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Histopathology. 2019 Jun 5. doi: 10.1111/his.13931. [Epub ahead of print]

Complicated appendiceal diverticulosis versus low grade appendiceal mucinous neoplasms: a major diagnostic dilemma.

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Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Sandford Road, Cheltenham, Gloucestershire, GL53 7AN.
Peritoneal Malignancy Institute, Basingstoke& North Hampshire Hospital, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, United Kingdom.



To research and identify how often complicated diverticular disease of the appendix (ADD) shows histological mimicry of low grade appendiceal mucinous neoplasms (LAMNs) and to provide guidance on the useful histopathological features that allow the appropriate diagnosis to be made.


74 cases of complicated appendiceal diverticular disease were identified from two specialist centres. Of the second opinion/consult cases, 71% of the ADD cases had been diagnosed by referring pathologists as LAMNs. Salient pathological features were identified and agreed upon to reach the applicable diagnosis. For a diagnosis of complicated diverticulosis, particularly when associated with mucus cysts, the following morphological features were regarded as important: relative retention of the normal mucosal architecture with lamina propria and a maintained crypt architecture, crypts arranged in regular array, epithelial hyperplasia and a lack of nuclear abnormalities extending the length of the crypts. In a formal case control study undertaken on 30 cases with each diagnosis, ADD and LAMN, loss of lamina propria, a filiform architecture and hypermucinosis were significantly associated with low grade appendiceal mucinous neoplasms. Mucosal neuromas were significantly associated with diverticular disease of the appendix.


This study represents the largest series in the world literature and serves to highlight the important pathological features to distinguish complicated diverticular disease of the appendix from LAMNs and emphasises the difficulties experienced by diagnostic pathologists in diagnosing complicated appendiceal diverticulosis. This is important as LAMNs have a significant risk of transcoelomic spread, whilst complicated appendiceal diverticulosis has no such risk. This article is protected by copyright. All rights reserved.


LAMN ; appendix; diagnosis; diverticular disease; diverticulitis; low grade appendiceal mucinous neoplasm; mimics; mucin


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