Concurrent Appendectomy in Patients Undergoing Surgery for Gynecological Malignancies: A Retrospective Analysis from a Tertiary Referral Center

Summary

Objectives:

To evaluate appendectomy specimen findings and their association with tumor type and stage. Concurrent appendectomy is frequently performed during gynecologic oncology surgery to prevent postoperative appendicitis and detect occult pathology, yet its value remains debated.

Methods:

In this study, we reviewed the medical records of 300 women who underwent gynecologic oncologic surgery accompanied by appendectomy at Başakşehir Çam and Sakura City Hospital (Istanbul, Türkiye) over the period from July 2020 to April 2025. Clinical, surgical, andhistopathologic data were collected. Appendiceal pathologies were categorized as reactive hyperplasia, chronic inflammation, benign neoplasms, metastatic tumors, or primary. Statistical analyses included chi-square, t-test, and ANOVA.

Results:

Participants had an average age of 55.6 ± 13.4 years, and 61.7% of them were postmenopausal. Among ovarian tumors, malignant epithelial lesions represented 54.7% of cases, while borderline tumors accounted for 17.7% and benign tumors for 17%. Histopathology revealed chronic inflammation in 40.7%, reactive changes in 34.3%, metastatic disease in 23.3%, benign neoplasms in 1.3%, and primary malignancy in 0.3%. Metastases occurred only in malignant ovarian tumors (35.7%), predominantly high-grade serous carcinomas (p < 0.001). Borderline and benign tumors were mainly associated with reactive findings, and no metastatic involvement was detected.

Conclusion:

Concurrent appendectomy during gynecologic oncology surgery is safe and frequently reveals clinically relevant pathology. Appendectomy should be encouraged during cytoreduction, while its role in benign and early-stage cases warrants further investigation.

Introduction

Gynecological malignancies, including ovarian, endometrial, and cervical cancers, are major causes of morbidity and mortality in women worldwide. Surgery is the cornerstone of treatment, often combined with adjuvant therapies depending on the disease stage. During cytoreductive surgery, appendectomy is frequently performed for diagnostic and preventive purposes. Incidental appendectomy performed at the time of gynecologic oncology laparotomy has been shown to be a safe procedure that frequently reveals occult appendiceal pathology, even when the appendix appears grossly normal intraoperatively [1].

Appendectomy remains one of the most frequently performed abdominal operations. According to retrospective epidemiologic estimates, the lifetime probability of developing appendicitis is approximately 8.6% for men and 6.7% for women, whereas the likelihood of undergoing appendectomy at some point in life is higher about 12% in males and 23.1% in females [2, 3]. Additionally, a U.S.-based systematic review indicated that roughly 1 in 15 people, or nearly 6.7% of the population, will experience appendicitis during their lifetime [4].

Chronic inflammation of the appendix, known as chronic appendicitis, remains controversial because classical acute symptoms are often absent. Histopathological studies have confirmed the existence of persistent or recurrent appendiceal inflammation, usually presenting as long-term abdominal pain, which is often diagnosed after appendectomy. These findings suggest that chronic inflammatory changes of the appendix may be underrecognized but clinically relevant, particularly in gynecologic oncology, where concurrent appendectomy often reveals pathological findings of this kind [5].

In gynecologic oncology, the appendix can occasionally contain unsuspected primary or secondary pathology, particularly when dealing with tumors of mucinous character in the ovary, which may influence surgical staging and subsequent treatment planning [6, 7]. Additionally, performing an appendiceal removal during the primary operative intervention may reduce the likelihood of patients developing appendicitis during chemotherapy a scenario that carries increased morbidity due to treatment-related immunosuppression [8].

Recent large-database studies advise caution regarding routine removal of a normal appendix during staging surgery for early ovarian cancer. For example, Bernard et al. [9] used National Surgical Quality Improvement Program (ACS-NSQIP) data (2010–2017) with multivariable adjustment and propensity score stratification and found that concurrent appendectomy doubled the risk of infection within 30 days postoperatively, mainly in the form of superficial surgical-site infections, but did not affect the rates of readmission and reoperation, length of hospital stays, or likelihood of mortality. These results suggest that the diagnostic benefit must be weighed against infection risk in early-stage staging surgery. In contrast, our study focused on cytoreductive procedures in gynecologic oncology, in which appendectomy may improve staging accuracy and completeness of debulking, and in which appendiceal pathology, including metastasis, is more common.

Recent literature has provided a clearer understanding of why appendiceal evaluation may or may not be necessary when managing ovarian tumors of mucinous origin. In an analysis that combined data from 8 retrospective reports, Manuel and Co-Hidalgo examined women with borderline or invasive mucinous ovarian pathology who had undergone comprehensive surgical staging that included removal of the appendix. Their synthesis demonstrated that unexpected appendiceal abnormalities were identified in roughly 3–13% of operated patients, while excising the appendix did not meaningfully improve survival outcomes and did not appear to elevate postoperative complication rates [10]. Taken together, these observations indicate that, in the setting of mucinous ovarian disease, the decision to remove the appendix should carefully weigh its modest diagnostic yield against its limited but present surgical burden.

Methods

This retrospective observational study was carried out at the Department of Gynecologic Oncology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey. The hospital is the second largest in Turkey and among the largest medical centers in Europe, which strengthens the generalizability of the findings. Patient records and pathology archives were reviewed between July 2020 and April 2025. The study included all women who underwent surgery for gynecological malignancies with a concurrent appendectomy during the study period. Inclusion criteria were i) confirmed diagnosis of gynecological malignancy, ii) simultaneous appendectomy performed during primary surgery, and iii) availability of pathology reports and follow-up data. Exclusion criteria were i) absence of appendectomy, ii) missing or incomplete pathology reports, or iii) uncertain diagnosis. Because the design was retrospective, withdrawal criteria were not applicable.

Details regarding the patients' demographic and clinical profiles were obtained from the hospital's electronic medical record system, and included the following, age and menopausal status, laboratory values (hemoglobin, C-reactive protein, white blood cell count), type of gynecological malignancy and FIGO stage, surgical approach and procedure performed, histopathological findings of the appendix. Appendiceal pathologies were classified into five categories, reactive hyperplasia (nonpathological appendix), chronic inflammation (appendicitis, periappendicitis, fibrous obliteration, or related changes), benign neoplasms (adenoma, villous adenoma, leiomyoma, etc.), metastases from gynecological or extra-abdominal tumors, primary appendiceal malignancies (for example, carcinoma in situ, adenocarcinoma).

Ethical approval for this research was granted by the Scientific Research Ethics Committee No. 1 of Başakşehir Çam and Sakura City Hospital in Istanbul, Turkey (Approval ID: KAEK/09.07.2025.188). As the study relied solely on retrospective data, the committee issued a formal waiver for informed consent. All methodological steps were carried out in accordance with the ethical standards of the 1964 Helsinki Declaration and its subsequent revisions.

Statistical analysis

The statistical evaluations were carried out using SPSS software (version 25.0; IBM Corp., Armonk, NY, USA). The distribution characteristics of continuous variables were examined through skewness–kurtosis coefficients and confirmed using the Kolmogorov–Smirnov or Shapiro–Wilk tests. Variance equality was assessed with Levene's test. For variables meeting normal distribution assumptions, group comparisons were performed with independent samples t-tests or one-way ANOVA. In contrast, non-normally distributed data were evaluated using the Mann–Whitney U test or the Kruskal–Wallis test. Categorical data were analyzed with chi-square testing. To investigate relationships between appendiceal pathology and clinical parameters, correlation analyses and regression modeling were undertaken. A p-value below 0.05 was interpreted as statistically significant.

Results

A total of 300 women were analyzed in the cohort, with the average age calculated as 55.6 ± 13.4 years. Laboratory assessments showed a median hemoglobin concentration of 11.6 ± 1.6 g/dL. The peripheral leukocyte count had a mean value of 8.5 ± 4.8 ×10³/μL, while C-reactive protein levels demonstrated a wide distribution, averaging 90.3 ± 78.0 mg/L. Among the patients, 116 (38.7%) were premenopausal and 184 (61.3%) were postmenopausal. Lymphovascular invasion was identified in 128 patients (42.7%) (Table 1).

Table 1.

Baseline characteristics and histopathological diagnoses of patients.

Variables		n (%)
Age (years)		55.6 ± 13.4
Hemoglobin (g/dL)		11.7 ± 1.6
WBC (×103/μL)		8.5 ± 4.8
CRP (mg/L)		90.3 ± 78
Menopause	No	116 (38.7)
	Yes	184 (61.3)
Lymphovascular invasion	Absent	172 (57.3)
	Present	128 (42.7)
Malignancy status	Benign	47 (15.7)
	Borderline	54 (18.0)
	Malignant	199 (66.3)
Appendiceal pathology	Reactive	103 (34.3)
	Chronic inflammation	122 (40.7)
	Metastasis	70 (23.3)
	Benign neoplasm	4 (1.3)
	Primary malign appendiceal tumor	1 (0.3)
Benign tumors (n = 51, 17%)	Unspecified benign	27 (9.0)
	Leiomyoma	2 (0.7)
	Mucinous cystadenoma	12 (4.0)
	Seromucinous cystadenoma	2 (0.7)
	Seromucinous cystadenofibroma	3 (1.0)
	Serous cystadenofibroma	2 (0.7)
	Mucinous cystadenofibroma	1 (0.3)
	Fibrotecoma	2 (0.7)
Borderline tumors (n = 53, 17.7)	Borderline mucinous tumor	33 (11.0)
	Serous borderline tumor	14 (4.7)
	Seromucinous borderline tumor	4 (1.3)
	Endometrioid borderline tumor	2 (0.7)
Malignant epithelial tumors (n = 164, 54.7%)	High-grade serous carcinoma	108 (36.0)
	Mucinous adenocarcinoma	12 (4.0)
	Clear cell carcinoma	16 (5.3)
	Endometrioid adenocarcinoma	25 (8.3)
	Malignant epithelial tumor (NOS)	2 (0.7)
	Mesonephric-like carcinoma	1 (0.3)
Nonepithelial ovarian tumors (n = 6, 20%)	Granulosa cell tumor	4 (1.3)
	Mixed germ cell tumor	1 (0.3)
	Dysgerminoma	1 (0.3)
Sarcomas/carcinosarcoma (n = 12, 4%)	Carcinosarcoma	6 (2.0)
	Leiomyosarcoma	4 (1.3)
	Malignant mesenchymal tumor	2 (0.7)
Metastatic tumors (n = 14, 4.7%)	Cervical carcinoma	6 (2.0)
	Lung adenocarcinoma	1 (0.3)
	Breast carcinoma metastasis	1 (0.3)
	Colon carcinoma metastasis	2 (0.7)
	Gastrointestinal neuroendocrine tumor	1 (0.3)
	Appendiceal goblet cell adenocarcinoma	2 (0.7)
	Appendiceal mucinous carcinoma	1 (0.3)

Values are presented as mean ± standard deviation or number (percentage).stated. SD: standard deviation, WBC: white blood cell, CRP: C-reactive protein, NOS: not otherwise specified. Comparisons between categorical variables were performed using the Chi-square test; continuous variables were compared using Student's t-test or ANOVA where appropriate. Statistical significance was defined as p < 0.05. Appendiceal metastases were observed only in malignant epithelial ovarian tumors, most commonly in high-grade serous carcinoma (p < 0.001).

Ovarian tumor subtypes included benign tumors in 51 (17%) patients, borderline tumors in 53 (17.7%), malignant epithelial tumors in 164 (54.7%), nonepithelial tumors in 6 (2%), sarcomas/carcinosarcomas in 12 (4%), and metastatic tumors in 14 (4.7%). High-grade serous carcinoma accounted for the largest proportion of malignant tumors (36%) (Table 1).

Appendiceal pathology revealed chronic inflammation in 122 patients (40.7%), reactive changes in 103 (34.3%), metastatic involvement in 70 (23.3%), benign neoplasms in 4 (1.3%), and primary appendiceal malignancy in 1 (0.3%) (Table 1).

When stratified by tumor type, reactive changes were more common in benign and borderline tumors (52.9% and 45.3%, respectively) than in malignant ones (26.5%). Chronic inflammation occurred at similar rates across the groups. Metastatic involvement was detected only in malignant tumors (35.7%), while it was absent in benign and borderline ones, which constituted a statistically significant difference (p < 0.001) (Table 2).

Table 2.

Patient characteristics and histopathological diagnoses by malignancy group.

Variable/Diagnosis		Benign (n = 51)	Borderline (n = 53)	Malignant (n = 196)	P value
Agea (years)		53.2a,b ± 14.3	48.7a ± 15.0	58.0b ± 12.0	<0.001
Hemoglobina (g/dL)		11.8 ± 1.7	12.0 ± 1.5	11.5 ± 1.6	0.061
WBCb (×103/μL)		7.8 (1.6–18.9)	7.9 (4.5–15.7)	7.6(1.4–70.0)	0.595
CRPb (mg/L)		73.8 (0.40–337.0)	85.9 (1.6–327.0)	78.3(0.3–323.0)	0.633
Menopausec		24a (47.1%)	23a (43.4%)	137b (69.9%)	<0.001
Lymphovascular invasionc		0a (0.0%)	2a (3.8%)	126b (64.3%)	<0.001
Appendiceal pathologyc	Reactive	27a (52.9%)	24a (45.3%)	52b (26.5%)	<0.001
	Chronic inflammation	22a (43.1%)	27a (50.9%)	73a (37.2%)
	Metastasis	0a (0.0%)	0a (0.0%)	70b (35.7%)
	Benign neoplasm	1a (0.0%)	2a (3.8%)	1a (0.5%)
	Primary malign appendiceal tumor	1a (2.0%)	0a,b (0.0%)	0a (0.0%)

SD: standard deviation, WBC: white blood cell, CRP — C-reactive protein; ANOVA — analysis of variance.

^aParametric variables are presented as mean ± standard deviation and were compared using one-way ANOVA.

^bNonparametric variables are presented as median (25th–75th percentile) and were compared using the Kruskal–Wallis test.

^cCategorical variables are presented as n (%) and were compared using the chi-square test. Each subscript letter denotes a subset of diagnosis categories whose column proportions do not differ significantly from each other at the 0.05 level.

In nonmucinous tumors, reactive changes were found in 45.5% of benign, 56.3% of borderline, and 27.9% of malignant tumors. Metastasis was observed exclusively in malignant tumors (37.2%). In mucinous tumors, reactive changes were identified in 66.7% of benign, 40.5% of borderline, and 7.7% of malignant tumors. Metastatic involvement was limited to malignant mucinous tumors (15.4%). Benign appendiceal neoplasms were rare in both groups, and only one case of primary appendiceal carcinoma was reported (Table 3).

Table 3.

Distribution of appendix findings according to malignancy groups in mucinous and nonmucinous cases.

	Nonmucinous				Mucinous
Appendiceal pathology	Benign (n = 33)	Borderline (n = 16)	Malignant (n = 183)	P-value	Benign (n = 18)	Borderline (n = 37)	Malignant (n = 13)	P-value
Reactive	15a (45.5%)	9a (56.2%)	51b (27.9%)	<0.001	12a (66.7%)	15a (40.5%)	1b (7.7%)	0.007
Chronic inflammation	17a (51.5%)	7a (43.8%)	64a (35.0%)		5a (27.8%)	20a,b (54.0%)	9b (69.2%)
Metastasis	0a (0.0%)	0a (0.0%)	68b (37.1%)		0a,b (0.0%)	0b (0.0%)	2a (15.4%)
Benign neoplasm	0a (0.0%)	0a (0.0%)	0a (0.0%)		1a (5.6%)	2a (5.4%)	1a (7.7%)
Primary malign appendiceal tumor	1a (3.0%)	0a,b (0.0%)	0b (0.0%)		0a (0.0%)	0a (0.0%)	0a (0.0%)

NOS:not otherwise specified. Each subscript letter denotes a subset of diagnosis categories whose column proportions do not differ significantly from each other at the 0.05 level.

^aValues are presented as number (percentage).

^bComparisons among groups were performed using the Chi-square test. A p-value <0.05 was considered statistically significant.

^cEach subscript letter denotes a subset of diagnosis categories whose column proportions do not differ significantly from each other at the 0.05 level.

^dAppendiceal metastasis was observed predominantly in malignant nonmucinous ovarian tumors (37.1%) and was rare in mucinous malignancies (15.4%).

^ePrimary appendiceal malignancy was extremely uncommon and identified in only 1 nonmucinous benign group case (3%).

Discussion

This retrospective study analyzed outcomes of concurrent appendectomy in 300 women who underwent surgery for gynecological malignancies. We found that the appendix often harbors significant pathology, including reactive and inflammatory changes, benign neoplasms, metastatic disease, and, on rare occasions, primary appendiceal tumors. Metastatic involvement occurred only in malignant ovarian tumors, especially high-grade serous carcinomas, confirming the staging and cytoreductive value of appendectomy.

The high rate of appendiceal pathology in our series matches the findings in the broader literature. Addiss et al. [2] reported that appendectomy is one of the most common operations worldwide, with the lifetime risk of appendicitis reaching 6.7% in females. Jocko et al. [3] found that 59% of appendectomy specimens obtained during gynecologic surgery showed abnormalities, including 64% in women with endometriosis and 38% in those with chronic pelvic pain. Notably, 44% of grossly normal appendices contained pathology. These results parallel our findings and support the removal of the appendix as a diagnostic adjunct.

Salom et al. [4] showed that incidental appendectomy during abdominal hysterectomy for benign conditions did not increase complications such as fever, wound infection, or ileus. They also found that 31% of appendiceal specimens had histological abnormalities, most often fibrous obliteration. In our study, appendectomy performed during cytoreductive surgery likewise did not elevate morbidity, confirming its safety when performed by trained gynecologic oncologists.

Metastatic involvement of the appendix was seen in 35.7% of malignant ovarian tumors in our cohort. Previous studies also highlighted the appendix as a common site of occult metastasis in mucinous and serous carcinomas [6, 7]. These results emphasize the importance of appendectomy in cytoreduction and staging. Benign neoplasms and primary malignancies were rare, but their detection has diagnostic value.

Bernard et al. found that appendectomy during early-stage ovarian cancer staging doubled the risk of superficial surgical-site infection [11]. They thus recommended against routine removal of a normal appendix in early disease. In contrast, our cytoreductive cohort showed no increase in morbidity, and we documented metastatic disease in more than one-third of malignant ovarian tumors. This supports the role of appendectomy in advanced cases.

Badiner et al. [12] reported that 12% of grossly normal appendices contained pathology, while more than half of appendices with an abnormal appearance were benign. They found no upstaging due to isolated appendiceal metastasis in early-stage disease but confirmed that the procedure was safe. Our results align with these findings and show that intraoperative appearance is unreliable.

Elsewhere, Benoit et al. [13] reviewed 1,876 incidental appendectomies and reported significant disease in 11.8% of specimens, including primary appendiceal cancer (1.7%), metastases (3.8%), other metastatic tumors (0.6%), endometriosis (2.1%), and appendicitis (1.3%). They reported no complications attributable to appendectomy and no effect of body mass index or surgical route. Their large mixed-risk cohort complements our malignancy-focused cohort.

Our findings are also consistent with a recent large series by Khalid et al., who evaluated appendiceal lesions in two cohorts of women undergoing appendectomy either for mucinous ovarian neoplasms or as part of cytoreductive surgery for gynecological malignancies and reported primary appendiceal pathology in 13% and 7% of cases, respectively, with 7% of macroscopically normal appendices harboring significant lesions. In line with their conclusion that the appendix is a frequent site of primary and metastatic disease and that macroscopic assessment alone is unreliable, our data—showing a non-negligible rate of metastatic involvement and rare primary tumors despite routine removal—further support performing concurrent appendectomy and careful histopathologic examination in selected gynecologic oncology patients [14].

In addition, our findings parallel case-based reports highlighting that appendiceal mucinous lesions may closely mimic right adnexal masses and only be correctly identified intraoperatively or on final histopathology. Sklyarova et al. [15] described 2 women initially thought to have right adnexal pathology who were ultimately diagnosed with appendiceal mucinous cystadenoma and cystadenocarcinoma, underscoring the diagnostic overlap between appendiceal and ovarian disease and supporting careful intraoperative assessment and consideration of appendectomy in selected gynecologic cases.

Additionally, previous literature has highlighted that unexpected appendiceal pathology may occasionally be detected during gynecologic surgery even when the appendix appears macroscopically normal. Al-Jabri and Tulandi [16] reported that incidental appendiceal abnormalities were identified in a subset of women undergoing pelvic surgery for gynecologic indications, supporting the rationale for considering appendectomy in selected cases to avoid missed diagnoses. Our findings align with this perspective by demonstrating that concurrent appendectomy can reveal occult pathology in a small but clinically relevant proportion of patients with gynecologic malignancies.

Furthermore, appendiceal pathology is not uncommon in gynecologic surgery, even when the preoperative suspicion is low. Gustofson et al. [17] demonstrated that the appendix may harbor clinically relevant disease, including endometriosis, despite an unremarkable gross appearance during pelvic surgery. This reinforces the rationale for considering concurrent appendectomy in selected oncologic cases, as occult appendiceal abnormalities may otherwise be overlooked. Together, these results indicate that concurrent appendectomy is safe, adds staging accuracy, and contributes to complete cytoreduction in selected patients with gynecological malignancies.

This study is subject to several important constraints. To begin with, the retrospective nature of the investigation restricts the ability to fully account for unmeasured confounders. Additionally, because the research was carried out at a single high-volume tertiary oncology center, the external validity of the findings may be limited. The duration of patient follow-up was also relatively brief, preventing an assessment of long-term survival or oncologic outcomes. Moreover, the lack of detailed information regarding intraoperative events and postoperative infectious complications restricts a more thorough evaluation of procedural safety. Future research preferably prospective, multicenter, and with extended follow-up is needed to substantiate these results.

In conclusion, concurrent appendectomy during surgery for gynecological malignancies is a safe and valuable procedure. It frequently reveals pathology, including chronic inflammation, reactive changes, and metastatic disease, as well as primary neoplasms on rare occasions. In this study, metastatic involvement occurred only in malignant ovarian tumors, especially high-grade serous carcinomas, emphasizing its role in staging and cytoreduction. Our findings, together with previous international series, support the consideration of routine appendectomy during cytoreductive surgery in selected patients. This approach may improve diagnostic accuracy, guide adjuvant therapy, and prevent complications such as acute appendicitis during chemotherapy.

This study was carried out at Başakşehir Çam and Sakura City Hospital, the second largest hospital in Turkey and one of the largest centers in Europe, strengthening the relevance of our results. Future multicenter prospective studies with long-term follow-up are needed to confirm the prognostic value of appendiceal pathology in gynecologic oncology.

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Conflict of interest

The authors declare no conflict of interest.

Funding

The authors did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Funding data are available and will be provided upon request.

Acknowledgment

The authors gratefully acknowledge the contribution of the clinical and nursing staff of the Department of Gynecologic Oncology Surgery, Başakşehir Çam and Sakura City Hospital, for their support in data collection and patient care.