Adenocarcinoma of the appendix: an unusual case and review

A case report of incarcerated inguinal hernia: Amyand's hernia with adenocarcinoma tumor

INTRODUCTION

Inguinal hernia is one of the most common surgical problems, often posing technical challenges even to expert surgeons. Amyand's hernia (AH) is an inguinal hernia whose sac contains the vermiform appendix. Primary appendiceal neoplasms are rare. We report the case of an appendiceal adenocarcinoma within an Amyand's hernia, presenting as an incarcerated right inguinal hernia.

PRESENTATION OF CASE

A 87-year-old male presented in the emergency department due to a persistent right inguinal pain. Clinical examination revealed a tender right groin mass. Under the diagnosis of an right inguinal hernia, an operation was taken. Intraoperatively, an inflamed appendix and a part of the cecum were found in the hernia sac. The operation was completed with an ileocecal resection and a modified Bassini hernia repair. Histological examination revealed a adenocarcinoma of the appendix.

DISCUSSION

Amyand's hernia is an inguinal hernia that contains vermiform appendix in its sac. It consists 1% of all inguinal hernias while appendicitis in an Amyand's hernia accounts for 0.1% of all appendicitis cases. Adenocarcinomas of the appendix are even rarer, accounting for 0.2% to 0.5% of all intestinal malignancies, and 4%-6% of primary appendiceal neoplasms. Diagnosis is usually established intraoperatively.

CONCLUSION

A malignancy of the appendix should always be in the differential diagnosis of a right inguinal mass, in order to provide optimum surgical treatment.

Synchronous primary adenocarcinoma of the appendix and colon: Case report and literature review

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Primary adenocarcinoma of appendix is rare pathology that is discovered usually on histopathologic examination of resected appendix.

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It is important to report all pathologic reports to the primary physician in order to confirm primary diagnosis and discuss it with their patients.

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If a diagnosis of PAA is reported, a surveillance lifelong colonoscopy screening is mandatory to rule out synchronous or metachronous occurrence of colonic malignances.

Introduction

Primary adenocarcinoma of the appendix (PAA) is rare with fewer than 300 cases reported from 1882 Up to 2004. Synchronous occurrence of PAA with a second primary colonic carcinoma is even more unusual. Literature review shows a total of 40 reported synchronous cases in the English literature from the first case reported in1947 up to 2017. Hereby, an additional case is presented, which is the first case reported in Jordan.

Presentation of case

A 39-year-old woman presented in October 2016 with persistent right lower quadrant abdominal pain diagnosed clinically as acute appendicitis. Abdominal computed tomography showed an oval shaped 3 × 3.4 cm mass at the sub-hepatic region, associated with increased attenuation of surrounding mesenteric fat and multiple enlarged lymph nodes. Three days later, a right hemicolectomy was carried out. A diagnosis of invasive primary adenocarcinoma of the ascending colon with an incidental, microscopic primary adenocarcinoma of the distal part of the appendix was reported.

Discussion

Primary appendiceal adenocarcinoma is rare pathology with an incidence ranges from 0.01% to 0.3% that is characterized by presence of adenocarcinomatous cells originating in the appendix that are in direct continuity with the normal appendiceal mucosa. Even it is less common, synchronous primary adenocarcinoma of the appendix and the colon has been reported in literature, with less than 37 cases being reported in literature so far. PAA are seldom suspected in preoperative phase or even intraoperatively, and it is diagnosed based on histopathologic examination of the resected appendix. Once PAA is diagnosed, a lifelong surveillance with colonoscopy is mandatory to detect synchronous or metachronous colonic malignancies.

Conclusions

Once a diagnosis of primary appendiceal adenocarcinoma is proved histologically, it is it is warranted to perform surveillance for synchronous or metachronous tumors because of the increased risk of a second primary malignancy in the gastrointestinal tract.

A Unique Case of Low-Grade Mucinous Neoplasm in Stump Appendectomy

Background

We describe a case of a young male with a history of appendectomy one year ago, who developed symptoms of stump appendicitis, and after removing this stump, histopathology showed low grade neoplasm. Summary. Stump appendicitis is an uncommon complication after appendectomy and may lead to serious complications. Management of low-grade appendiceal mucinous neoplasm (LAMN) is controversial, and we discuss the importance of the case.

Conclusion

The case of young male post stump appendectomy with histopathology showing LAMN in the stump of the appendix, which to our knowledge, is the first in the medical literature and, discuss the stump appendicitis and incomplete appendectomy concerning malignancy, mucinous neoplasm, and adenocarcinoma.

Adenocarcinoma of Stump Appendicitis: An Extremely Rare Pathology - A Literature Review

Emergency appendectomy for acute appendicitis is the most common emergency surgical procedure performed all over the world. While amputating the appendix from the cecum, a small (usually less than 5 mm) stump is left behind. Below this, the suture or stapler is applied to secure the base of the appendix, which is now known as a stump. Stump appendicitis, the inflammation of appendiceal remnant after an appendectomy, is a rare phenomenon. Additionally, the incidence of adenocarcinoma in the stump of the appendix is also extremely rare and can present with the symptoms of appendicitis. Adenocarcinoma in stump appendectomy patients can present from 5-43 years after the index appendectomy surgery. The majority of patients present with symptoms similar to that of appendicitis, with right lower quadrant abdominal pain, usually diagnosed via CT scans, after which they undergo stump appendectomy. The diagnosis of adenocarcinoma is only made on the histopathology report. We engaged in a review of the relevant literature published in the English language for the last 100 years. This was conducted by reviewing Google Scholar, PubMed, and MEDLINE® databases, as well as references to all related articles. There are only six cases reported in the literature, which shows the rarity of this condition. Regarding the appropriate treatment for this rare entity, multi-disciplinary team discussions should be carried out for optimum management of the individual patients. Right hemicolectomy is the recommended procedure for all patients, and prognosis depends on the staging of the disease.

Appendicular mucocele: two case reports and literature review

The classification of mucinous tumors of the vermiform appendix is quite controversial, and includes a spectrum of neoplastic lesions ranging from benign proliferations, intraluminal, to invasive adenocarcinomas. Among the complications of appendicular mucinous neoplasms we should mention the "pseudomyxoma peritonei", a condition caused by cancerous cells (mucinous adenocarcinoma) that produce abundant mucin or gelationous ascites. Mucinous neoplasms of the appendix are rare diseases of unknown etiology. The diagnosis is difficult because of poorly specific clinical, biochemical and imaging parameters, and their detection can be occasional. Most of the reported cases involving women of reproductive age (with a history of endometriosis, abdominal surgery or pelvic inflammatory disease). The definitive diagnosis requires histology and immunohistochemistry. Cytoredutive surgery combined with hyperthermic intraperitoneal chemoterapy (HIPEC) is now considered the best treatment for this disease. We present two cases treated with surgery and HIPEC.

Autotransplantation of cryopreserved ovarian tissue in cancer survivors and the risk of reintroducing malignancy: a systematic review

BACKGROUND The risk of recurrent oncological disease due to the reintroduction of cancer cells via autotransplantation of cryopreserved ovarian tissue is unknown. METHODS A systematic review of literature derived from MEDLINE, EMBASE and the Cochrane Library was conducted. Studies on follow-up after autotransplantation; detection of cancer cells in ovarian tissue from oncological patients by histology, polymerase chain reaction or xenotransplantation; and epidemiological data on ovarian metastases were included. RESULTS A total of 289 studies were included. Metastases were repeatedly detected in ovarian tissue obtained for cryopreservation purposes from patients with leukaemia, as well as in one patient with Ewing sarcoma. No metastases were detected in ovarian tissue from lymphoma and breast cancer patients who had their ovarian tissue cryopreserved. Clinical studies indicated that one should be concerned about autotransplantation safety in patients with colorectal, gastric and endometrial cancer. For patients with low-stage cervical carcinoma, clinical data were relatively reassuring, but studies focused on the detection of metastases were scarce. Oncological recurrence has been described in one survivor of cervical cancer and one survivor of breast cancer who had their ovarian tissue autotransplanted, although these recurrences may not be related to the transplantation. CONCLUSIONS It is advisable to refrain from ovarian tissue autotransplantation in survivors of leukaemia. With survivors of all other malignancies, current knowledge regarding the safety of autotransplantation should be discussed. The most reassuring data regarding autotransplantation safety were found for lymphoma patients.

A retrospective clinicopathological analysis of appendiceal tumors from 3,744 appendectomies: a single-institution study

PURPOSE

This study was conducted to describe the clinicopathological characteristics of appendiceal tumors and to evaluate their appropriate management.

METHODS

Between September 2000 and September 2005, 28 appendiceal tumors were identified by a retrospective review of 3,744 appendectomies.

RESULTS

Twenty-eight patients were found to have appendiceal tumors (incidence, 0.7%).The largest single group of tumors were benign mucinous cystadenomas (50%); carcinoids (32.1%) were next, and they were followed by malignant tumors (17.9%). Four out of five patients who had malignant appendiceal tumors presented with periappendiceal abscess. None of the patients was correctly diagnosed preoperatively. One-stage curative resection was possible in more than 76% of the patients, and the rate of making the correct preoperative diagnosis was 35%.

CONCLUSION

Most appendiceal tumors presented with appendicitis and periappendiceal abscess. Appendiceal tumors should be included in the differential diagnosis when an unexpected appendiceal mass is encountered during appendectomy.

Definitive diagnosis of primary adenocarcinoma of the appendix by laparoscopic appendectomy

We report a 62-year-old woman with a primary adenocarcinoma of the appendix mimicking ovarian tumor. We had diagnosed it definitively by laparoscopic appendectomy, and additional surgery was required in this case. However, the present case suggests that, in some cases, if cancer of the appendix can be diagnosed early, laparotomy can be avoided and the cancer treated with minimally invasive laparoscopic surgery alone.

Malignant neoplasms of the appendix

BACKGROUND

Appendiceal neoplasms, first described in 1882, are still rare, with pre-operative diagnosis invariably difficult. We present our 10-year experience of these lesions with a review of current epidemiology, pathology and treatment modalities.

MATERIALS AND METHODS

A retrospective histopathological review of all appendicectomy specimens was completed between April 1994 and December 2003 to identify patients diagnosed with malignant neoplasms. Patient demographics, operative details, histopathology and clinical outcomes were obtained from case notes. A literature search of the PubMed database was then performed using the medical search headings; appendix, tumour, neoplasm and malignancy.

RESULTS

Twenty-two patients (eight men) were identified during the study period, with no age difference between gender (mean age in women 58, range 14-83 vs mean age in men 55, range 16-78). Eleven patients were found to have carcinoid-type tumours, eight patients with adenocarcinomas and three patients with lymphomas. Other appendiceal pathologies were identified after appendicectomies, hemicolectomy and oophorectomy. Mean follow-up was 41 months (range 1-125 months). Fourteen patients were alive at the end of follow-up. Patients with classical carcinoid tumours (CCT) had better outcomes than patients with the goblet cell carcinoid, adenocarcinoma and lymphoma.

CONCLUSIONS

From our own experience and a subsequent review of the literature, we recommend right hemicolectomy as the treatment of choice for all malignant appendiceal neoplasms, except for small CCT less than 2 cm in diameter at the tip of the appendix, with a low proliferative index, without angiolymphatic or mesoappendiceal extension. Further adjuvant therapy should be considered after oncological assessment.

Stump appendicitis: case report and review

The purpose of this study is to review the medical literature regarding the prevalence of appendicitis in patients with previous appendectomy. Stump appendicitis is a real entity not often considered when evaluating patients with right lower quadrant pain and a history of appendectomy. This leads to delays in diagnosis and treatment. An extensive review of the world literature using Medline, MD Consult, and the references of articles found using these methods to gather information regarding stump appendicitis. Results showed 29 cases of stump appendicitis have been reported in the world literature. Herein we review the literature as well as present a case study. Stump appendicitis is a real, yet probably underreported entity. It can occur after either laparoscopic or open appendectomy. Avoidance of a long appendiceal stump is the only suggested means by which to avoid its occurrence.

Krukenberg tumor from an occult appendiceal adenocarcinoid: a case report and review of the literature

Appendiceal neoplasms with ovarian metastasis are rare. A 35-year-old woman with a left ovarian tumor underwent left salpingo-oophorectomy, partial resection of the right ovary, and a total hysterectomy. Pathological diagnosis of both ovaries was typical, Krukenberg tumor with signet-ring cells, and the second laparotomy revealed an occult appendiceal tumor to be the primary lesion. The appendix showed no evidence of malignant change of the mucosa, but the tumor cells were observed infiltrating from the basiglandular region into the underlying stroma, associated with mucocele. Although, argentaffin and argyrophil staining were negative, a few tumor cells showed immunohistochemical positivity for Chromogranin A. Accordingly, the tumor was diagnosed as adenocarcinoid rather than adenocarcinoma of the appendix. A review of the literature showed less than 40 cases of metastatic ovarian tumor from appendiceal primary, one-third of which were occult and could be detected at the second laparotomy. Cisplatin-based chemotherapy may have partial effect in the treatment of patient with adenocarcinoid tumor.

Primary mucinous adenocarcinoma of the appendix: a rare entity in the differential diagnosis of ovarian cancer

We report a 58-year-old female patient with the suspected diagnosis of ovarian cancer. Upon surgical exploration, examination of the appendix revealed the histological diagnosis of primary mucinous adenocarcinoma. This is an unusual consideration in the differential diagnosis of the ovarian cancer. We discuss the diagnosis, classification and treatment of the cancer of the appendix in relation to ovarian cancer.

Primary adenocarcinoma of appendix, colonic type associated with perforating peritonitis in an elderly patient

We report a case of colonic type adenocarcinoma of the appendix with perforating peritonitis in a 92-year-old man. The preoperative diagnosis was localized peritonitis due to acute appendicitis and emergency laparotomy was performed. A gray, hard tumor was palpated at the base of the appendix. Appendiceal cancer was suspected, and right hemicolectomy was performed. The histopathological diagnosis was moderately differentiated adenocarcinoma of the appendix. The tumor obstructed the orifice of the appendix, and this may have caused the perforation of the appendix. The patient had an uneventful postoperative course and there have been no signs of recurrence in the 2 years since the operation.

Management and prognosis of adenocarcinoma of the appendix

PURPOSE

Adenocarcinoma of the appendix is a rare neoplasm, and controversies persist regarding management. The purpose of this study was to identify prognostic factors and define management strategies for patients with adenocarcinoma of the appendix.

METHODS

A retrospective case series was conducted at three medical school teaching hospitals over a 20-year period from 1972 to 1992. Overall survival was determined by the actuarial life table method. Comparisons of prognostic factors were made using exact nonparametric log-rank tests.

RESULTS

Thirteen patients were diagnosed during the study period. Median age was 62 years. There were five males and eight females. The disease was not suspected in any patient preoperatively. Seventy-seven percent of patients had metastatic disease at presentation. Second primary malignancies were found in 15 percent of patients. Thirty-eight percent of female patients had synchronous ovarian lesions. Median survival was 22 months, with an estimated five-year survival of 43 percent (95 percent confidence interval, 22-84 percent). Patients with colonic histology had significantly worse survival than patients with mucinous histology (P = 0.0093). Patients with carcinomatosis had a significantly worse survival than noncarcinomatosis patients (P = 0.0078). Patients who underwent right hemicolectomy had a better prognosis for survival than appendectomy patients, but the difference was not statistically significant.

CONCLUSIONS

Carcinoma of the appendix is very difficult to diagnose preoperatively, and most patients are not identified until disease is advanced. Good prognostic factors include mucinous histology and the absence of carcinomatosis. Right hemicolectomy appears to be a reasonable option, although its superiority to appendectomy alone has not been definitively proven. High frequency of ovarian metastases in women suggests a role for bilateral oophorectomy. In addition, a complete work-up of the patient for a synchronous malignancy, especially in the gastrointestinal tract, should be considered.

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

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.

Papillary cystadenocarcinoma of the appendiceal stump with mucocele and peritoneal metastases

A 54-year-old Polynesian male developed a mucocele of the appendiceal stump 25 years after appendicectomy. Scattered peritoneal deposits up to 0.4 cm in diameter were also identified at laparotomy, and these were confined to the right iliac fossa. The cyst was excised with a right hemicolectomy and histology showed a mucus-producing papillary cystadenocarcinoma arising in the unburied appendiceal stump. There was invasion of the cyst wall and the peritoneal nodules contained metastatic tumour acini. The patient is well 12 months after surgery. This is a case of a rare tumour arising uniquely in an appendiceal stump and producing a mucocele. The term mucocele is discussed and recommendations made for its usage in pathological diagnosis.

Adenocarcinoma of the appendix

Thirty-two patients with primary adenocarcinoma of the appendix were studied in this collective review. Immediate operation was performed in 21 patients with a diagnosis of acute appendicitis. At operation, tumor of the appendix was only identified in 50 percent of the 32 patients studied. Survival was unrelated to the histologic tumor type, but significantly correlated with the extent of tumor spread. Right hemicolectomy led to a significant increase in survival compared with appendectomy alone and to a significant decrease in risk of recurrence. In Dukes' B2 and C patients, differences in the survival curves were in favor of right hemicolectomy. Long-term survival was obtained by repeat laparotomy with resection of mucinous material in patients with pseudomyxoma peritonei.

Primary adenocarcinoma of the appendix: report of five cases and review of the literature

Five patients with primary adenocarcinoma of the appendix are reported. All patients presented with symptoms resembling those of acute appendicitis or periappendicular abscess. In none of them was malignancy suspected prior to operation. It is advisable that every patient above 50 years of age presenting with symptoms of appendicitis undergo laparotomy, thus enabling a better exploration of the cecal region. If an appendiceal mass is present and frozen section shows malignancy, a right hemicolectomy should be performed. The prognosis of adenocarcinoma of the appendix is dismal as most patients present with an advanced stage of the disease.

Adenocarcinoma of the appendix

Three cases of adenocarcinoma of the appendix are reported. All three patients presented with acute appendicitis and the tumors were diagnosed only on histologic examination of the excised appendix. The first patient subsequently had a right hemicolectomy and was proven to have a Dukes' B tumor. The second patient probably had a Dukes' B also, but no further surgery was performed because of advanced presenile dementia. Advanced disease was found in the third patient. Analysis of 145 cases reported over the last ten years suggests that, unless the tumor is in Dukes' A stage, right hemicolectomy should be carried out if the patient is fit for radical surgery. The overall prognosis appears to be the same as that for carcinoma of the colon.

Primary adenocarcinoma of the vermiform appendix: report of a series of ten cases, and review of the literature

Ten cases of primary adenocarcinoma of the vermiform appendix are presented. The condition is rare and usually presents after middle age as acute appendicitis. It is seldom recognized during appendicectomy. The tumours resemble colonic adenocarcinomas but, because of peculiarities in the anatomy of the appendix, there is a tendency to early local spread. Right hemicolectomy performed as soon as the true nature of the lesion is recognized is the treatment of choice and has been shown to improve survival. Even after hemicolectomy the prognosis must be guarded, as local spread of disease may not be controlled in many cases.

Intussusception of the appendix

Two cases of intussusception of the appendix are reported--one caused by adenocarcinoma and adenomatous polyp and the other by an endometrioma. Appendiceal intussusception and adenocarcinoma are both uncommon entities and this is the first report of the two occurring concomitantly. Due to variable symptoms, the correct diagnosis of appendiceal intussusception has rarely been made preoperatively. Classification, symptoms, radiographic appearance, and differential diagnosis are discussed, and the authors suggest a new classification for intussusception of the appendix.

Primary adenocarcinoma of the appendix with bilateral Krukenberg ovarian tumors

An unusual case of a 22-year-old white female with known chronic ulcerative colitis presented with a several-day history of lower abdominal pain and a pelvic mass. Laparotomy revealed a primary carcinoma of the appendix with Krukenberg metastasis to both ovaries. Pathologically this tumor appeared to arise from an appendix which showed no evidence of chronic ulcerative colitis and therefore could not be associated with the above-mentioned entity.

Primary adenocarcinoma of the appendix

Two cases of carcinoma of the appendix presenting as appendicular masses are discussed. Carcinoma of the appendix is rare and hence a pre-operative diagnosis is seldom made. Awareness of the condition would naturally arouse suspicion of its presence, especially in elderly patients who present with cute appendicitis or an appendix mass. It is known to have occurred in an appendix stump several years after the initial appendicectomy, and also in a 17-year-old patient. The need for histological examination of all appendicetomy specimens is stressed. The operation of choice is right hemicolectomy, either as a primary or as a secondary procedure. This is associated with better survival rates than when the condition is treated by appendicectomy alone.

Primary epithelial tumors of the appendix and a reappraisal of the appendiceal "mucocele"

A 28-year review of the records at Hines V.A. Medical Center revealed 17 primary epithelial tumors of the appendix. Five of these tumors were benign and 12 malignant. It is suggested that the term mucocele be abandoned, because it represents the end result rather than a definite pathologic entity. The majority of benign tumors and carcinoid tumors of the appendix are discovered incidentally to other procedures. The majority of adenocarcinomas cause symptoms and signs of appendicitis. Simple appendectomy is sufficient treatment of all benign tumors of the appendix, and for all carcinoids that show no gross local metastases and are less than 2 cm in diameter. Simple appendectomy followed by right hemicolectomy or initial right hemicolectomy is the treatment of choice for all carcinoids of the appendix that show gross local metastases and are 2 cm or more in diameter and for all adenocarcinomas of the appendix, whether mucinous or colonic, in the absence of distant metastasis. A new classification for primary epithelial tumors of the appendix is suggested.