Objective
To determine how frequently the appendix harbors pathology in women having surgery for mucinous neoplasms of the ovary and assess the associated morbidity.
Study Design
A retrospective chart review of patients operated on at our institution with the diagnosis of a mucinous neoplasm of the ovary or appendix.
Results
A total of 327 cases were identified. Of the 309 women with mucinous ovarian neoplasms, 197 (64%) were benign, 68 (22%) low malignancy potential, and 44 (14%) were invasive. Of 155 appendectomies performed, only 1 metastatic low grade mucinous appendiceal tumor was found, but this appendix was grossly abnormal. There was no association between wound complications and appendectomy.
Conclusion
When a grossly normal appendix is removed during surgery for a mucinous ovarian neoplasm without evidence of pseudomyxoma peritonei, no primary or metastatic mucinous appendiceal tumors are found.
Some experts recommend routine appendectomy during ovarian cancer staging. They propose that removing the appendix leads to upstaging of disease, prevention of acute appendicitis, more accurate diagnosis (including ruling out primary appendiceal disease), and decreased risk of future surgical complications from extensive adhesions. However, it remains controversial whether appendectomy should be performed as a routine part of the staging procedure for early ovarian cancer because the exact magnitude of these benefits is unknown. Mucinous ovarian tumors account for 15-20% of all ovarian neoplasms, with the majority being benign. For those that are invasive or of low malignant potential (LMP), appendectomies have been recommended to rule out the possibility of a primary appendiceal adenocarcinoma or metastasis from a gastrointestinal source. This recommendation has often been extended in clinical practice to benign mucinous tumors as well.
These recommendations have stemmed from data looking at all ovarian histologies, as well as older experience with pseudomyxoma peritonei, or mucinous ascites and deposits within the peritoneal cavity. Pseudomyxoma peritonei was thought to originate in the ovary or peritoneal cavity; however, recent research has shown that this disease almost exclusively originates in the appendix.
Although it has historically been reported that the appendix is the site of metastasis in 8% of mucinous ovarian cancers, none of these cases were isolated metastases that changed the final stage. Although it is known that appendiceal adenocarcinomas often metastasize to the ovary, the rate of positive appendiceal pathology in women having surgery for mucinous ovarian tumors without obvious metastatic disease is unknown.
Our primary objective was to determine how often the appendix is involved, or the primary source of cancer, in women undergoing appendectomy at the time of surgery for a mucinous ovarian tumor. Our secondary objective was to determine the frequency of complications arising from such appendectomies to better determine the risk/benefit ratio of the procedure.
Materials and Methods
Approval of the University of Wisconsin Hospital and Clinic’s Institutional Review Board for Health Sciences Research was obtained for this retrospective observational cross-sectional study. All patients operated on or seen in consultation at our institution from January 1994 to September 2009 with the final diagnosis of a mucinous neoplasm of the ovary or appendix were included. Cases were identified from pathology records of any mucinous ovarian tumors (benign, LMP, invasive) or mucinous appendiceal neoplasm from January 1994 to September 2009. Including all primary appendiceal cases was necessary to ensure that we did not miss any women operated on for an ovarian tumor that were found on final pathology to have a primary appendiceal tumor with ovarian metastasis. During this period, the practice of appendectomy for mucinous ovarian tumors was provider dependent.
Medical record numbers corresponding to pathology records were used to locate charts through the University of Wisconsin Hospital and Clinics electronic medical record. Paper charts were obtained if no or limited information was found electronically. Final pathology reports were reviewed for information pertaining to final ovarian and appendiceal diagnoses, tumor diameter, and cytology. Operative reports were reviewed for information pertaining to date of surgery, type of surgery, tumor laterality, presence of ascites, and gross appearance of appendix. We assumed a grossly normal appendix when there was no mention of appendiceal abnormality on the operative note. Other information collected included diagnosis (stage, grade, and histology), age, history of appendectomy, postoperative admissions, and wound complications, including abscess formation, relating to appendectomy. Complications occurring within 30 days of surgery were considered related to the surgical procedure.
Cases were excluded if no other information besides pathology record was available either electronically or in the paper chart and if the primary source of mucinous carcinoma was from neither ovary nor appendix.
Statistical analysis was performed using SAS version 9.2 software (SAS Institute Inc, Cary, NC). Fisher exact text was used to examine the significance of associations between categorical variables.
Results
A total of 327 cases meeting criteria were identified, including 308 primary ovarian mucinous neoplasms and 19 primary appendiceal neoplasms. Only 1 of the 19 primary appendiceal neoplasms presented preoperatively as an isolated ovarian mass. The others presented preoperatively with either obvious metastatic disease, found intraoperatively to be pseudomyxoma peritonei, or a known appendiceal mass preoperatively. Therefore, we included the 1 patient with an isolated ovarian mass preoperatively in our analysis for a total of 309 patients who went to the operating room with the preoperative diagnosis of an ovarian mass only. Median patient age was 49 years.
The procedures performed included 147 (45%) total abdominal hysterectomies with bilateral salpingo-oophorectomy, 84 (26%) unilateral salpingo-oophorectomies, 64 (20%) bilateral salpingo-oophorectomies, 17 (5%) ovarian cystectomies, 11 (3%) total abdominal hysterectomies with unilateral salpingo-oophorectomy, and 4 (1%) other procedures. Other procedures included staging procedures after hysterectomy, removal of ovarian remnant, and right hemicolectomy.
Of these 309 patients operated on for ovarian neoplasms, 197 (64%) had benign, 68 (22%) LMP, and 44 (14%) invasive mucinous pathology ( Figure 1 ). Fifty-six (18%) women had previously undergone appendectomy. Of 253 appendices present during procedures for mucinous ovarian neoplasms, 155 (61%) appendectomies were performed.
Of the 197 women with benign mucinous neoplasms, 88 (45%) had appendectomies, of which, 1 grossly abnormal appendix revealed a primary low-grade mucinous tumor of the appendix. Thirty-two (16%) had prior appendectomies and 77 (39%) had no appendectomy performed during the surgery for a benign mucinous ovarian neoplasm.
Of the 68 women with mucinous ovarian LMP tumors, 41 (60%) had appendectomies, 15 (22%) had prior appendectomies, and 12 (18%) had no appendectomy. One incidental appendiceal carcinoid tumor was found of the 41 appendectomies performed for LMP tumors. No mucinous tumors of the appendix were identified in the LMP group.
For the 44 women with invasive mucinous ovarian tumors, 26 (59%) had appendectomies, 9 (20.5%) had prior appendectomies, and 9 (20.5%) had no appendectomy performed. One incidental appendiceal carcinoid tumor was found of the 26 appendectomies performed for invasive mucinous ovarian tumors. No mucinous tumors of the appendix were identified in the invasive group.
Nineteen primary mucinous appendiceal cancers were identified. Sixteen (84%) of these were associated with pseudomyxoma peritonei. The appendix was noted to be grossly abnormal at the time of surgery in the remaining 3, with pathology showing mucinous cystadenocarcinoma for 2 appendices and 1 appendix harboring a primary appendiceal mucinous low-grade tumor detailed earlier and included in the benign mucinous ovary group ( Figure 2 ). Gross appendiceal abnormalities included nodules, thickening of the wall, adhesions, and tumor implants.
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