Increased risk of malignancy for patients older than 40 years with appendicitis and an appendix wider than 10 mm on computed tomography scan: A post hoc analysis of an EAST multicenter study

Abstract

Background: The incidence of underlying malignancy in appendicitis ranges between 0.5% and 1.7%. We sought to identify the subset of patients with appendicitis who are at increased risk of appendiceal malignancy. Methods: Using the Eastern Association for the Surgery of Trauma Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, we included all patients from 28 centers undergoing immediate, delayed, or interval appendectomy between 2017 and 2018. Univariate then multivariable analyses were performed to compare patients with and without malignancy and to identify independent demographic, clinical, laboratory, and/or radiological predictors of malignancy. Akaike information criteria for regression models were used to evaluate goodness of fit. Results: A total of 3,293 patients were included. The median age was 38 (27e53) years, and 46.5% were female patients. On pathology, 48 (1.5%) had an underlying malignancy (adenocarcinoma [60.4%], neuroendocrine [37.5%], and lymphoma [2.1%]). Patients with malignancy were older (56 [34.5e67] vs 37 [27e52] years, P < .001), had longer duration of symptoms before presentation (36e41 vs 18e23 hours, P ¼ .03), and were more likely to have a phlegmon on imaging (6.3% vs 1.3%, P ¼ .03). Multivariable analyses showed that an enlarged appendiceal diameter was independently associated with malignancy (odds ratio ¼ 1.06, 95% confidence interval ¼ 1.01e1.12; P ¼ .01). The incidence of malignancy in patients >40 years with an appendiceal diameter >10 mm on computed tomography was 2.95% compared with 0.97% in patients 40 years old with appendiceal diameter 10 mm. The corresponding risk ratio for that population was 3.03 (95% confidence interval: 1.24e7.42; P ¼ .02). Conclusion:The combination of age >40 and an appendiceal diameter >10 mm is associated with a greater than 3-fold increased risk of malignancy in patients presenting with appendicitis.

Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study

“…Potential missed appendiceal malignancy is a clinical concern of non-operative management. This study found four cases of malignancy and three neuroendocrine tumours in the initial non-operative management group, and an overall rate of malignancy of 1.3 per cent, consistent with the population reported incidence of 0.5-1.7 per cent 26 . Known risk factors for appendiceal malignancy are age, appendiceal dilatation on CT and complicated appendicitis 26,27 .…”

Appendiceal Adenocarcinoma Found by Surgery for Acute Appendicitis is Associated with Older Age

“…Our findings corroborate recent findings in prospectively collected data, analyzed post-hoc, from the MUSTANG trial (13). Taken together we concur that age older than 40 must be considered a risk factor for malignancy when considering appendectomy at initial presentation or at a later date (13,32).…”

Patient backgrounds and short‐term outcomes of complicated appendicitis differ from those of uncomplicated appendicitis

“… 20 Increasing age increases the odds of a cancer diagnosis after appendectomy 35 and age >40 is associated with a greater risk of malignancy. 36 In the present study the proportion of CA increased with increasing age. Thus, the pros and cons of IA cannot be discussed without considering these two concerns.…”