Endosonographic features of mucocele of the appendix: report of a case

Mucinous appendiceal neoplasms: Report of a case and brief literature review

INTRODUCTION

Appendiceal tumors are rare neoplasms detected in about 2 % of appendicectomies. The clinical presentation is often unspecific, varying from unspecific abdominal pain or presenting as an acute appendicitis or being asymptomatic.

CASE PRESENTATION

We present a case of a patient presenting as an acute appendicitis with a mucocele, and then classified as HAMN. The patient was treated with initial laparoscopic approach and then conversion in laparotomy with appendectomy. Histology demonstrated a high grade appendiceal mucinous neoplasm limited to submucosa (pT3), with concomitant acute phlegmonous appendicitis. The patient was subsequently sent to a referral center where a right hemicolectomy with HIPEC was performed.

DISCUSSION

HAMN is a rare entity, only recently classified as a new kind of appendiceal mucinous neoplasm. Due to the supposed higher aggressivity, HAMN must be treated as an appendiceal adenocarcinoma. The treatment of this rare entity is not yet well standardized, because of the rarity of this disease.

CONCLUSION

HAMN is a very rare tumor. In the emergency setting, it is mandatory to avoid rupture of the appendix, to minimize the risk of developing pseudomyxoma peritonei. Pathology is essential for further decisions in these patients and plays a very important role in treatment and prognosis.

Giant appendiceal mucocele: report of a case

Mucoceles of the appendix are a group of mucus-filled lesions causing obstructive dilation of the ileocecal appendix. We report a rare case of giant appendiceal mucocele. A 48-year-old woman, with no discomfort, was admitted to our hospital after a mass was detected in the right lower quadrant of the abdomen. The patient underwent right hemicolectomy on the basis of the clinical diagnosis of a possible appendiceal tumor. The final pathologic diagnosis was mucocele of the appendix.

Molecular analysis of appendiceal mucinous cystadenoma and rectal adenocarcinoma in a patient with urothelial carcinoma: a case report

Introduction

In this report, we present the case of a patient affected by appendiceal cystadenoma, a colorectal adenocarcinoma, and a concomitant bladder carcinoma, as well as the results of the molecular study of the most relevant mutational pathways involved in these tumors.

Case presentation

A 68-year-old Italian man was admitted to our unit complaining of macrohematuria, rectorrhagia, and rectal tenesmus for about 2 months. A colonoscopy showed the presence of a rectal lesion at 11cm from the anal margin; multiple biopsies were performed and a diagnosis of moderately differentiated adenocarcinoma was made. Abdominal ultrasonography and total body computed tomography performed subsequently to stage the rectal cancer showed the presence of two round nodules, interpreted as swollen lymph nodes of neoplastic origin, at the anterior aspect of the iliopsoas muscle and a budding lesion affecting the bladder. The patient underwent transurethral biopsy of the lesion in the right retrotrigonal region; the diagnosis was grade II urothelial carcinoma. The patient underwent an open anterior rectal resection with loco-regional lymphadenectomy. An enlarged appendix and a voluminous whitish soft-tissue lesion requiring an appendicectomy were detected perioperatively. Transurethral resection of the bladder lesion was also performed. The histological examination revealed that the nodular lesions in the appendix were due to a cystadenoma. For mutation analysis, genomic deoxyribonucleic acid was isolated from tumor tissue samples; for PIK3CA mutations, screening revealed that all three samples analyzed carried mutations in exon 9.

Conclusions

Appendiceal mucoceles are rare but require adequate surgical treatment, given their malignant potential and the possibility of causing peritoneal pseudomyxoma. It is essential to make a correct preoperative evaluation based on a colonoscopy rather than ultrasound and computed tomography to exclude synchronous neoplasias often associated with mucoceles and to plan the optimum surgical strategy. The association between appendiceal mucoceles and other neoplasias is relatively frequent, especially with colorectal cancer. Oncogenic activation in the PIK3CA-depending pathway may contribute substantially to the pathogenesis of the different solid tumors in the same patient.

Evaluation of subepithelial abnormalities of the appendix by endoscopic ultrasound

Background. The use of through-the-scope (TTS) miniprobe catheter endoscopic ultrasound is a valuable technique for evaluating subepithelial lesions in the proximal colon. Few reports include the evaluation of the appendix by EUS. Objective. To describe endoscopic and endosonographic characteristics of subepithelial lesions of the appendix. Methods. Retrospective case series in a single academic medical center. Adult patients referred for evaluation of subepithelial lesions of the appendix identified by colonoscopy between April 1, 2003 to February 29, 2008. Data were abstracted from an electronic endoscopic database for all patients undergoing miniprobe endoscopic ultrasound examination of the appendix. Medical records were reviewed for patient followup and outcomes. Results. Nine cases were identified. Seven (78%) patients were female. Seven (78%) utilized the 12 MHz miniprobe device and two (22%) used the 20 MHz device. Three mucoceles were described and confirmed by surgical resection. Cases also included one inverted appendix, one gastrointestinal stromal tumor, and one lipoma. In three cases, no abnormality was found. Conclusions. EUS evaluation of the appendix is feasible with standard miniprobe devices and may assist in the selection of patients who may benefit from surgical management.

Adenocarcinoma of the appendix is rarely detected by colonoscopy

INTRODUCTION

Appendiceal tumors represent a subset of colonic neoplasms that frequently defy early diagnosis only to present at advanced stage with peritoneal metastasis. Data on early detection by colonoscopy is limited to case reports or series. The aim of this study is to determine the diagnostic yield of colonoscopy in detecting appendiceal lesions in patients with appendiceal adenocarcinoma and pseudomyxoma peritonei.

METHODS

We reviewed clinicopathologic data on 121 consecutive patients with histologically confirmed appendiceal adenocarcinoma with pseudomyxoma peritonei presenting to our institution for intraperitoneal hyperthermic chemotherapy (IPHC) and cytoreductive surgery between February, 1993 and August, 2007, focusing on the colonoscopy findings.

RESULTS

Preoperative colonoscopic data were available on 64 patients (average age = 51; 52 for IPHC patients). Abnormal findings included seven patients with appendiceal lesions (11%), 12 patients with cecal abnormalities (19%), and 28 patients with polyps (44%). Twenty-three patients (36%) had a normal colonoscopy. Malignancy was documented in two of the 64 (3.1%) patients on preoperative colonoscopy biopsies.

CONCLUSIONS

Appendiceal abnormalities are infrequently seen on colonoscopy and rarely yield a diagnostic biopsy in patients with appendiceal carcinoma. We found that nearly 42% of patients with carcinoma of the appendix have synchronous colonic polyps, a much higher prevalence than would be expected, supporting a role for a perioperative colonoscopy.

[Mucocele of the appendix]

INTRODUCTION

Mucoceles of the appendix are infrequent entities and are found in only 0.25% of all appendectomies and 8% of all appendicular tumors.

MATERIAL AND METHODS

We describe 27 cases of mucocele of the appendix treated at Donostia Hospital between January 1978 and December 2006.

RESULTS

The mean age of the patients was 54.4 +/- 21.7 years (range: 17-88). Of the 27 patients, 15 (55.5%) were males and 12 (44.5%) were females. Emergency surgery was performed in 17 patients (62.9%). Mucoceles were identified as operative findings during surgery for other reasons in seven patients (25.9%). Three patients (11.1%) underwent surgery because of a diagnosis of abdominal tumor. The main reason for emergency surgery was lower right abdominal pain in 14 patients (82.2%), intestinal obstruction in one (5.8%), a diagnosis of endometriosis in one (5.8%) and a diagnosis of pyosalpinx in one (5.8%). Three patients underwent surgery due to pseudomyxoma peritonei after 24, 36 and 41 months' follow-up. The third patient is asymptomatic after peritonectomy and a follow-up of 78 months. We found an overall incidence of 11 cases (40.7%) presenting with synchronous or metachronous neoplasms from other locations.

CONCLUSIONS

We recommend monitoring of all patients with mucocele of the appendix, because these masses can sometimes be associated with neoplasms in other locations and there is a risk of pseudomyxoma peritonei even after a long follow-up.

Mucocele of the appendix

BACKGROUND

Mucocele of the appendix is an infrequent event, representing 0.3%-0.7% of appendiceal pathology and 8% of appendiceal tumors. It is characterized by a located or diffuse distension of the appendix with a mucus-filled lumen.

MATERIALS AND METHODS

We describe 35 cases of mucocele of the appendix diagnosed at Ramón y Cajal Hospital between January 1985 and January 2006.

RESULTS

A total of 21 males and 14 females with a mean age of 52.7 years are described. Most cases manifested as abdominal pain located in right iliac fossa, but 2 cases were incidental findings at CT-scan and 1 at ultrasonography, performed for other reasons. In 4 cases, mucocele coexisted with colorectal cancer and was an incidental finding during laparotomy performed for tumor resection. Ultrasonography and computed tomography (CT) scan helped to achieve a correct diagnosis. Preoperative diagnosis of mucocele was achieved in 29% of the cases; 88% of patients underwent appendectomy, 2 had ileocecal resection, and 2 others underwent right hemicolectomy. Pathology revealed mucous hyperplasia in 34% of the cases, simple mucocele in 29%, cystadenoma in 31%, and cystadenocarcinoma in 2 patients. Two other patients developed adenocarcinoma of the cecum 12 and 33 months after surgery, and one patient developed pseudomyxoma peritonei after 62 months, causing his death.

CONCLUSIONS

The pathologist is forced to do an exhaustive study, looking for inadvertent perforations that can change the good prognosis of mucocele. We recommend follow-up of all patients with mucoceles, because sometimes they are associated with colorectal neoplasms and recurrence as pseudomyxoma peritonei.

Appendiceal intussusception diagnosed with endoscopic sonography

Intussusception of the appendix vermiformis is an uncommon cause of abdominal pain. Several imaging modalities are of limited value in diagnosing this rare condition, including barium enema, transabdominal sonography, and CT. We report a case of intussusception of the appendix vermiformis with the clinical presentation of intermittent abdominal pain in the right lower quadrant. Colonoscopy revealed an erythematous polypoid lesion at the cecal base. Endoscopic sonography demonstrated a multiconcentric structure and enabled the tentative diagnosis of intussusception of the appendix vermiformis. Laparoscopic surgery with a reduction of the appendix and appendectomy was performed and confirmed the diagnosis.

Colonoscopic diagnosis of mucocele of the appendix

BACKGROUND

Appendiceal mucoceles are uncommon cystic neoplasms characterized by distension of the appendiceal lumen with mucus. There have been no reported series of colonoscopically diagnosed mucoceles with clinicopathologic correlation.

METHODS

A retrospective review of colonoscopies performed at our institution over the past 14 years was undertaken with patient demographics, clinical data, surgical outcomes, and histopathology obtained from hospital records.

OBSERVATIONS

Seven patients (6 women) with mucocele of the appendix were identified at colonoscopy. Three had complained of right lower quadrant pain. All 7 patients underwent surgical resection. Histopathology demonstrated mucinous cystadenoma in all. No cases revealed carcinoma, and there have been no deaths related to the mucocele.

CONCLUSIONS

Appendiceal mucoceles may be recognized at colonoscopy as a smooth bulbous submucosal lesion of the cecum with an impression formed by the appendiceal orifice. Recognition at colonoscopy is important because it enables accurate diagnosis and directs management. Surgery is recommended in all cases given the risk of malignancy or perforation with resultant pseudomyxoma peritonei.