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 CM | APPENDECTOMY: TUMORS > 2 CM | |||||
| OR | 95% CI | P-VALUE | OR | 95% CI | P-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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