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Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Case 9A+B Prof. Dr. med. Paul KOMMINOTH
Institute of Pathology
City Hospital Triemli
Birmensdorferstrasse 497
CH-8063 Zürich, Switzerland
www.triemli.ch/pathologie
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
• Patients with symptoms of acute
appendicitis
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland CgA
1 mm
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
• NET G1 of the appendical tip Dm 0.9
cm with minimal invasion (< 3mm) of
the mesoappendix, fully removed
• NET G1 of the appendical tip Dm 1.3
cm with deep invasion (> 3mm) of the
mesoappendix, fully removed
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Appendical NENs
TNM 7.ed ENETS
Tis Intraepithelial/L. propria
T1 T1a: < 1cm
T1b: > 1 - 2 cm
< 1 cm; invasion of muscularis
propria
T2 > 2 – 4 cm; or invasion of
coecum
< 2 cm; < 3 mm invasion
of subserosa/ mesoapp
T3 > 4 cm; or invasion of ileum > 2 cm; > 3 mm invasion of
subserosa/ mesoapp
T4 invasion of peritoneum/ other
organs
invasion of peritoneum/ other
organs
Virchows Arch 2006;449:395 Virchows Arch 2007;451:757
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
1 cm
TNM 7.ed
2 cm 1 cm
pT1b pT1a
1 cm
2 cm
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
1 cm
ENETS
pT1 pT3
<3mm
>3mm
1 cm
1 cm 2 cm
2 cm
pT2
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
ENETS and AJCC/UICC TNM are different for
appendiceal and pancreatic NENs
use both in your report
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
• NET G1 of the appendical tip Dm 0.9 cm with
minimal invasion (< 3mm) of the mesoappendix,
fully removed
TNM: pT1a G1; ENETS TNM: pT2 G1
• NET G1 of the appendical tip Dm 1.3 cm with
deep invasion (> 3mm) of the mesoappendix,
fully removed
TNM: pT1b G1; ENETS TNM: pT3 G1
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
• mostly detected incidentically
• 50-70% tip, 5-21% middle, 7-10% base
• 80% <1cm, 14% 1-2cm, 6% >2cm
• small tumors may not be seen macroscopically
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
A
B 1/100 – 1/300
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
• <1 cm hardly ever metastasize
• >2cm have a risk for regional metastases (21-44%)
• Moertel et al. 1987: 150 patients
127 with < 2cm -> no LN mets
3/14 with 2-3 cm -> LN mets (21%)
4/9 with > 3cm -> LN mets (44%)
• Anderson and Wilson 1985: 147 patients with <2cm
2/147 with < 2cm -> LN mets (1.3%)
• Syracuse et al. 1979: 92 patients with <1cm
2/92 with < 1cm -> LN mets (2.1%)
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Landry et al. Arch Surg 2008
143 (7): 664-670
TNM: USA proposal
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
• Meso invasion 30-40% children
10-20% adults
• Risk of LN mets in Tu < 2cm: 3.5% with
versus 0.3% without meso invasion
• 47/1248 with LN mets (3.8%) 2/3 > 2cm
and 1/3 < 2cm
• Secondary hemicolectomy 69/574:
83% T0N0, 11% Tu rest, 22% N1
Dralle H. Chirurg 2011, 82:598-606
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
LN + 10 yrs/survival
LN +
< 1 cm 15% (4/27) 100%
> 1cm - < 2cm 47% (16/34) 92%
> 2cm 86% (24/28) 91%
Appendical NET
Mullen & Savarese. J Surg Oncol 2011;104:41-44
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
Appendical NENs: Therapy
3
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
• NEN of the appendix are often detected incidentically
• Adequate dissection -> 1/100 – 1/300
• Two TNM classifications
• Lymph node metastases more frequent than previously thought (also in tumors < 2cm: 1-2%)
• Look for mesoappendical and subserosal invasion
Prof. Dr. med. P. Komminoth
STZH Zürich, Switzerland
Prof. Dr. med. A. Perren
Uni Bern, Switzerland
NET G1 tubular type
Questions ?
