Appendiceal Submucosal Tumors: Surgical Approaches and Considerations

Submucosal tumor of the appendix

Doctor, I recently underwent a colonoscopy and a tumor approximately 2 cm in size was found in the cecum.
At that time, only a biopsy was performed and no removal was done because the doctor believed that the wall of the cecum was thinner, and removal would carry risks.
The biopsy results were benign, but since the doctor could not confirm whether there were any abnormalities in the submucosa, a CT scan was recommended for further evaluation, and I was subsequently referred to a colorectal surgeon.
The surgeon's plan is to remove the right colon, as they are concerned that if only the cecum is removed and the pathology results indicate malignancy, a second surgery would be necessary.
Is this approach standard practice in the medical community? After all, is it reasonable to perform such a significant organ resection for a tumor that is possibly benign? Additionally, why can't the doctor use techniques like EMR (Endoscopic Mucosal Resection) or ESD (Endoscopic Submucosal Dissection) to address this tumor?

Flack, 30~39 year old female. Ask Date: 2020/03/04

Dr. Yu Mingchang reply Surgery

Hello; it is possible to first perform an appendectomy and send the tissue for frozen section examination during the procedure.
If acute appendicitis is confirmed, then a colectomy may be considered.
The Ministry of Health and Welfare Changhua Hospital cares about you.

Reply Date: 2020/03/04

More Info

Understanding appendiceal submucosal tumors, particularly in the context of surgical approaches and considerations, is crucial for both patients and healthcare providers. Your situation, where a 2 cm tumor was identified in the cecum (the beginning of the large intestine), raises several important points regarding diagnosis, management, and the rationale behind surgical decisions.

Firstly, the initial approach of performing a biopsy rather than an immediate excision is a common practice, especially when there are concerns about the structural integrity of the bowel wall. In cases where the wall is thin, as you mentioned, there is a risk of perforation or complications during surgery. The biopsy allows for histological evaluation without the immediate risks associated with a more invasive procedure.

The subsequent finding that the tumor was benign is reassuring; however, the uncertainty regarding submucosal involvement necessitates further investigation. This is where imaging studies, such as a CT scan, become essential. They help in assessing the extent of the tumor and any potential involvement of surrounding structures, which is critical for planning further management.

Regarding the recommendation to perform a right hemicolectomy (removal of the right side of the colon), this is indeed a standard approach in certain circumstances, particularly when there is a concern for malignancy or when the tumor's characteristics suggest a higher risk of being malignant than benign. The rationale behind this recommendation is to minimize the need for a second surgery if the tumor is found to be malignant upon further examination. This is a common practice in surgical oncology, where the goal is to achieve complete resection of any potentially malignant tissue in one operation, thereby reducing the risk of recurrence and the need for additional surgeries.

As for the question of why endoscopic techniques such as Endoscopic Mucosal Resection (EMR) or Endoscopic Submucosal Dissection (ESD) were not utilized, there are several factors to consider. EMR and ESD are generally reserved for lesions that are confined to the mucosal layer and are accessible via endoscopy. If there is any suspicion that the tumor extends into the submucosal layer or if the lesion's characteristics suggest a higher risk of malignancy, surgical resection is often preferred. Additionally, the size and location of the tumor, as well as the expertise of the endoscopist, can influence the decision to use these techniques.

In conclusion, the approach taken by your healthcare team appears to align with standard medical practices for managing appendiceal submucosal tumors. The decision to perform a more extensive surgical procedure is often based on a careful consideration of the potential risks and benefits, with the overarching goal of ensuring the best possible outcome for the patient. It is always advisable to have open discussions with your healthcare providers about the rationale behind their recommendations and to seek second opinions if you have concerns about the proposed management plan.

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