Children with cancer can face a number of unexpected diagnostic and therapeutic dilemmas, including whether to operate on a child with cancer who is neutropenic and has all the signs, symptoms, and imaging consistent with acute appendicitis. While you might think surgery is the way to quickly and effectively treat this well-recognized cause for an acute abdomen, being neutropenic can increase the risk of infection and sepsis suggesting the non-surgical approach of treating with parenteral antibiotics should be considered as an alternative. So, which is the better option?
Many et al (10.1542/peds.2020-027797) share with us a retrospective review of 66 children with neutropenic appendicitis (NA) (confirmed by ultrasound, CT, or MRI with neutropenic colitis or typhlitis cases excluded) collected over 7 years in 15 North American children’s hospitals that are part of the Pediatric Surgery Oncology Research Collaborative. 27 patients had an appendectomy within the first 24 hours of diagnosis and the remainder had initial non-operative management (including one receiving a percutaneous drain). The good news is that rates of complications in terms of abscess or perforation were similar between the two groups. About half (46%) of those who were not initially treated surgically were operated on due to failure of nonoperative management or because white blood cell counts recovered. Not undergoing surgery initially did result in longer length of stay (29 vs 12 days, p=.01), more post-op complications, and more delay in cancer treatment than those who got immediate surgical treatment. So, does this mean surgery is the way to go when faced with this dilemma in a patient of yours with cancer, appendicitis, and neutropenia? Are 66 patients sufficient to make the surgical choice that “a chance to cut is a chance to cure?”
To add some perspective to this study we invited pediatric surgeons Drs. Kibileri Williams (Children’s National Hospital) and Tolulope Oyetunji (Children’s Mercy Hospital) to share with us their thoughts in an accompanying commentary (10.1542/peds.2020-035279). The authors of this editorial note some key strengths of this study and remark that this is probably the largest series of cases of NA ever compiled so it is well worth paying attention to. On the other hand, they raise some limitations that this study, retrospective in nature, could not answer such as how severely ill these children were with their cancer at the time of a decision being made, or if granulocyte colony stimulating factor had been given prior to developing their symptoms to enable white cells to return sooner so a surgical approach was more likely to go without complications.
It is interesting to note that the majority (75%) of children with NA who were not operated on initially required no further surgical treatment for this problem if they were able to get their full course of antibiotics rather than move to surgical treatment after only a partial course of antimicrobials, so perhaps there are subgroups of cancer patients who can avoid the risk of surgery, but this study cannot answer that question. The study does set the table for future prospective analyses and hopefully larger samples of patients who can better predict whether or not the benefits of immediate surgery outweigh the risk. Until then check out this study and commentary which will take you to the cutting edge—and likely convince you that with the data that currently exists, surgery may be the better option if the patient is clinically otherwise stable to tolerate an operation in the setting of their neutropenia.