and T4 tumors (p < 0.01).

Conclusions

In appendiceal adenocarcinoma, the rate of lymph node metastases is substantial, even for small tumors. Tumor size should play no role in the decision of whether to perform a hemicolectomy. Appendectomy alone does not produce an adequate lymph node sample. Right hemicolectomy should be performed for all appendiceal adenocarcinomas.

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Plan

Methods

Database

Participant selection

Demographics and outcomes variables

Disclosure Information: Nothing to disclose.

Disclosures outside the scope of this work: Dr Mills has been paid as an instructor by Ethicon and Medtronic. Dr Pigazzi is paid as a consultant by MedRobotics, Cook, and Intuitive; for lectures by Novadaq; and as an instructor by Ethicon, Medtronic, Cook, and Intuitive. Dr Stamos is paid as a consultant by Ethicon, Olympus, Edwards Life Sciences, Novadaq, and CR Bard; for lectures by Novadaq, Ethicon, and Covidien; and for developing educational presentations by Ethicon; he holds stock in Novadaq, and he received royalties from Elsevier and grants from Novadaq and Ethicon. Dr Carmichael is paid as a consultant by MedRobotics; as a lecturer for Novadaq; and for developing educational presentations by Ethicon and Medtronic.