ORIGINAL STUDY

The Importance of Appendectomy in Surgery for

Mucinous Adenocarcinoma of the Ovary
Mikkel Rosendahl, MD, PhD, Laura Amalie Haueberg Oester, MD, and Claus Kim Høgdall, MD, DMSc

Objective: The aim of this study was to assess the importance of appendectomy during
surgery for mucinous ovarian cancer. It can be difficult to distinguish between primary ovarian
and primary appendiceal cancers clinically, histologically, and immunohistochemically. Re-
moval of the appendix may facilitate differential diagnosis, improve staging, and possibly
increase 5-year survival but may also be associated with increased postsurgical morbidity. In
the largest population published to date, we analyze and discuss these matters.
Methods: Prospectively gathered data on 269 patients with confirmed mucinous ovarian
adenocarcinoma from a national database were analyzed. The impact of appendectomy and
metastases to the appendix on 5-year and overall survival was analyzed.
Results: Appendectomy was performed in 172 cases (64%), and in 10 cases (4%), pathologic
evaluation of the removed appendix revealed metastases from ovarian cancer. Three of the
cases were macroscopically normal, and metastases were discovered only during microscopic
evaluation. Patients with metastatic disease to the appendix had significantly worse 5-year
survival (22%) compared with patients without metastases (73%) (W2 = 31.998, P G 0.0001).
Equally, 5-year survival was significantly higher in patients who had been adequately staged
with hysterectomy, omentectomy, bilateral salpingo-oophorectomy, and appendectomy (74%
vs 52%, W2 = 7.322, P = 0.007). In multivariate analysis, increase in revised 2013 International
Federation of Gynecology and Obstetrics classification stage (IA reference) was significantly
associated with worsened prognosis (hazard ratio, 1.13; P G 0.0001). Equally, each stepwise
increase in performance status score was related to a poorer prognosis with hazard ratio of 1.63
(P G 0.0001). Metastases to the appendix and staging did not remain significant factors of
survival in multivariate analysis.
Conclusions: Univariate analysis suggests that metastatic disease to the appendix and
failure to perform complete staging including appendectomy are related to a worsened
prognosis. A normal-looking appendix does not exclude metastatic disease, and because
appendectomy is easily performed and does not increase morbidity, it should be performed
during surgery for suspected mucinous ovarian cancer.
Key Words: Appendectomy, Appendix, Metastases, Mucinous, Ovarian cancer, Staging,
Survival

Received July 13, 2016, and in revised form October 4, 2016.

Accepted for publication October 7, 2016.
(Int J Gynecol Cancer 2017;27: 430Y436)

From the Department of Gynecology and Obstetrics, Copenhagen

University Hospital - RIGSHOPITALET, København Ø, Denmark.
Address correspondence and reprint requests to Mikkel Rosendahl, PhD,
Department of Gynecology and Obstetrics, Copenhagen University
M ucinous adenocarcinomas account for approximately
7% of malignant epithelial tumors of the ovary. They 1

are characterized by an intestinal-like histology, and clinically,

Hospital - RIGSHOSPITALET, Blegdamsvej 9, DK-2100 KBH Ø,
Denmark. E-mail: Mikkel.rosendahl@regionh.dk. histologically, and immunohistochemically, it is often difficult
The authors declare no conflicts of interest. to differentiate between primary malignant ovarian neoplasms
Copyright * 2017 by IGCS and ESGO and metastatic lesions from intestinal malignancies.2
ISSN: 1048-891X Perioperative evaluation of the size and laterality of the
DOI: 10.1097/IGC.0000000000000910 ovarian neoplasm may indicate the origin. Yemelyanova et al3

430 International Journal of Gynecological Cancer & Volume 27, Number 3, March 2017

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 Appendectomy in Mucinous
International Journal of Gynecological Cancer & Volume 27, Number 3, March 2017 Ovarian Cancer

published a series of 194 cases of primary and metastatic Statistical Analysis

mucinous ovarian tumors and were able to correctly identify Data analysis was performed in IBM SPSS version 22.
98% of primary and 82% of metastatic tumors using the Kaplan-Meier curves including life tables and log-rank
following criteria: metastasis: bilateral tumors or unilateral test (Mantel-Cox) were used for analysis of 5-year survival.
tumors less than 13 cm in diameter and primary ovarian or- Five-year survival rates (5YSRs) are displayed as percent
igin: unilateral lesions greater than 13 cm in diameter.3,4 alive at 60 months with 95% confidence intervals (CIs). Cox
Perioperative frozen sections may be helpful; however, some regression (enter) was used for analysis of overall survival.
uncertainty often remains during surgery, and many surgeons Hazard ratios (HRs) are displayed with 95% CI. All P values
will decide to remove a normal-looking appendix as a part of a were 2-sided, and P G 0.05 was considered significant.
normal staging procedure in order to exclude primary appen-
diceal cancer. Nevertheless, it is often discussed whether
appendectomy is really warranted in case of an apparently
normal-looking appendix. RESULTS
Danish national guidelines5 recommend routine appen- The database contained information on 288 patients with
dectomy in the management of mucinous ovarian neoplasms. In histologically confirmed mucinous ovarian cancer. Nine patients
addition, guidelines recommend full staging for ovarian mu- were excluded because surgery was not performed: 8 patients
cinous carcinomas including bilateral salpingo-oophorectomy, were directly referred to chemotherapy, and 1 patient died prior to
hysterectomy, omentectomy, and peritoneal biopsies. Patients surgery. In additional 9 patients, sufficient information about the
with stages IA and IB high-grade disease and all patients in surgery was unavailable, and they were excluded. Histological
stage IC or greater, regardless of grade, are referred to adjuvant review of 1 patient revealed pseudomyxoma peritonei, and the
chemotherapy containing paclitaxel/docetaxel and carboplatin. patient was excluded.
In Denmark, with a population of 5.4 million, all surgery for In the remaining 269 patients, surgery was performed
gynecologic cancer is performed in 3 highly specialized centers. between 2002 and 2013. Mean age at surgery was 60 years
For optimal data storage and safety, all patient data are collected (range, 13Y93 years). Mean follow-up time was 43 months
and stored in the Danish Gynecologic Cancer Database (DGCD). (range, 0Y103 years). Data on stage, tumor grade, American
All Danish citizens are issued with a personal and unique ID Society of Anesthesiologists score (ASA score), and Perfor-
number in the Danish Civil Registration System, which au- mance Status (PS) are listed in Table 1. For contemporary
tomatizes survival registration and is also linked to PATOBANK comparison, all patients were restaged according to the 2013
(The Danish National Pathology Registry). The combination International Federation of Gynecology and Obstetrics (FIGO)
of centralized surgical units, prospective data collection, val- classification for ovarian, peritoneal, and fallopian tube cancer.1
idated databases, and a national survival registry provides a All patients had histologically and immunohistochemically
unique platform for clinical and epidemiological studies of confirmed ovarian mucinous adenocarcinoma.
high integrity, and in the present study, we used this data There were 75 deaths in the entire group (28%) during the
foundation to analyze the incidence of appendiceal metastases observation period. Median survival was 85 months, and the
in mucinous ovarian cancer, the positive predictive value of a 5YSR for the entire group was 71% (range, 65%Y77%).
normal-looking appendix, and the influence of such metas- Number of deaths/stage are listed in Table 1; however, as many
tases on metastases. of the stages contained very few patients and had few deaths,
5YSR per stage was not calculated.

Appendectomy
MATERIALS AND METHODS Appendectomy was performed in 172 patients (64%)
Women undergoing surgery for a mucinous adeno- and had previously been removed in 22 patients (8%). In 75
carcinoma of the ovary in Denmark between 2005 and 2013 patients (28%), appendectomy was not performed. The exact
were included. reason to not perform appendectomy was not available.
In Denmark, surgery for suspected ovarian cancer is In 10 patients (4%), pathologic evaluation of the re-
centralized in 3 tertiary specialized gynecologic cancer centers. moved appendix revealed malignant involvement. In patient 1,
This allows all data on patients with gynecologic cancer to be appendiceal origin of the adenocarcinoma was considered.
registered in a centralized databaseVthe DGCD. Preoperative However, the immune profile was more suggestive of an
information and patient examination data are entered after the ovarian origin. In 3 patients,6Y8 the metastases to the ap-
first outpatient visit, and surgical information is recorded im- pendix were localized to the periappendix and not the ap-
mediately after surgery. Pathological data are entered by the pendix itself. In 2 of those patients, the appendix had normal
specialized gynecologic pathologist after completion of the macroscopic appearance. In a 1 case, a macroscopically normal
histological analysis. Finally, a quality check is performed where appendix concealed mucinous adenocarcinoma metastasis in
missing data are collected and entered. Data were obtained from the appendix itself. In patient 3, macroscopic evaluation raised
the DGCD and linked to survival data from the Danish Civil suspicion of pseudomyxoma peritonei, but microscopic eval-
Registration System. Elaborate histology was gathered from uation revealed metastasis from primary ovarian mucinous
PATOBANK. Death is registered as death from any cause. The adenocarcinoma. All patients with appendiceal metastases had
study was approved by the DGCD and the Danish Data Pro- stage IIIC disease, and the discovery of the metastatic lesion did
tection Agency (file no. 2007Y58Y0014). not alter the stage.

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Rosendahl et al International Journal of Gynecological Cancer & Volume 27, Number 3, March 2017

TABLE 1. Patient details, stage and survival analysis

All Alive Dead

n = 269 Median Range Median Range Median Range
Age, y 60 13Y93 58 13Y93 63 23Y91
Follow up, mo 41 0Y103 53 3Y93 13 0Y83
Survival, mo 85 0Y103 V V V V
ASA n % n % n %
1 128 48 105 54 23 31
2 102 38 72 37 30 40
3 34 13 14 7 20 27
4 3 1 1 1 2 3
Unknown 2 4 2 1
PS n % n % n %
0 185 69 152 78 33 44
1 65 24 35 18 30 40
2 11 4 5 3 6 8
3 6 2 2 1 4 5
4 2 1 V V 2 3
Stage n % No. of Deaths %
IA 105 39 13 12
IB 4 2 1 25
IC1 33 12 5 15
IC2 31 12 5 16
IC3 27 10 4 15
IIA 6 2 2 33
IIB 8 3 1 13
IIIA1 1 0.4 1 100
IIIA2 4 2 3 75
IIIB 10 4 9 90
IIIC 23 9 20 87
IVA 1 0.4 1 100
IVB 9 5 8 89
Missing 7 3
Appendectomy n % 5YSR, % 95% CI P
Yes 172 64 75 68Y82 Yes vs no, 0.390
No 75 28 66 54Y77
Previously removed 22 8 57 35Y79 Yes vs prev, 0.039
Staging n % 5YSR, % 95% CI P
Complete staging 227 84 74 68Y80* G0.0001
Incomplete staging 42 16 58 40Y76*
Grade
1 168 62 75 68Y82 1 vs 2, 0.023
2 60 22 63 50Y76 1 vs 3, 0.147
3 13 5 62 35Y88 2 vs 3, 0.828
Unknown 28 10

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 Appendectomy in Mucinous
International Journal of Gynecological Cancer & Volume 27, Number 3, March 2017 Ovarian Cancer

In 3 patients, benign carcinoid tumors localized to the was performed in 227 patients (84%). In the remaining 42
appendix were discovered. One case was macroscopically patients (16%), staging was incomplete. In univariate anal-
normal; the remaining 2 patients had tumor on the serosa of ysis, 5YSR was significantly superior in patients who had
the appendix. In 2 patients, moderate dysplasia of the appendix their lesions completely staged (74% [68%Y80%]) versus
was discovered; in one of the patients, a slight brown discoloration those whose lesions did not undergo complete staging (52%
of the appendix was described. All remaining appendices were [34%Y70%]; W2 = 7.322, P = 0.007. Kaplan-Meier curves are
macroscopically and microscopically normal. An overview of displayed in Figure 3.
malignant tumors of the appendices is listed in Table 2.
Grade
Univariate Analysis Patients were evenly distributed among grades 1 to 3
Metastases to the appendix were associated to a sig- (Table 1). In univariate analysis, 5YSR in grade 1 (75%; 95%
nificantly poorer 5YSR. Patients with metastatic disease to CI, 68%Y82%) was significantly better than grade 2 (63%; 95%
the appendix had a 5YSR of 22% (j5% to 49%) compared CI, 50%Y76%; W2 = 5.163, P = 0.023). However, comparing
with 73% (67%Y79%) for patients without metastases (W2 = grade 1 versus 3 and grade 2 versus 3, there was no significant
31.998, P G 0.0001). However, the CI for the 5YSR of pa- difference (Table 1).
tients with appendiceal metastases went from less than 0,
indicating a very uncertain estimate. Kaplan-Meier curves Multivariate Analysis
are shown in Figure 1. In Cox regression, age, ASA score, PS, tumor grade, revised
Appendectomy during the surgery (whether metastatic or stage, appendectomy, appendiceal metastases, staging, residual
not) was associated with higher 5YSR compared with patients disease, and residual carcinosis were included as covariates.
who did not undergo appendectomy, although the results were Increase in revised 2013 FIGO stage (IA reference) was
not significant (75% [68%Y82%] vs 66% [54%Y77%]; W2 = significantly associated with worsened prognosis (HR, 1.13;
0.735, P = 0.39). Surprisingly, previous appendectomy had the 95% CI, 1.10Y1.16; P G 0.0001).
poorest 5-year survival at 57% (36%Y79%), which was sig- Equally, each stepwise increase in PS score was related
nificantly worse than that in patients who underwent appen- to a poorer prognosis with HR of 1.63 (95% CI, 1.28Y2.08;
dectomy during the present surgery (W2 = 4.246, P = 0.039). P G 0.0001).
Kaplan-Meier curves are shown in Figure 2. Although metastases to the appendix, appendectomy, and
complete staging were highly significant factors in the univariate
Staging analysis, the importance of these covariates faded in the multi-
Comprehensive staging with hysterectomy, bilateral variate analysis, and none of them reached statistical signifi-
salpingo-oophorectomy, omentectomy, and appendectomy cance: metastases to the appendix: HR, 0.79 (95% CI,

TABLE 2. Overview of the 10 patients with malignancy in the appendix

Case No. Histological Result Macroscopic Appearance FIGO Stage

1 Metastasis from primary ovarian mucinous Normal macroscopic appearance IIIC
adenocarcinoma
2 Metastasis from primary ovarian mucinous Hemorrhagic discoloration and fibrin covered IIIC
adenocarcinoma
3 Metastasis from primary ovarian mucinous Covered in gray, soft gel IIIC
adenocarcinoma
4 Metastasis from primary ovarian mucinous Normal surface but fibrotic IIIC
adenocarcinoma
5 Metastasis from primary ovarian mucinous Surface with signs of vascular congestion IIIC
adenocarcinoma
6 Metastasis from primary ovarian mucinous Surface covered in slime IIIC
adenocarcinoma
7 Metastasis to periappendix from primary Normal macroscopic appearance IIIC
ovarian mucinous adenocarcinoma
8 Metastasis to periappendix from primary Normal macroscopic appearance IIIC
ovarian mucinous adenocarcinoma
9 Metastasis to periappendix from primary 12-mm Irregular tumor on the surface IIIC
ovarian mucinous adenocarcinoma
10 Metastasis from primary ovarian Brown discoloration IIIC
mucinous adenocarcinoma
P values calculated with log-rank test, pairwise comparison.

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Rosendahl et al International Journal of Gynecological Cancer & Volume 27, Number 3, March 2017

FIGURE 1. Kaplan-Meier curves for patients with and without metastases to the appendix. Five-year survival rate with
metastases, 22% (95% CI, j5% to 49%); without metastases, 73% (95% CI, 67%Y79%) (W2 = 31.998, P G 0.0001).
0.33Y1.88), P = 0.590; appendectomy current surgery: HR, 1.22 The appendix was removed, during surgery, in 64% of the
(95% CI, 0.85Y1.75); complete staging: HR, 1.28 (95% CI, patients, and even though there was a clear graphical trend toward
0.69Y2.39), P = 0.437. a survival benefit in case of appendectomy, the results were not
significant either in univariate or multivariate analysis.
DISCUSSION Metastatic disease in the appendix was significantly as-
In this study, we evaluated the importance of appendec- sociated with a worse prognosis in univariate analysis. However,
tomy during surgery for mucinous ovarian adenocarcinoma. again, in the multivariate analysis, it was not significant.

FIGURE 2. Five-year survival rate according to previous appendectomy/appendectomy/no appendectomy during

surgery for ovarian cancer; appendectomy: 75% (95% CI, 68%Y82%) versus no appendectomy 66% (95% CI,
54%Y77%) (W2 = 0.735, P = 0.39); previous appendectomy: 57% (95% CI, 36%Y79%).

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 Appendectomy in Mucinous
International Journal of Gynecological Cancer & Volume 27, Number 3, March 2017 Ovarian Cancer

FIGURE 3. Five-year survival rate according to staging; complete staging: 74% (95% CI, 68%Y80%); incomplete
staging: 52% (95% CI, 34%Y70%) (W2 = 7.322, P = 0.007).

Five-year survival was significantly increased in right ovary and the right paracolic gutter, and migration of ma-
cases where comprehensive staging with bilateral salpingo- lignant cells to the appendix and periappendix is easily imagined.
oophorectomy, hysterectomy, appendectomy, and omentectomy Several studies have discussed the necessity to remove a
was performed; however, as for metastases to the appendix, the normal-looking appendix during surgery for mucinous ovarian
importance of complete staging was lost in the multivariate cancer. Ramirez et al9 found no involvement of the appendix in
analysis where only stage and PS were significantly associated 40 cases of mucinous ovarian cancer but still recommend
with poorer prognosis. routine appendectomy. In an overview of ovarian manifestations
The reason for the disappearance of metastases to the of primary appendiceal cancer, Dietrich et al6 found ovarian
appendix and staging as significant cofactors in the multi- metastases in 38% of the cases of primary appendiceal cancer
variate analysis may be due to the lack of statistical power in and address the difficulties in distinguishing primary ovarian
the study but is most likely due to the incorporation of these and appendiceal cancer. The authors conclude that staging for
factors in the final stage. With comprehensive staging, stage mucinous ovarian cancer should include routine appendectomy.
migration may occur. Hence, an apparent stage I lesion may Two other groups found only malignant involvement of the
be categorized as at a higher stage after complete staging and appendix in 155 and 36 cases, respectively, when the appendix
hence does not negatively influence the survival of the pa- was grossly abnormal and recommend that only grossly ab-
tients with true stage I disease. Second, sufficient staging may normal appendices be removed.7,8 In a very recent publication
be an expression of a more comprehensive surgery performed of 35 patients with mucinous ovarian cancer, 29 had appen-
in skilled hands where complete debulking is the result dectomy performed. In 21 of the cases, the appendix was
compared with inadequate surgery with residual disease in the macroscopically normal, and histology was normal in 20 cases
peritoneum. Despite these speculations, however, we were (95%), and 1 patient had a serrated adenoma. The authors
unable to show an effect of residual tumor and carcinosis. concluded that normal-looking appendix could be left in situ in
Because appendectomy does not independently, in a case of ovarian mucinous adenocarcinoma.10
multivariate analysis, improve prognosis, why should an ap- Although routine appendectomy could be related to
parently normal appendix be removed? In the present study, 3 of postoperative complication, 2 studies did not find an increased
the 10 patients with appendiceal metastases had completely number of complications after 40 and 155 cases of appendec-
normal macroscopic evaluation, and the metastases in those tomy, respectively.8,9 In additional 121 cases of routine pro-
patients are likely to have been overlooked if routine appen- phylactic appendectomy during laparoscopic hysterectomy for
dectomy had not been performed. In addition, 2 macroscopi- benign conditions, Wang et al11 did not experience an increase
cally normal appendices harbored dysplasia and carcinoid in postoperative complications.
tumors, respectivelyVconditions that may be harmless but do Collectively, there are many reasons for routine ap-
show that microscopic conditions may lie under the surface of a pendectomy: It will result in a more complete staging, and it
normal-looking appendix. The appendix is in close relation to the may remove microscopic disease that may otherwise have

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Rosendahl et al International Journal of Gynecological Cancer & Volume 27, Number 3, March 2017

been overlooked and be the cause of progression. Even the 2013 FIGO Classification for Ovarian, Fallopian Tube, and
though all patients with appendiceal metastases had stage IIIC Primary Peritoneal Cancer. Int J Gynecol Cancer.
lesions, appendectomy resulted in a more radical surgery and 2016;26:680Y687.
may possibly have contributed to a lower risk of recurrence. 2. Rouzbahman M, Chetty R. Republished: mucinous tumours of
This is supported by the findings in the univariate analysis appendix and ovary: an overview and evaluation of current
practice. Postgrad Med J. 2015;91:41Y45.
suggesting that appendiceal metastases and failure to perform
3. Yemelyanova AV, Vang R, Judson K, et al. Distinction of
comprehensive staging including appendectomy may be of
primary and metastatic mucinous tumors involving the ovary:
importance for survival. Second, it is of major importance for analysis of size and laterality data by primary site with
the differential diagnosis of mucinous ovarian tumors because it reevaluation of an algorithm for tumor classification. Am J Surg
is a contributor to the final pathological evaluation in cases Pathol. 2008;32:128Y138.
where pseudomyxoma peritonei is considered. Finally, it will 4. Khunamornpong S, Suprasert P, Pojchamarnwiputh S, et al.
eliminate the risk of a future appendicitis necessitating surgery Primary and metastatic mucinous adenocarcinomas of the
in already adherent field. ovary: evaluation of the diagnostic approach using tumor size
The only reason not to perform the appendectomy during and laterality. Gynecol Oncol. 2006;101:152Y157.
staging surgery should be the potentially increased risk of 5. Danish Gynaecological Cancer Group (DGCG) Ovarian Cancer
postoperative peritonitis. However, none of the available studies Guidelines; http://dgcg.dk/index.php/guidelines/ovariecancer-
documented an augmented risk if appendectomy was performed. guidelines. Accessed December 12, 2016.
This study contains data on 288 patients with mucinous 6. Dietrich CS 3rd, Desimone CP, Modesitt SC, et al. Primary
ovarian cancer. It is to our knowledge by far the largest popu- appendiceal cancer: gynecologic manifestations and treatment
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