Appendix cancer natural history, complications and prognosis: Difference between revisions
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*Common complications of [[Vermiform appendix|appendix]] [[cancer]] include: | *Common complications of [[Vermiform appendix|appendix]] [[cancer]] include: | ||
**[[Appendicitis|Acute appendicitis]] | **[[Appendicitis|Acute appendicitis]] | ||
*** Most of appendix [[adenocarcinoma]]<nowiki/>s present with [[Appendicitis|acute appendicitis]] | *** Most of appendix [[adenocarcinoma]]<nowiki/>s present with [[Appendicitis|acute appendicitis]]. | ||
*** | ***However, majority of <nowiki/>[[Carcinoid Tumor|carcinoid]]<nowiki/>s are located in the distal one third of the [[Vermiform appendix|appendix]], hence rarely present with [[appendicitis]]. | ||
***Merely 10 percent of appendiceal [[Carcinoid Tumor|carcinoid]]<nowiki/>s are located at the base of [[Vermiform appendix|appendix]] and may tend to obstruction and [[appendicitis]]. | ***Merely 10 percent of appendiceal [[Carcinoid Tumor|carcinoid]]<nowiki/>s are located at the base of [[Vermiform appendix|appendix]] and may tend to obstruction and [[appendicitis]]. | ||
**[[Pseudomyxoma peritonei]] | **[[Pseudomyxoma peritonei]] | ||
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* | * | ||
* | * | ||
*Major [[Prognosis|prognostic]] factors are [[Cancer staging|tumor stage]], [[tumor]] size, [[Histology|histologic]] as well [[Genetics|genetic]] characteristics of appendiceal [[tumor]]<nowiki/>s. [[TNM|TNM classification]] of [[tumor]]<nowiki/>s of the [[Vermiform appendix|appendix]] | *Major [[Prognosis|prognostic]] factors are [[Cancer staging|tumor stage]], [[tumor]] size, [[Histology|histologic]] as well [[Genetics|genetic]] characteristics of appendiceal [[tumor]]<nowiki/>s. For [[TNM|TNM classification]] of [[tumor|t]]<nowiki/>[[tumor|umor]]<nowiki/>s of the [[Vermiform appendix|appendix]], [[Appendix cancer diagnostic study of choice|click here]].<ref name="WHO">Chapter 5: Tumours of the Appendix - IARC. https://www.iarc.fr/en/publications/pdfs-online/pat-gen/bb2/bb2-chap5.pdf Accessed on January 15, 2019</ref> | ||
*[[Prognosis]] is generally excellent and good in [[Carcinoid Tumor|carcinoid tumors]] and [[adenocarcinoma]]<nowiki/>s respectively. | *[[Prognosis]] is generally excellent and good in [[Carcinoid Tumor|carcinoid tumors]] and [[adenocarcinoma]]<nowiki/>s respectively. | ||
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*The prognosis varies with the [[histology]] of tumor. | *The prognosis varies with the [[histology]] of tumor. | ||
*[[Carcinoid Tumor|Carcinoid tumors]] are associated with a better [[prognosis]] among patients with appendiceal cancer. | *[[Carcinoid Tumor|Carcinoid tumors]] are associated with a better [[prognosis]] among patients with appendiceal cancer. | ||
*Localized | *Localized [[Carcinoid Tumor|carcinoid tumors]] are associated with the most favorable [[prognosis]]. | ||
*The presence of tubular pathology is also associated with a particularly good prognosis among patients with appendix adenocarcinoma. | *The presence of tubular pathology is also associated with a particularly good prognosis among patients with appendix adenocarcinoma. | ||
*Goblet cell carcinoids are generally more aggressive than other [[Carcinoid Tumor|carcinoid tumors]]. | *Goblet cell carcinoids are generally more aggressive than other [[Carcinoid Tumor|carcinoid tumors]]. | ||
*According to surveillance, [[epidemiology]] and end results (SEER) database of the [[National Cancer Institute|national cancer institute]] five-year appendiceal [[Carcinoid Tumor|carcinoid]] [[survival rate]]<nowiki/>s were as follows: | *According to surveillance, [[epidemiology]] and end results (SEER) database of the [[National Cancer Institute|national cancer institute]] five-year appendiceal [[Carcinoid Tumor|carcinoid]] [[survival rate]]<nowiki/>s were as follows: | ||
:* '''Tumor size <3 cm''' without regional nodal or distant [[Metastasis|metastas]]<nowiki/>es: | :* '''Tumor size <3 cm''' without regional nodal or distant [[Metastasis|metastas]]<nowiki/>es: 100 percent | ||
:* '''Tumor size between 2 and 3 cm''' plus regional node [[Metastasis|metastases]] / tumor size ≥3 cm with or without regional nodal or distant [[Metastasis|metastases]] : 78 percent | :* '''Tumor size between 2 and 3 cm''' plus regional node [[Metastasis|metastases]] / tumor size ≥3 cm with or without regional nodal or distant [[Metastasis|metastases]]: 78 percent | ||
:* '''Distant metastasis:''' 32 percent | :* '''Distant metastasis:''' 32 percent | ||
{| style="border: 5px; font-size: 90%; margin: 5px; width: 300px" align="center" | {| class="wikitable" style="border: 5px; font-size: 90%; margin: 5px; width: 300px" align="center" | ||
! | ! style="padding: 5px 5px; background: #D5D5D5; font-weight: bold; text-align:center;" |<sub>'''<big>Five year survival rates</big>'''</sub> | ||
|+ | |+ | ||
|- | |- | ||
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** Advanced [[Cancer staging|stage]] | ** Advanced [[Cancer staging|stage]] | ||
**High grade | **High grade | ||
** | ** Non-mucinous [[histology]] | ||
** Spread of the [[tumor]] beyond the left lower quadrant | ** Spread of the [[tumor]] beyond the left lower quadrant | ||
** Presence of [[malignant]] cells outside of the visceral [[peritoneum]] of the appendix | ** Presence of [[malignant]] cells outside of the visceral [[peritoneum]] of the appendix | ||
Revision as of 15:27, 22 February 2019
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]
Overview
Because of the location and size of appendix, most of the patients with appendix cancer may be initially asymptomatic. Early clinical features might include periodical unspecific abdominal pain, bloating, and nausea. Most of appendix cancer cases are discovered after surgical or histological evaluation of a patient with acute appendicitis, or are an accidental finding in imaging studies for the other reasons. Around one percent of all appendectomy specimens are malignant. Appendix cancer account for 0.5 percent of all intestinal neoplasms. If left untreated, the majority of patients with appendix cancer may progress to develop peritoneal carcinomatosis and metastasis. Prognosis is generally excellent and good in carcinoid tumors and adenocarcinoma respectively. Prognostic factors including tumor stage, tumor size, histologic as well genetic characteristics of appendiceal tumors were discussed in details.
Natural History, Complications, and Prognosis
Natural History
- The majority of patients with appendix cancer may be initially asymptomatic.
- Early clinical features might include periodical unspecific abdominal pain, bloating, and nausea.
- Most of appendix cancer cases are discovered after surgical or histological evaluation of a patient with acute appendicitis, or are an accidental finding in imaging studies for the other reasons.
- Around one percent of all appendectomy specimens are malignant.
- Appendix cancer account for 0.5 percent of all intestinal neoplasms.
- If left untreated, the majority of patients with appendix cancer may progress to develop peritoneal carcinomatosis and metastases.
Complications
- Common complications of appendix cancer include:
- Acute appendicitis
- Most of appendix adenocarcinomas present with acute appendicitis.
- However, majority of carcinoids are located in the distal one third of the appendix, hence rarely present with appendicitis.
- Merely 10 percent of appendiceal carcinoids are located at the base of appendix and may tend to obstruction and appendicitis.
- Pseudomyxoma peritonei
- Metastasis
- Carcinoid syndrome
- More commonly seen in midgut (appendix and small bowel) carcinoids.
- Almost always (90%) seen in metastatic disease, typically liver is the involved organ.
- Acute appendicitis
Prognosis
- Major prognostic factors are tumor stage, tumor size, histologic as well genetic characteristics of appendiceal tumors. For TNM classification of tumors of the appendix, click here.[1]
- Prognosis is generally excellent and good in carcinoid tumors and adenocarcinomas respectively.
- The overall 5-year survival rate for adenocarcinoma of appendix is approximately 71% (see the Table below).[2]
- Tumor size plays a crucial role in determining prognosis.
- The prognosis varies with the histology of tumor.
- Carcinoid tumors are associated with a better prognosis among patients with appendiceal cancer.
- Localized carcinoid tumors are associated with the most favorable prognosis.
- The presence of tubular pathology is also associated with a particularly good prognosis among patients with appendix adenocarcinoma.
- Goblet cell carcinoids are generally more aggressive than other carcinoid tumors.
- According to surveillance, epidemiology and end results (SEER) database of the national cancer institute five-year appendiceal carcinoid survival rates were as follows:
- Tumor size <3 cm without regional nodal or distant metastases: 100 percent
- Tumor size between 2 and 3 cm plus regional node metastases / tumor size ≥3 cm with or without regional nodal or distant metastases: 78 percent
- Distant metastasis: 32 percent
| Five year survival rates |
|---|
| Carcinoid tumors |
|
| Adenocarcinoma |
|
| * Shows that mucinous adenocarcinomae are less aggressive than nunmnucinous tumors |
- Poor prognostic factors for appendiceal adenocarcinoma are as follows:
- Advanced stage
- High grade
- Non-mucinous histology
- Spread of the tumor beyond the left lower quadrant
- Presence of malignant cells outside of the visceral peritoneum of the appendix
- Poor prognostic factors in the presence of pseudomyxoma peritonei are as follows:
- Abdominal distension
- Weight loss
- High histological grade
- Morphological evidence of invasion of underlying structures
- Genetic prognostic markers of appendiceal cancers are as follows:
- Genetic studies revolutionized cancer treatment; appendix cancer is not an exception.
- Traditionally appendiceal cancers were approached the same as colorectal cancers.
- Recent genetic studies demonstrated that appendiceal tumors are clearly differ from colorectal cancers. [5]
- Presence of mutated TP53 and APC genes were significantly lower in appendiceal cancers compared to colorectal cancers.
- It has been shown that mutation profiles are associated with the patients’ prognosis. [6]
- Mutations in the TP53 significantly decrease life expectancy in patients with appendix cancer.
- Regardless of tumor grade, TP53 mutations were associated with poorer outcomes.
- Patients with GNAS mutations had a life expectancy of 10 years after diagnosis.
- Appendiceal tumors with GNAS mutations rarely develop into high-grade tumors.
References
- ↑ Chapter 5: Tumours of the Appendix - IARC. https://www.iarc.fr/en/publications/pdfs-online/pat-gen/bb2/bb2-chap5.pdf Accessed on January 15, 2019
- ↑ Modlin IM, Sandor A (1997). "An analysis of 8305 cases of carcinoid tumors". Cancer. 79 (4): 813–29. PMID 9024720.
- ↑ Irvin M. Modlin, Kevin D. Lye & Mark Kidd (2003). "A 5-decade analysis of 13,715 carcinoid tumors". Cancer. 97 (4): 934–959. doi:10.1002/cncr.11105. PMID 12569593. Unknown parameter
|month=ignored (help) - ↑ A poorer survival has been reported for the black patients with carcinoid tumors. <ref name=":0">Melinda A. Maggard, Jessica B. O'Connell & Clifford Y. Ko (2004). "Updated population-based review of carcinoid tumors". Annals of surgery. 240 (1): 117–122. PMID 15213627. Unknown parameter
|month=ignored (help) - ↑ </nowiki>Levine EA, Blazer DG, Kim MK, Shen P, Stewart JH, Guy C; et al. (2012). "Gene expression profiling of peritoneal metastases from appendiceal and colon cancer demonstrates unique biologic signatures and predicts patient outcomes". J Am Coll Surg. 214 (4): 599–606, discussion 606-7. doi:10.1016/j.jamcollsurg.2011.12.028. PMC 3768122. PMID 22342786.
- ↑ Levine EA, Votanopoulos KI, Qasem SA, Philip J, Cummins KA, Chou JW; et al. (2016). "Prognostic Molecular Subtypes of Low-Grade Cancer of the Appendix". J Am Coll Surg. 222 (4): 493–503. doi:10.1016/j.jamcollsurg.2015.12.012. PMC 4808611. PMID 26821970.