Skip to main content

Surgical Evaluation of Appendiceal Neuroendocrine Tumors

  • Chapter
  • First Online:
Neuroendocrine Tumors

Abstract

Appendiceal neuroendocrine tumors (NETs) are rare with an incidence rate of 0.15–0.6 cases per 100,000 each year. The majority of appendiceal neuroendocrine tumors are diagnosed retrospectively after appendectomy that was performed for other indications. Workup includes histopathology review, biochemical laboratory studies, and cross-sectional and/or functional imaging. The extent of surgical resection, appendectomy versus right hemicolectomy with mesenteric lymphadenectomy, depends upon assessment of tumor size, location, and other high risk features. The management of advanced or metastatic disease is more complex and often requires a multidisciplinary approach but can include hepatic debulking, local ablative therapies, and/or medical therapies including somatostatin analogues, targeted therapies, and cytotoxic chemotherapies. Patients with locoregional disease have excellent survival, while patients with advanced and metastatic disease have a worse prognosis. The purpose of this text is to review the diagnosis and surgical management of well-differentiated appendiceal NETs.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Klöppel G, Perren A, Heitz PU. The gastroenteropancreatic neuroendocrine cell system and its tumors: the WHO classification. Ann N Y Acad Sci. 2004;1014(1):13–27.

    Article  PubMed  Google Scholar 

  2. Oronsky B, Ma PC, Morgensztern D, Carter CA. Nothing but NET: a review of neuroendocrine tumors and carcinomas. Neoplasia. 2017;19(12):991–1002.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Oberndorfer S. Karzinoide tumoren des dünndarms. Frankf Z Pathol. 1907;1:426–32.

    Google Scholar 

  4. Yao JC, Hassan M, Phan A, Dagohoy C, Leary C, Mares JE, Abdalla EK, Fleming JB, Vauthey JN, Rashid A, Evans DB. One hundred years after “carcinoid”: epidemiology of and prognostic factors for neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol. 2008;26(18):3063–72.

    Article  PubMed  Google Scholar 

  5. Amr B, Froghi F, Edmond M, Haq K, Kochupapy RT. Management and outcomes of appendicular neuroendocrine tumours: retrospective review with 5-year follow-up. Eur J Surg Oncol (EJSO). 2015;41(9):1243–6.

    Article  CAS  Google Scholar 

  6. Ellis L, Shale MJ, Coleman MP. Carcinoid tumors of the gastrointestinal tract: trends in incidence in England since 1971. Am J Gastroenterol. 2010;105(12):2563–9.

    Article  PubMed  Google Scholar 

  7. Pape UF, Niederle B, Costa F, Gross D, Kelestimur F, Kianmanesh R, Knigge U, Öberg K, Pavel M, Perren A, Toumpanakis C. ENETS consensus guidelines for neuroendocrine neoplasms of the appendix (excluding goblet cell carcinomas). Neuroendocrinology. 2016;103(2):144–52.

    Article  CAS  PubMed  Google Scholar 

  8. Modlin IM, Lye KD, Kidd M. A 5-decade analysis of 13,715 carcinoid tumors. Cancer: Interdiscip Inter J American Cancer Soc. 2003;97(4):934–59.

    Article  Google Scholar 

  9. Pawa N, Clift AK, Osmani H, Drymousis P, Cichocki A, Flora R, Goldin R, Patsouras D, Baird A, Malczewsk A, Kinross J. Surgical management of patients with neuroendocrine neoplasms of the appendix: appendectomy or more. Neuroendocrinology. 2018;106(3):242–51.

    Article  CAS  PubMed  Google Scholar 

  10. Boudreaux JP, Klimstra DS, Hassan MM, Woltering EA, Jensen RT, Goldsmith SJ, Nutting C, Bushnell DL, Caplin ME, Yao JC. The NANETS consensus guideline for the diagnosis and management of neuroendocrine tumors: well-differentiated neuroendocrine tumors of the jejunum, ileum, appendix, and cecum. Pancreas. 2010;39(6):753–66.

    Article  PubMed  Google Scholar 

  11. Strosberg JR, Halfdanarson TR, Bellizzi AM, Chan JA, Dillon J, Heaney AP, Kunz PL, O’Dorisio TM, Salem R, Segelov E, Howe J. The North American Neuroendocrine Society (NANETS) consensus guidelines for surveillance and medical management of midgut neuroendocrine tumors. Pancreas. 2017;46(6):707.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Halperin DM, Shen C, Dasari A, Xu Y, Chu Y, Zhou S, Shih YCT, Yao JC. Frequency of carcinoid syndrome at neuroendocrine tumour diagnosis: a population-based study. Lancet Oncol. 2017;18(4):525–34.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Taupenot L, Harper KL, O’Connor DT. The chromogranin–secretogranin family. N Engl J Med. 2003;348(12):1134–49.

    Article  CAS  PubMed  Google Scholar 

  14. Yang X, Yang Y, Li Z, Cheng C, Yang T, Wang C, Liu L, Liu S. Diagnostic value of circulating chromogranin A for neuroendocrine tumors: a systematic review and meta-analysis. PLoS One. 2015;10(4):e0124884.

    Google Scholar 

  15. Yao JC, Hainsworth JD, Wolin EM, Pavel ME, Baudin E, Gross D, Ruszniewski P, Tomassetti P, Panneerselvam A, Saletan S, Klimovsky J. Multivariate analysis including biomarkers in the phase III RADIANT-2 study of octreotide LAR plus everolimus (E+ O) or placebo (P+ O) among patients with advanced neuroendocrine tumors (NET). J Clin Oncol. 2012;30:157.

    Article  Google Scholar 

  16. Nobels FR, Kwekkeboom DJ, Coopmans W, Schoenmakers CH, Lindemans J, De Herder WW, Krenning EP, Bouillon R, Lamberts SW. Chromogranin A as serum marker for neuroendocrine neoplasia: comparison with neuron-specific enolase and the α-subunit of glycoprotein hormones. J Clin Endocrinol Metab. 1997;82(8):2622–8.

    CAS  PubMed  Google Scholar 

  17. O’Toole D, Grossman A, Gross D, Delle Fave G, Barkmanova J, O’Connor J, Pape UF, Plöckinger U. ENETS consensus guidelines for the standards of care in neuroendocrine tumors: biochemical markers. Neuroendocrinology. 2009;90(2):194–202.

    Article  PubMed  CAS  Google Scholar 

  18. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: neuroendocrine tumors. Ver. 1.2019. Fort Washington: NCCN; 2017.

    Google Scholar 

  19. Sundin A, Arnold R, Baudin E, Cwikla JB, Eriksson B, Fanti S, Fazio N, Giammarile F, Hicks RJ, Kjaer A, Krenning E. ENETS consensus guidelines for the standards of care in neuroendocrine tumors: radiological, nuclear medicine and hybrid imaging. Neuroendocrinology. 2017;105(3):212–44.

    Article  CAS  PubMed  Google Scholar 

  20. Assarzadegan N, Montgomery E. What is new in 2019 World Health Organization (WHO) classification of tumors of the digestive system: review of selected updates on neuroendocrine neoplasms, appendiceal tumors, and molecular testing. Arch Pathol Lab Med. 2020;

    Google Scholar 

  21. Rault-Petit B, Do Cao C, Guyétant S, Guimbaud R, Rohmer V, Julié C, Baudin E, Goichot B, Coriat R, Tabarin A, Ramos J. Current management and predictive factors of lymph node metastasis of appendix neuroendocrine tumors: a national study from the french group of endocrine tumors (GTE). Ann Surg. 2019;270(1):165–71.

    Article  PubMed  Google Scholar 

  22. Debnath D, Rees J, Myint F. Are we missing diagnostic opportunities in cases of carcinoid tumours of the appendix? Surgeon. 2008;6(5):266–72.

    Article  CAS  PubMed  Google Scholar 

  23. Safioleas MC, Moulakakis KG, Kontzoglou K, Stamoulis J, Nikou GC, Toubanakis C, Lygidakis NJ. Carcinoid tumors of the appendix. Prognostic factors and evaluation of indications for right hemicolectomy. Hepato-Gastroenterology. 2005;52(61):123–7.

    PubMed  Google Scholar 

  24. Lloyd RV, Osamura RY, Klöppel G, et al., editors. WHO classification of tumours of endocrine organs, vol. 10. 4th ed. Lyon: International Agency for Research on Cancer; 2017.

    Google Scholar 

  25. Nagtegaal ID, Odze RD, Klimstra D, Paradis V, Rugge M, Schirmacher P, Washington KM, Carneiro F, Cree IA, WHO Classification of Tumours Editorial Board. The 2019 WHO classification of tumours of the digestive system. Histopathology. 2020;76(2):182–8.

    Article  PubMed  Google Scholar 

  26. Rindi G, Klimstra DS, Abedi-Ardekani B, Asa SL, Bosman FT, Brambilla E, Busam KJ, de Krijger RR, Dietel M, El-Naggar AK, Fernandez-Cuesta L. A common classification framework for neuroendocrine neoplasms: an International Agency for Research on Cancer (IARC) and World Health Organization (WHO) expert consensus proposal. Mod Pathol. 2018;31(12):1770–86.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Raoof M, Dumitra S, O’Leary MP, Singh G, Fong Y, Lee B. Mesenteric lymphadenectomy in well-differentiated appendiceal neuroendocrine tumors. Dis Colon Rectum. 2017;60(7):674–81.

    Article  PubMed  Google Scholar 

  28. Pape UF, Perren A, Niederle B, Gross D, Gress T, Costa F, Arnold R, Denecke T, Plöckinger U, Salazar R, Grossman A. ENETS consensus guidelines for the management of patients with neuroendocrine neoplasms from the jejuno-ileum and the appendix including goblet cell carcinomas. Neuroendocrinology. 2012;95(2):135–56.

    Article  CAS  PubMed  Google Scholar 

  29. Grozinsky-Glasberg S, Alexandraki KI, Barak D, Doviner V, Reissman P, Kaltsas GA, Gross DJ. Current size criteria for the management of neuroendocrine tumors of the appendix: are they valid? Clinical experience and review of the literature. Neuroendocrinology. 2013;98(1):31–7.

    Article  CAS  PubMed  Google Scholar 

  30. Rossi G, Valli R, Bertolini F, Sighinolfi P, Losi L, Cavazza A, Rivasi F, Luppi G. Does mesoappendix infiltration predict a worse prognosis in incidental neuroendocrine tumors of the appendix? A clinicopathologic and immunohistochemical study of 15 cases. Am J Clin Pathol. 2003;120(5):706–11.

    Article  PubMed  Google Scholar 

  31. Syracuse DC, Perzin KH, Price JB, Wiedel PD, Mesa-Tejada R. Carcinoid tumors of the appendix. Mesoappendiceal extension and nodal metastases. Ann Surg. 1979;190:58–63.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Moertel CG, Weiland LH, Nagorney DM, Dockerty MB. Carcinoid tumor of the appendix: treatment and prognosis. N Engl J Med. 1987;317(27):1699–701.

    Article  CAS  PubMed  Google Scholar 

  33. Daskalakis K, Alexandraki K, Kassi E, Tsoli M, Angelousi A, Ragkousi A, Kaltsas G. The risk of lymph node metastases and their impact on survival in patients with appendiceal neuroendocrine neoplasms: a systematic review and meta-analysis of adult and paediatric patients. Endocrine. 2019;67:20–34.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  34. Galanopoulos M, McFadyen R, Drami I, Naik R, Evans N, Luong TV, Watkins J, Caplin M, Toumpanakis C. Challenging the current risk factors of appendiceal neuroendocrine neoplasms: can they accurately predict local lymph nodal invasion? Results from a large case series. Neuroendocrinology. 2019;109(2):179–86.

    Article  CAS  PubMed  Google Scholar 

  35. Blakely AM, Raoof M, Ituarte PH, Fong Y, Singh G, Lee B. Lymphovascular invasion is associated with lymph node involvement in small appendiceal neuroendocrine tumors. Ann Surg Oncol. 2019;26(12):4008–15.

    Article  PubMed  Google Scholar 

  36. Brighi N, La Rosa S, Rossi G, Grillo F, Pusceddu S, Rinzivillo M, Spada F, Tafuto S, Massironi S, Faggiano A, Antonuzzo L. Morphological factors related to nodal metastases in neuroendocrine tumors of the appendix: a multicentric retrospective study. Ann Surg. 2020;271(3):527–33.

    Article  PubMed  Google Scholar 

  37. Sarshekeh AM, Advani S, Halperin DM, Conrad C, Shen C, Yao JC, Dasari A. Regional lymph node involvement and outcomes in appendiceal neuroendocrine tumors: a SEER database analysis. Oncotarget. 2017;8(59):99541.

    Article  Google Scholar 

  38. Mullen JT, Savarese DM. Carcinoid tumors of the appendix: a population-based study. J Surg Oncol. 2011;104(1):41–4.

    Article  PubMed  Google Scholar 

  39. Edge SB, Edge SB. AJCC Cancer staging manual. 8th ed. New York: Springer; 2017.

    Google Scholar 

  40. Goede AC, Caplin ME, Winslet MC. Carcinoid tumour of the appendix. Br J Surg. 2003;90(11):1317–22.

    Article  CAS  PubMed  Google Scholar 

  41. Hsu C, Rashid A, Xing Y, Chiang YJ, Chagpar RB, Fournier KF, Chang GJ, You YN, Feig BW, Cormier JN. Varying malignant potential of appendiceal neuroendocrine tumors: importance of histologic subtype. J Surg Oncol. 2013;107(2):136–43.

    Article  PubMed  Google Scholar 

  42. Fanciulli G, Ruggeri RM, Grossrubatscher E, Calzo FL, Wood TD, Faggiano A, Isidori A, Colao A. Serotonin pathway in carcinoid syndrome: clinical, diagnostic, prognostic and therapeutic implications. Rev Endocr Metab Disord. 2020;21:1–14.

    Google Scholar 

  43. Clement D, Ramage J, Srirajaskanthan R. Update on pathophysiology, treatment, and complications of carcinoid syndrome. J Oncol. 2020;2020:1–11.

    Article  CAS  Google Scholar 

  44. Loughrey PB, Zhang D, Heaney AP. New treatments for the carcinoid syndrome. Endocrinol Metab Clin. 2018;47(3):557–76.

    Article  Google Scholar 

  45. Howe JR, Cardona K, Fraker DL, Kebebew E, Untch BR, Wang YZ, Law CH, Liu EH, Kim MK, Menda Y, Morse BG. The surgical management of small bowel neuroendocrine tumors: consensus guidelines of the North American Neuroendocrine Tumor Society (NANETS). Pancreas. 2017;46(6):715.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Landry CS, Woodall C, Scoggins CR, McMasters KM, Martin RC. Analysis of 900 appendiceal carcinoid tumors for a proposed predictive staging system. Arch Surg. 2008;143(7):664–70.

    Article  PubMed  Google Scholar 

  47. Hallet J, Law CHL, Cukier M, Saskin R, Liu N, Singh S. Exploring the rising incidence of neuroendocrine tumors: a population-based analysis of epidemiology, metastatic presentation, and outcomes. Cancer. 2015;121(4):589–97.

    Article  PubMed  Google Scholar 

  48. Chambers AJ, Pasieka JL, Dixon E, Rorstad O. The palliative benefit of aggressive surgical intervention for both hepatic and mesenteric metastases from neuroendocrine tumors. Surgery. 2008;144(4):645–53.

    Article  PubMed  Google Scholar 

  49. Cai B, Broder MS, Chang E, Yan T, Metz DC. Predictive factors associated with carcinoid syndrome in patients with gastrointestinal neuroendocrine tumors. World J Gastroenterol. 2017 Oct 28;23(40):7283.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Givi B, Pommier SJ, Thompson AK, Diggs BS, Pommier RF. Operative resection of primary carcinoid neoplasms in patients with liver metastases yields significantly better survival. Surgery. 2006;140(6):891–8.

    Article  PubMed  Google Scholar 

  51. Graff-Baker AN, Sauer DA, Pommier SJ, Pommier RF. Expanded criteria for carcinoid liver debulking: maintaining survival and increasing the number of eligible patients. Surgery. 2014;156(6):1369–77.

    Article  PubMed  Google Scholar 

  52. Tierney JF, Kosche C, Schadde E, Ali A, Virmani S, Pappas SG, Poirier J, Keutgen XM. 68Gallium-DOTATATE positron emission tomography–computed tomography (PET CT) changes management in a majority of patients with neuroendocrine tumors. Surgery. 2019;165(1):178–85.

    Article  PubMed  Google Scholar 

  53. Pavel M, Costa F, Capdevila J, Gross D, Kianmanesh R, Krenning E, Knigge U, Salazar R, Pape UF, Öberg K. ENETS consensus guidelines update for the management of distant metastatic disease of intestinal, pancreatic, bronchial neuroendocrine neoplasms (NEN) and NEN of unknown primary site. Neuroendocrinology. 2016;103(2):172–85.

    Article  CAS  PubMed  Google Scholar 

  54. Wright BE, Lee CC, Bilchik AJ. Hepatic cytoreductive surgery for neuroendocrine cancer. Surg Oncol Clin N Am. 2007;16(3):627–37.

    Article  PubMed  Google Scholar 

  55. Anthony LB, Strosberg JR, Klimstra DS, Maples WJ, O’Dorisio TM, Warner RR, Wiseman GA, Benson AB III, Pommier RF. The NANETS consensus guidelines for the diagnosis and management of gastrointestinal neuroendocrine tumors (nets): well-differentiated nets of the distal colon and rectum. Pancreas. 2010;39(6):767–74.

    Article  PubMed  Google Scholar 

  56. Mayo SC, De Jong MC, Pulitano C, Clary BM, Reddy SK, Gamblin TC, Celinksi SA, Kooby DA, Staley CA, Stokes JB, Chu CK. Surgical management of hepatic neuroendocrine tumor metastasis: results from an international multi-institutional analysis. Ann Surg Oncol. 2010;17(12):3129–36.

    Article  PubMed  Google Scholar 

  57. Que FG, Nagorney DM, Batts KP, Linz LJ, Kvols LK. Hepatic resection for metastatic neuroendocrine carcinomas. Am J Surg. 1995;169(1):36–43.

    Article  CAS  PubMed  Google Scholar 

  58. Sarmiento JM, Heywood G, Rubin J, Ilstrup DM, Nagorney DM, Que FG. Surgical treatment of neuroendocrine metastases to the liver: a plea for resection to increase survival. J Am Coll Surg. 2003;197(1):29–37.

    Article  PubMed  Google Scholar 

  59. Knox CD, Feurer ID, Wise PE, Lamps LW, Wright JK, Chari RS, Gorden DL, Pinson CW. Survival and functional quality of life after resection for hepatic carcinoid metastasis. J Gastrointest Surg. 2004;8(6):653–9.

    Article  PubMed  Google Scholar 

  60. Scott AT, Breheny PJ, Keck KJ, Bellizzi AM, Dillon JS, O’Dorisio TM, Howe JR. Effective cytoreduction can be achieved in patients with numerous neuroendocrine tumor liver metastases (NETLMs). Surgery. 2019;165(1):166–75.

    Article  PubMed  Google Scholar 

  61. Maxwell JE, Sherman SK, O’Dorisio TM, Bellizzi AM, Howe JR. Liver-directed surgery of neuroendocrine metastases: what is the optimal strategy? Surgery. 2016;159(1):320–35.

    Article  PubMed  Google Scholar 

  62. Dromain C, de Baere T, Lumbroso J, Caillet H, Laplanche A, Boige V, Ducreux M, Duvillard P, Elias D, Schlumberger M, Sigal R. Detection of liver metastases from endocrine tumors: a prospective comparison of somatostatin receptor scintigraphy, computed tomography, and magnetic resonance imaging. J Clin Oncol. 2004;23(1):70–8.

    Article  Google Scholar 

  63. Maxwell JE, Howe JR. Imaging in neuroendocrine tumors: an update for the clinician. Int J Endocr Oncol. 2015;2(2):159–68.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Morin C, Drolet S, Cousineau J, Daigle C, Deshaies I, Ouellet JF, Ball CG, Dixon E, Marceau J, Ouellet JFB. Additional value of gadoxetic acid-enhanced MRI to gadolinium-enhanced MRI for the surgical management of colorectal and neuroendocrine liver metastases. HPB. 2017;19:S69.

    Article  Google Scholar 

  65. Giesel FL, Kratochwil C, Mehndiratta A, Wulfert S, Moltz JH, Zechmann CM, Kauczor HU, Haberkorn U, Ley S. Comparison of neuroendocrine tumor detection and characterization using DOTATOC-PET in correlation with contrast enhanced CT and delayed contrast enhanced MRI. Eur J Radiol. 2012;81(10):2820–5.

    Article  CAS  PubMed  Google Scholar 

  66. Deppen SA, Blume J, Bobbey AJ, Shah C, Graham MM, Lee P, Delbeke D, Walker RC. 68Ga-DOTATATE compared with 111In-DTPA-octreotide and conventional imaging for pulmonary and gastroenteropancreatic neuroendocrine tumors: a systematic review and meta-analysis. J Nucl Med. 2016;57(6):872–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Deppen SA, Liu E, Blume JD, Clanton J, Shi C, Jones-Jackson LB, Lakhani V, Baum RP, Berlin J, Smith GT, Graham M. Safety and efficacy of 68Ga-DOTATATE PET/CT for diagnosis, staging, and treatment management of neuroendocrine tumors. J Nucl Med. 2016;57(5):708–14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Skoura E, Michopoulou S, Mohmaduvesh M, Panagiotidis E, Al Harbi M, Toumpanakis C, Almukhailed O, Kayani I, Syed R, Navalkissoor S, Ell PJ. The impact of 68Ga-DOTATATE PET/CT imaging on management of patients with neuroendocrine tumors: experience from a national referral center in the United Kingdom. J Nucl Med. 2016;57(1):34–40.

    Article  CAS  PubMed  Google Scholar 

  69. Quaedvlieg PF, Visser O, Lamers CB, Janssen-Heijen MLG, Taal BG. Epidemiology and survival in patients with carcinoid disease in the Netherlands: an epidemiological study with 2391 patients. Ann Oncol. 2001;12(9):1295–300.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Tanaz M. Vaghaiwalla .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2021 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Keutgen, X.M., Vaghaiwalla, T.M. (2021). Surgical Evaluation of Appendiceal Neuroendocrine Tumors. In: Cloyd, J.M., Pawlik, T.M. (eds) Neuroendocrine Tumors. Springer, Cham. https://doi.org/10.1007/978-3-030-62241-1_12

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-62241-1_12

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-62240-4

  • Online ISBN: 978-3-030-62241-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics