New England Surgical Society

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Practice Patterns and Guideline Non-Adherence in Surgical Management of Appendiceal Carcinoid Tumors
*Danielle R. Heller, Raymond A. Jean, *Vadim Kurbatov, *Daniel Jacobs, *Alexander S. Chiu, Sajid A. Khan
Yale University School of Medicine, New Haven, CT

OBJECTIVES: Surgical management of appendiceal carcinoid tumors is heavily debated, despite NCCN guidelines recommending aggressive resection of tumors>2cm. We sought to investigate national practice patterns and the factors associated with guideline non-adherence. DESIGN: Retrospective analysis of national database, queried for cases of appendiceal carcinoids from 2004-2015 treated with either appendectomy or hemicolectomy. Multivariable logistic regression identified significant associations with hemicolectomy versus appendectomy among patients stratified by tumor size≤2cm and >2cm. Overall survival (OS) was compared using Kaplan-Meier curves. SETTING: NCDB, representing >70% incident malignancies nationwide. INTERVENTIONS: Appendectomy vs hemicolectomy. OUTCOME MEASURES: Frequency of appendectomies for tumors>2cm; frequency of hemicolectomies for tumors≤2cm; predictive factors for treatment deviation. RESULTS: Of 3,198 cases of appendiceal carcinoids, 1,893 appendectomies and 1,305 hemicolectomies were performed. In conflict with NCCN guidelines, 33.7% of tumors>2cm were treated with definitive appendectomy, while 32.4% of tumors≤2cm were treated with hemicolectomy. On regression analysis, no predictors for resection type were found for tumors>2cm; however, for tumors≤2cm, hemicolectomy was associated with age>60 years (OR 1.7, 95%CI 1.3-2.2), diagnosis before 2011 (OR 2.2, 95%CI 1.7-2.8), and history of other malignancies (OR 2.0, 95%CI 1.5-2.5).[Table] There was no significant difference in OS between appendectomy and hemicolectomy for both small and large tumors (log-rank p=0.06). CONCLUSIONS: Despite well-known size-based treatment guidelines for appendiceal carcinoids, one-third of surgeons in the U.S. still perform appendectomy on large tumors and hemicolectomy on small tumors. Guideline non-adherence, however, does not appear to impact survival. Reasons for these practice patterns should be explored, and the guidelines revisited.

HEMICOLECTOMY: TUMORS ≤ 2 CMAPPENDECTOMY: TUMORS > 2 CM
OR95% CIP-VALUEOR95% CIP-VALUE
AGE (years)
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
1.0
0.6
1.0
1.1
1.5
1.7
2.0
2.6
---
0.4 1.0
0.6 1.6
0.7 1.8
1.0 2.4
1.0 2.8
1.1 3.5
1.3 5.2
---
0.068
0.996
0.626
0.121
0.041
0.017
0.008
1.0
1.0
1.3
1.2
0.8
2.4
2.0
2.2
---
0.3 2.7
0.5 3.6
0.4 3.3
0.3 2.3
0.8 7.1
0.6 6.8
0.4 13.2
0.148
0.914
0.630
0.743
0.736
0.106
0.299
0.390
SEX
Male
Female
1.0
1.0
---
0.8 1.2
---
0.755
1.0
0.9
---
0.6 1.4
---
0.791
INSURANCE
Not Insured
Private
Medicaid/ Medicare/ Government
1.0
1.0
1.4
---
0.6 1.6
0.8 2.2
0.061
0.973
0.219
1.1
0.9
0.5
---
0.4 2.1
0.2 1.3
0.120
0.870
0.180
INCOME QUARTILE ($)
<38,000
38,000 - 47,999
48,000 - 62,999
63,000+
1.0
1.0
1.0
1.2
---
0.7 1.4
0.7 1.4
0.8 1.8
0.572
0.985
0.996
0.365
1.0
0.8
0.7
0.8
---
0.4 1.6
0.3 1.5
0.4 1.9
0.811
0.537
0.358
0.624
NO HIGH SCHOOL DEGREE (%)
≥21
13.0 20.9
7.0 12.9
<7.0
1.0
1.0
0.9
0.7
---
0.7 1.4
0.6 1.2
0.5 1.1
0.246
0.804
0.406
0.089
1.0
0.8
0.8
0.6
---
0.4 1.6
0.4 1.7
0.3 1.4
0.690
0.554
0.594
0.271
URBAN/ RURAL (# persons)
Metro
Urban
Rural
1.0
1.1
1.9
---
0.8 1.5
0.9 3.9
0.250
0.697
0.100
1.0
0.4
0.3
---
0.2 0.8
0.0 2.9
0.025
0.010
0.296
CHARLSON/ DEYO SCORE
0
1
2
3
1.0
1.2
1.3
3.4
---
0.9 1.6
0.7 2.3
1.1 10.3
0.103
0.234
0.407
0.033
1.1
0.5
0.6
7.6
---
0.3 1.0
0.1 2.7
0.8 76.7
0.053
0.044
0.523
0.085
HX OTHER MALIGNANCIES
No
Yes
1.0
2.0
---
1.5 2.5
---
<0.001
1.0
1.1
---
0.7 2.0
---
0.645
YEAR OF DIAGNOSIS
2004 2010
2011 2015
2.2
1.0
1.7 2.8
---
<0.001
<0.001
1.0
1.0
---
0.7 1.5
---
0.921
TUMOR SIZE
≤1
1.1 2
2.1 3
3.1 4
4+
1.0
3.1
---
2.5 3.8
---
<0.001
1.0
0.6
0.6
---
0.4 1.1
0.4 1.0
0.053
0.077
0.037


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