Adenocarcinoma of the appendix

Vesico-appendiceal fistula secondary to adenocarcinoma of the appendix: a case report and literature review

A 50-year-old woman presented with a 5-month history of recurrent urinary tract infections. She had no complaints of any intestinal symptoms. She had been treated previously with oral antibiotics. The episodes became more frequent and she started with pain in the lower abdomen and fetid urine. Complete study lead to diagnosis of adenocarcinoma of the appendix with bladder fistula. The lesion was removed by laparoscopic right hemicolectomy and en bloc partial cystectomy. Pathological examination revealed a mucinous adenocarcinoma that had originated in the appendix and extended into the bladder wall. Six years after the operation, the patient remains asymptomatic with no evidence of recurrent or metastatic disease. Appendiceal carcinoma extending to the bladder is extremely rare and approximately 40 cases have been described. Management of recurrent urinary tract infections should not limit to empiric antibiotic therapy before the exclusion of possible organic causes. Appendiceal carcinoma may invade the bladder without intestinal symptoms but with urinary symptoms only, because of its anatomical position. The recommended treatment for non-carcinoid appendiceal tumours is right hemicolectomy and for T4 tumours en bloc resection of the involved structures. Further study is needed to determine adjuvant therapy. A literature review was made.

Primary Appendicular Malignancy Presenting as Abdominal Wall Abscess with Secondary Tuberculosis Infection: an Interesting Case Report

Cancers of the appendix are rare. Most of them are found accidentally on appendectomies performed for appendicitis. When reviewed, majority of the tumors were carcinoid, adenoma, and lymphoma. Adenocarcinomas of the appendix are only 0.08% of all cancers, and the treatment remains controversial. It can present as appendicitis or lump or abscess. Gastrointestinal tuberculosis most commonly involves the ileocecal region. Disruption of the integrity of mucosal barriers and impairment in cell-mediated immunity associated with cancerous growth are known to predispose to bacterial infection. The role of antituberculosis therapy and chemotherapy is unclear due to lacking randomized trials but seems to be accepted if there is lymph node involvement or peritoneal seeding. Here, we are reporting a 69-year-old lady presented with symptoms of abdominal wall abscess with tuberculosis infection which was then diagnosed with mucinous adenocarcinoma of the appendix. The patient was treated with incision and drainage followed by the right hemicolectomy. Up to date, she remains asymptomatic and continuing with chemotherapy.

Mucinous epithelial neoplasms of the appendix and pseudomyxoma peritonei

The classification of appendiceal mucinous neoplasms has been controversial, largely focused on a particular subset of low-grade mucinous tumors that, despite their innocuous appearance, can disseminate to the peritoneal cavity as pseudomyxoma peritonei (PMP). Recent WHO classification of these tumors as low-grade appendiceal mucinous neoplasms acknowledges their unique morphologic appearance and biologic behavior. Still, debate about the use of this term and its parameters continues to impede the adoption of consensus classification for appendiceal mucinous neoplasms. The classification of PMP has also been the subject of debate, with international authorities advocating for the use of malignant terminology to describe all grades of PMP, even though some authorities consider low-grade PMP to be dissemination of adenomatous epithelium in the peritoneum. Recent data also emphasize the importance of histologic grade of the peritoneal tumors in defining prognosis of these patients.

Cancers of the appendix: review of the literatures

Cancers of the appendix are rare. Most of them are found accidentally on appendectomies performed for appendicitis. When reviewed, majority of the tumors were carcinoid, adenoma, and lymphoma. Adenocarcinomas of appendix are only 0.08% of all cancers and the treatment remains controversial. Here we are reporting a 46-year-old male presented with symptoms of appendicitis, diagnosed with adenocarcinoma of the appendix. The patient was treated with appendectomy and refused further surgical intervention to complete hemicolectomy. Up to date, he remains asymptomatic. We performed literature review of the tumors of the appendix. Most of the benign conditions are treated with surgery alone. Lymphomas require CHOP-like chemotherapy and carcinoid syndrome treatment with somatostatin analogues. It is generally recommended that right hemicolectomy is the preferred treatment for adenocarcinoma of appendix. The role of chemotherapy is unclear due to lacking randomized trials but seems to be accepted if there is lymph node involvement or peritoneal seeding.

Primary Mucinous Adenocarcinoma of Appendix Treated with Chemotherapy and Radiotherapy: A Case Report

A rare case of primary appendiceal mucinous adenocarcinoma is reported. The presenting signs and symptoms were suggestive of acute appendicitis. An appendectomy was performed resulting in a histological diagnosis of grade 2 mucinous adenocarcinoma of the appendix. The patient was referred to our clinic where he underwent a complementary right hemicolectomy with lymph node dissection. Two of the 17 resected lymph nodes were tumor positive but there was no residual tumor in the hemicolectomy specimen. The patient was staged as T4N1M0 and adjuvant multimodality treatment was planned because he was considered at high risk for local-regional recurrence and distant metastasis. Three cycles of capecitabine 1250 mg/m2 on days 1–14 and oxaliplatin 130 mg/m2 on day 1, every 21 days (CAPOX) were administered, then a total dose of 50.4 Gy external-beam radiation therapy was deliveredtothe primarytumor region and 45 Gy to the lymphatics, and finally3 further cycles of the CAPOX regimen were administered. Multimodality treatment was well tolerated by the patient, who is still alive 25 months after the hemicolectomy procedure with no evidence of disease progression.

Primary adenocarcinoma of the appendix invading the urinary bladder

We report a case of adenocarcinoma of the appendix invading the urinary bladder in a 75-year-old man. Although cystoscopic examination and computed tomography suggested a primary or secondary bladder tumor, repeated transurethral bladder biopsy could not confirm the neoplasm. At operation a primary neoplasm of the appendix invading the bladder was discovered and en bloc resection of the urinary bladder with the adherent cecum followed by an ileocolonic anastomosis and ureterocutaneostomy was performed. The patient died of carcinoma 13 months later.

Early cystoadenocarcinoma of vermiform appendix simulating submucosal tumor of the cecum

Colonoscopy was performed on a 54-year-old man with occult melena in our hospital. A submucosal tumor with a maximum diameter of 5cm was detected in the cecum. The tissue of the submucosal tumor was not obtained by endoscopic biopsy, and tumor diagnosis could not be confirmed by this method. A large, hypodense, cystic structure extending below the inferior wall of the cecum was revealed by computed tomography (CT). Because the tumor was too large to be a benign tumor, we were able to conclude it was malignant. After receiving informed consent from the patient, laparoscopic right colectomy was performed for both diagnosis and treatment in June 2004. As the swollen vermiform appendix pressed the cecum extraluminally, endoscopic examination indicated the possibility of submucosal tumor. Postoperative pathological diagnosis was cystoadenocarcinoma, the tumor was extended within the mucosal layer, and no lymph node metastasis was detected. Cancer cells were not present in the viscous liquid of the vermiform appendix intracavitary, either. The patient left the hospital in 10 days postoperatively. He regularly underwent examinations including CT, and no recurrence was detected for more than 24 months following the laparoscopic operation.

Primary epithelial neoplasms and other epithelial lesions of the appendix (excluding carcinoid tumors)

Epithelial tumors of the appendix range from low-grade mucosal-based tumors which, when confined to the appendix, have an excellent prognosis but, once outside the appendix, have a fair prognosis and often a prolonged disease course, to high grade invasive carcinomas that are rapidly fatal. Low grade mucinous neoplasms may rupture and spread to the peritoneum as pseudomyxoma peritonei, and the nomenclature of these tumors has been the subject of considerable disagreement among pathologists; the designation "low grade appendiceal mucinous neoplasm" has recently been proposed for reasons discussed herein. Demonstrating rupture of these neoplasms may require particularly diligent gross and microscopic evaluation as the rupture site often heals over leaving only subtle evidence of its presence. Invasive adenocarcinomas are often mucinous and may also spread to the peritoneum. Against this backdrop, the clinical and pathologic features of low grade appendiceal mucinous neoplasms and mucinous adenocarcinomas, as well as other types such as typical colorectal type and signet-ring cell type, are reviewed. In addition, emerging entities, serrated polyps and serrated adenomas, whose significance is only beginning to be understood, are considered. Retention cysts, hyperplastic polyps, and diffuse mucosal hyperplasia, although not necessarily neoplastic, are reviewed here as they may enter into the differential diagnosis of appendiceal mucinous neoplasms.

Asymptomatic primary mucinous cystadenocarcinoma of the appendix with a large abdominal mass: report of a case

A case of cystadenocarcinoma of the appendix with a large cystic lesion is reported. A 49-year-old man undergoing a routine ultrasonic scan was incidentally found to have an abdominal mass measuring some 30 cm in size. The clinical presentation was asymptomatic, and the patient underwent a laparotomy without ascertaining a diagnosis preoperatively. The lesion, which derived from the appendix, was removed and was found to be cystic and contained huge amounts of mucin. The histological findings revealed a well-differentiated cystadenocarcinoma of the appendix, and immunohistochemical staining of the epithelium and mucinous implants in the mass demonstrated a positive reaction for carcinogenic antigens, including carcinoembryonic antigen and carbohydrate antigen.

The natural history of surgically treated primary adenocarcinoma of the appendix

OBJECTIVE

The aim of this investigation was to determine the prognostic variables and optimal surgical procedure for patients with adenocarcinoma of the appendix.

SUMMARY BACKGROUND DATA

Primary adenocarcinoma of the appendix is a rare malignancy that constitutes less than 0.5% of all gastrointestinal neoplasms. However, the prognostic factors and the preferred surgical procedure and outcome are poorly understood.

METHODS

The authors reviewed their institutional experience from 1976 to 1992 in treating 94 consecutive patients with primary adenocarcinoma of the appendix. Patients with carcinoid tumors or those in whom the diagnosis of primary cecal cancer could not be ruled out were excluded from the study.

RESULTS

Fifty-two (55%) patients had the mucinous variety, of which 22 had pseudomyxoma peritonei; the other 45% had the colonic and adenocarcinoid types of tumor. The most common presentation was that of acute appendicitis. Interestingly, in no patients was the correct diagnosis made before surgery, and it was entertained intraoperatively in only 30 patients (32%). The cure 5-year survival rate was 55%, but it varied with stage (A, 100%; B, 67%; C, 50%; and D, 6%; p < 0.01) and with grade (I, 68%, and III, 7%; p < 0.01). Patients with the mucinous type had a better prognosis than those with the colonic type (p < 0.01). The survival rate was superior after right hemicolectomy versus appendectomy alone (68% vs. 20%, p < 0.001). Right hemicolectomy performed as a secondary procedure resulted in the upstaging of 38% of the patients' tumors. A second primary malignancy occurred in 33 patients (35%), of which 17 were located in the gastrointestinal tract.

CONCLUSIONS

Primary adenocarcinoma of the appendix should be treated by right hemicolectomy, even if it is a secondary procedure. Surveillance for synchronous or metachronous tumors, especially in the gastrointestinal tract, is warranted.

Unexpected findings in gastrointestinal tract surgery

We discussed the proper management of patients with asymptomatic lesions incidentally found during laparotomy for other problems. For common or important lesions, information about the natural history, significance, treatment guidelines, and possible risks or complications related to operations on such incidentalomas were given. Thus, we discussed gallstones, masses of the upper and lower gastrointestinal tract, and masses in solid organs, such as liver, ovaries, and pancreas.

Adenocarcinoma of the vermiform appendix. A population study

We report seven cases of adenocarcinoma of the vermiform appendix occurring in Iceland during 1974-1989. The patients ranged in age from 25-83 years, mean age 55.1 years. There were five males and two females. Five had mucinous adenocarcinoma, two had adenocarcinoma. Four patients presented with symptoms and signs of acute appendicitis and all had surgically resectable disease. Three of these patients were alive with no evidence of disease four months, two years and 15 years after presentation; one death of disease occurred seven years after ileocecal resection. In three cases, the clinical presentation was that of metastatic adenocarcinoma of unknown origin. Of these patients two were diagnosed at autopsy and one after appendectomy for perforated appendicitis. Survival in this group was six weeks, three months and twelve months, respectively. In none of our patients was the diagnosis made preoperatively and no tumors were found in appendices removed incidental to other intra-abdominal operations. The incidence of adenocarcinoma of the vermiform appendix in Iceland during 1974-1989 was approximately 0.2 cases/100.000/year.

Adenocarcinoma of the vermiform appendix

Primary adenocarcinoma of the appendix is rare. Eleven patients with this rare neoplasm have been evaluated at our institution over a 50-year period. We have reviewed the presentation and clinical course of these patients, and have compared them with those described in the literature. The presenting signs and symptoms, physical findings, and treatment were similar to those described in the literature. However, the 5-year survival of 20% is lower than most series, and reflects the advanced stage of disease at the time of diagnosis in this group of patients. Despite the low 5-year survival, we feel that aggressive therapy (right hemicolectomy) is necessary to obtain long-term survival.

Enterovesical fistula secondary to mucinous adenocarcinoma of appendix

We report an unusual case of an enterovesical fistula secondary to adenocarcinoma of the appendix.