Is Appendiceal Cancer a Risk of Nonoperative Management of Pediatric Uncomplicated Appendicitis?

Introduction: Nonoperative management (NOM) of pediatric uncomplicated appendicitis is becoming increasingly common. As most appendiceal cancer in children is incidentally diagnosed after appendectomy, there is a theoretical risk of missed appendiceal cancer with NOM. The objective of this study was to determine the incidence of appendiceal cancer in children who otherwise met the criteria for NOM. Methods: This study is a secondary analysis of a multi-intuitional, nonrandomized interventional trial comparing surgery to NOM of uncomplicated appendicitis in children 7 to 17 y across ten tertiary children's hospitals between May 2015 and October 2018. Inclusion criteria for this study were (1) imaging confirmed uncomplicated appendicitis without evidence of abscess, fecalith, or phlegmon and appendiceal diameter ≤1.1 cm; (2) white blood cell count between 5000/μL and 18,000 μL; and (3) abdominal pain for less than 48 h before presentation. Pathology was reviewed for all children who underwent laparoscopic appendectomy, including those who chose primary appendectomy and those who failed NOM within 1 y. Appendiceal cancer was defined as any type of cancer, including carcinoid. Results: A total of 826 patients (median age 12.5 y, interquartile range 10.4-14.8, 38% females) underwent an appendectomy during the study period, with 698 of these patients choosing upfront appendectomy and 128 patients undergoing appendectomy after failed NOM (242 of the 370 patients who chose NOM in the trial were successfully managed nonoperatively). Of the 128 patients who failed nonoperative management, 53 (41%) failed therapy and underwent laparoscopic appendectomy during initial admission, with pathology reports available for 52 patients, and 75 (59%) developed recurrent appendicitis and underwent appendectomy, 74 patients had available pathology reports. Among the 824 patients with available pathology reports, there were no appendiceal cancers (95% confidence interval 0%-0.36%). Conclusions: In children with uncomplicated appendicitis who qualify for NOM, the incidence of appendiceal cancer is exceedingly rare. Therefore, the risk of appendiceal cancer should minimally factor into counseling and decision-making between surgery and NOM in uncomplicated appendicitis in children.