Staged Colectomy May Be Preferable to Upfront Colectomy in Appendix Cancer

Muhammad Talha Waheed, MD, a postdoctoral research fellow at City of Hope Comprehensive Cancer Center in Duarte, California, spoke with CancerNetwork® about a poster that showed initial appendectomy followed by resection compared favorably with upfront right colectomy in patients with appendiceal cancer that he presented at the 2025 Society of Surgical Oncology Annual Meeting.

The results found that the best survival was with staged colectomy compared with appendectomy alone (HR, 0.52; 95% CI, 0.34-0.80; P = .003), and the worst survival was with upfront colectomy compared with staged colectomy (HR, 2.13; 95% CI, 1.42-3.16; P <.001). Waheed believes that these results should contribute to the conversation on the optimal sequence of resection in appendiceal cancer. Currently, there aren’t consensus guidelines that give specifications for when to use which approach, and that decision falls solely on the surgeon.

On top of the survival benefits of the staged approach, Waheed cited that 26% to 33% of identified appendiceal neoplasmsmay end up being localized mucinous neoplasms or benign neuroendocrine tumors, which may only require appendectomy. The staged approach would stop surgeons from performing an unnecessary, invasive procedure as, in some cases, an appendectomy is all that’s needed to treat these conditions.

Transcript:

In short, it means that there should be a conversation about the optimal sequence of resection. Currently, there are no national Academic Research Consortium [ARC] consensus guidelines that guide us regarding the optimal sequence of resection for these patients. The decision to perform an upfront colectomy or a staged colectomy is solely at that surgeon’s discretion depending on the level of suspicion that the surgeon has. Unfortunately, given the rarity of appendix cancers, it is almost impossible to conduct [randomized] clinical trials to look at the optimal sequence. Most of these data are guided by retrospective studies such as ours. Historically, a major concern with the staged approach is that it separates a primary tumor resection and the lymphadenectomy, which could potentially result in detrimental survival for [patients who receive] staged colectomy. But with these findings that we have now, we’ve reported that we do not see any differences in [OS], and the benefits do outweigh the risks here. Hence, the staged colectomy should be preferred. This should be picked up by consensus groups, and it should be a topic of discussion at these consensus meetings to help guide the surgeons forward.

Appendiceal malignancies are often diagnosed in emergency settings when patients undergo appendectomy for suspected appendicitis. The intraoperative frozen section is also very unreliable for subtyping the appendiceal neoplasm. Even with permanent pathology, expert appendicealcancer pathologists change their diagnosis around 20% of the time. At the end of the day, 26% [to] 33% of appendiceal neoplasmsmay turn out to be localized mucinous neoplasms or benign neuroendocrine tumors, where appendectomy alone may be the only operation that you need. Compared to appendectomy, colectomy is a more invasive procedure; it may be associated with higher comorbidity, increased unplanned readmissions, and prolonged length of stay compared to appendectomy alone. It should be avoided if not needed or indicated. If you do not need it for the histologic subtype that you have on hand, you should not be doing it. All of this could be avoided if a standard resection is planned for a subset of patients.

Reference

Waheed MT, Malik I, Ituarte PHG, et al. Upfront colectomy vs. initial appendectomy followed by completion colectomy for appendiceal cancer: comparison of outcomes. Presented at the 2025 Society of Surgical Oncology Annual Meeting; March 27-29, 2025; Tampa, FL.