Appendiceal mucocele: Case reports and review of current literature

The Vermiform Appendix and Its Pathologies

The vermiform appendix is a muscular cylindrical structure originating near the junction of the cecum and ileum, averaging 9 cm (5-35 cm) in size. As the most mobile viscera, it can adopt several positions, the most common being the retrocecal position. Perceived as an atavistic organ lacking physiological relevance, the vermiform appendix appears to be involved in immune function, serving in the maturation of B lymphocytes and the production of immunoglobulin A, in endocrine function, excreting amines and hormones in the 2-3 mL of mucus secreted daily, and in digestive function, by storing beneficial bacteria from where they can recolonize the colon. With a lumen of about 6 mm, the vermiform appendix has a reduced storage capacity, so any blockage of the appendix with fecoliths (fecaliths), seeds derailed from the colon, or enlarged lymph nodes prevents drainage and intraluminal accumulation of secreted mucus. Unable to relax, the appendix wall severely limits its intraluminal volume, so mucus accumulation leads to inflammation of the appendix, known generically as appendicitis. In addition, the vermiform appendix may be the site of the development of neoplastic processes, which may or may not involve mucus production, some of which can significantly affect the standard of living and ultimately lead to death. In general, mucinous tumors may have a better prognosis than non-mucinous tumors. This review takes a comprehensive path, starting by describing the anatomy and embryology of the vermiform appendix and further detailing its inflammatory pathologies, pathologies related to congenital anomalies, and appendix tumors, thus creating an up-to-date framework for better understanding, diagnosis, and treatment of these health problems.

Appendiceal mucocele with pseudomyxoma peritonei mimicking ovarian tumor with peritoneal carcinomatosis

Appendiceal mucocele with unprompted pseudomyxoma peritonei is a rare malignant tumor, which is difficult to diagnose before surgery. We present a case of a 62-year-old woman, and subsequently discuss the clinical and imaging presentation of mucoceles. Findings on CT scan suggested 2 diagnoses: appendiceal mucocele with pseudomyxoma peritonei and malignant ovarian tumor with peritoneal carcinosis. MRI suggested the former diagnosis, showing a large tubular mass at the base of appendix with discontinuous wall, and no ovarian abnormality, which was confirmed by mini laparotomy and histological study of peritoneal thickened tissue. Treatment consisted of neoadjuvant chemotherapy, with a good response. This case shows the role of imaging in the preoperative diagnosis of appendicular mucoceles; CT scan and MRI, which are useful tools in identifying undetermined lesions of the appendix.

Appendicitis mimicking the CT appearance of an appendiceal mucinous neoplasm

Occasionally, radiologically diagnosed acute appendicitis is found to harbour underlying appendiceal neoplasm on post-surgical histopathology. Conversely, a situation in which radiologically, the appendix demonstrates features consistent with an underlying tumour but post-operative pathology finds no evidence of neoplastic change is rare. We describe a case of a 50-year-old man who presented with a markedly dilated "mass-like" appendix with minimal inflammatory changes on a computed tomography scan. Radiological findings were suspicious for an appendiceal neoplasm/mucocele (i.e. low-grade mucinous neoplasm). However, the post-surgical histopathological diagnosis did not concur with the radiological diagnosis and instead demonstrated findings compatible with acute appendicitis without neoplastic change. In this case report we provide a histopathological correlation and an explanation as to how this may have happened with the hope of helping radiologists avoid this pitfall in the future.

Incidental low grade mucinous neoplasm of appendix in pregnancy: A case report & literature review

Introduction

Mucinous neoplasms of appendix account for 0.2–0.4% of all the appendix specimens. The occurrence of this neoplasm in pregnancy is extremely rare. We describe a case of a pregnant lady who was diagnosed as acute appendicitis and found to have Low-Grade Mucinous neoplasm on histopathology. In the existent literature, there are only a few such cases reported and none from our Middle East region.

Case presentation

42-year-old pregnant lady at 24 weeks of gestation presented with classical symptoms of acute appendicitis. She had leukocytosis but the Ultrasound was equivocal. She underwent laparoscopic appendectomy and found to have an inflamed appendix. Postoperative recovery was satisfactory and was discharged home. The histopathology report showed low-grade mucinous neoplasm of the appendix and she was detailed about it on follow up.

Discussion

The incidence of appendiceal neoplasm is rare in routine appendectomy and carcinoid is the most common tumor of the appendix. Low-Grade mucinous neoplasm is a rare entity and its presence in pregnancy is further rarer.

Conclusion

Since this neoplasm does not manifest with a characteristic clinical profile it is difficult to diagnose, even with extensive preoperative evaluation. Although surgical treatment is straight forward, the management of the appendiceal neoplasm during pregnancy necessitates full knowledge of the natural history of the disease to attain equilibrium of concern for maternal survival and fetal health.

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Mucinous neoplasms of appendix are known to be rarely found in all the appendix specimens, but the occurrence of this neoplasm in pregnancy is extremely rare.

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This neoplasm does not manifest with distinctive clinical profile and it is challenging to diagnose it, even with extensive preoperative evaluation.

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It is questionable to decide whether to allow pregnancy or terminate unless proper work up is not done to decide the nature of this neoplasm.

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Further studies dedicated to the understanding of the mucinous neoplasms can help us with designing a more targeted therapeutic plan for such patients.

Diagnosis and treatment of a caecal mucocoele in a dog

An 11-year-old male intact Staffordshire Bull terrier was referred for diabetic ketoacidosis. Abdominal ultrasonographic examination revealed a 5 cm × 2 cm intraluminal caecal mass-like structure. Exploratory laparotomy and typhlectomy were subsequently performed. Histopathology of the caecal mass-like structure was consistent with a caecal mucocoele, defined as a cystic dilation of the caecal lumen with stasis of mucus. This lesion has been previously described in humans, where it is termed an appendiceal mucocoele. The patient was euthanased 58 days post-operatively due to unrelated diabetic complications.

Effects of Sequence of Irrigation, Suction, and Extraction in Cases of Acute Purulent Appendicitis or Gangrenous Perforated Appendicitis After Laparoscopic Appendectomy

Objective: To evaluate rates of postoperative infection in patients with acute purulent appendicitis or gangrenous perforated appendicitis after laparoscopic appendectomy (LA). Methods: In this retrospective cohort study the medical records of patients who had undergone LA for acute appendicitis at Yijishan Hospital of Wannan Medical College between January 2015 and December 2019 were reviewed. The patients were divided into 2 groups based on the sequential order in which peritoneal irrigation, suction, and extraction of appendix had been performed. In Group 1 peritoneal irrigation and suction had been performed before extraction of the appendix, and in Group 2 they had been performed after extraction of the appendix. Demographic details, surgery duration, time to first flatus, length of hospital stay, total hospitalization expenses, and postoperative complications were analyzed. Results: The final study sample included 571 patients, 116 (20.3%) in Group 1 and 455 (79.7%) in Group 2. There were no significant differences in demographic characteristics, preoperative white blood cell counts, surgery durations, lengths of hospital stay, or total hospitalization expenses between the 2 groups (P > .05). Time to first flatus was significantly shorter in Group 1 (2.1 ± 0.5 days) than in Group 2 (2.3 ± 0.6) (P = .016), and the incidence of surgical wound infection was lower in Group 1 (6.9%) than in Group 2 (14.1%) (P = .038). There were no significant differences in the rates of intra-abdominal abscess, small bowel obstruction, or readmission within 30 days between the 2 groups (P > .05). Conclusion: Patients with acute purulent appendicitis or gangrenous perforated appendicitis are at high risk of surgical wound infection. Peritoneal irrigation and suction before appendix extraction may reduce the incidence of postoperative wound infection.

A case report of appendix mucinous adenocarcinoma that recurred after additional surgery and a brief literature review

BACKGROUND

The clinical incidence of appendiceal mucinous adenocarcinoma is low. Moreover, the case reports of postoperative relapse after surgery are rarely based on literature search results. Here, we report such a case spanning nearly 7 years and and review the relevant literature.

CASE PRESENTATION

A 50-year-old female underwent additional surgery after appendectomy, and pathological examination confirmed mucinous adenocarcinoma. The patients underwent HIPEC (hyperthermic intraoperative chemotherapy) and adjuvant chemotherapy. Twenty-six months after the previous surgeries, another surgery, HIPEC, and adjuvant chemotherapy were performed again due to tumour recurrence. To date, the follow-up time is 43 months, and no recurrence or metastasis has been found.

CONCLUSIONS

Appendix mucinous adenocarcinoma has a poor prognosis and the diagnosis depends on pathological and immunohistochemical examinations. Its clinical manifestations are non-specific, and CRS + HIPEC should be used for treatment, which is safe and effective.

Minimally invasive surgery for appendiceal intussusception caused by mucocele of the appendix: case report and review of the literature

Appendiceal intussusception caused by mucocele of the appendix is extremely rare. In the current study, a 32-year-old woman was admitted to the department of general surgery of our hospital, complaining of persistent right, lower quadrant pain without an obvious cause for 17 hours. Physical examination indicated significant pain and tenderness in the right, lower abdominal quadrant. Blood analysis indicated that leukocyte count, the percentage of neutrophils and the serum C-reactive protein were increased. Abdominal and pelvic computed tomography revealed a well-encapsulated cystic mass surrounded by the caecum and intussusception. The appendiceal intussusception caused by mucocele of the appendix was revealed during the laparoscopic exploration. Appendectomy and partial cecectomy were conducted using the laparoscopic approach. Postoperative pathological examinations showed ileocecal intussusception and chronic inflammation, appendiceal mucocele and acute suppurative appendicitis. The patient showed satisfactory recovery that was observed during 15-months of follow-ups. This case highlights that laparoscopic appendectomy and partial cecectomy may be a beneficial, minimally invasive approach for appendiceal intussusception caused by mucocele of the appendix.

Analysis of Clinical Characteristics of Low-Grade Appendiceal Mucinous Neoplasm (LAMN): A Retrospective Cohort Study of 51 LAMN Patients

INTRODUCTION

Low-grade appendiceal mucinous neoplasm (LAMN) is a rare disorder. There is no consensus on the prognosis and management of LAMN.

MATERIALS AND METHODS

We reviewed 51 consecutive patients with LAMN from 2013 to 2018. We divided our patients into two groups. The first is patients with an intact appendix. The second group comprises patients with the potential to develop a malignant condition. Comparisons of serum tumor markers between two groups were performed. Survival curves were estimated. Univariate and multivariate Cox proportional hazards were computed for 46 patients with median follow-up of 2.7 years.

RESULTS

Comparison of patients in two groups revealed significant differences in the mean level and abnormal ratio of CA125 (p < 0.001, p < 0.001), CA19-9 (p = 0.04, p = 0.04), and CEA (p = 0.001, p = 0.02). Eight patients had relapsed by the last follow-up in the second group. Patients with normal CEA had significantly longer disease-free survival (DFS) time than those with abnormal CEA (p = 0.04). CA19-9 exhibited a significant association with DFS (HR = 5.72, p = 0.02) in the Univariate Cox proportional hazards.

DISCUSSION

The prognosis of LAMN is related to serum tumor markers, the surgical procedure and the pathology.

Mucocele of the appendix presenting as an exacerbated chronic tubo-ovarian abscess: A case report and comprehensive review of the literature

RATIONALE

Appendiceal mucocele is a rare entity of mucinous cystic dilatation of the appendix. It has no typical clinical presentation and is considered a potentially premalignant condition.

PATIENT CONCERNS

We present a case of accidental intraoperative finding of an appendiceal mucocele in a 54-year old woman that clinically presented with an exacerbated chronic tubo-ovarian abscess.

DIAGNOSES

Trans-vaginal ultrasonography showed an encapsulated, oval, unilocular mass above the uterus with a heteroechogenic structure, homogeneous fluid content, and smooth regular walls without inner proliferation. The histopathologic diagnosis was consistent with an appendiceal cystadenoma.

INTERVENTIONS

The patient underwent a simple appendectomy.

OUTCOMES

There were no clinical, biochemical or imaging signs of the disease recurrence at 6 months follow up.

LESSONS

To our knowledge, this is the only well-documented case of appendiceal mucocele mimicking exacerbated chronic tubo-ovarian abscess reported in the literature. Awareness of a rare entity such as an appendiceal mucocele, which is frequently misdiagnosed as a potential cause of acute abdomen, is necessary for the appropriate management strategy in order to prevent complications.

Giant low-grade appendiceal mucinous neoplasm: A case report

BACKGROUND

Appendiceal mucinous neoplasm (AMN) is extremely rare. Since the disease does not manifest a characteristic profile of clinical symptoms, it is easy to misdiagnose and still difficult to diagnose without operation. Here, we report a case of low-grade AMN (LAMN) and summarize its clinical features, diagnosis, and treatment.

CASE SUMMARY

A 63-year-old postmenopausal woman presented with a history of right lower abdominal mass. The patient underwent laparotomy, which showed an appendiceal mucocele originating from the apex of the appendix, and a simple appendectomy was performed. The subsequent histological assessment identified an LAMN with no lymph node involvement and negative surgical margin. The patient received six cycles of chemotherapy after surgery, and to date, more than a year after the surgery, the patient remains in good health.

CONCLUSION

A unified, standardized, detailed, and accurate pathological diagnosis is needed for LAMN, to facilitate selection of an appropriate surgical plan. In addition, the surgeon should record the details of the tumors in the surgical records in order to facilitate follow-up after surgery.

Dilated Appendix: Is There More to It? Case Report and Brief Review of Literature with Radiologic-Pathological Correlation

Mucocele of the appendix is rare and represents only the tip of the iceberg of underlying benign and malignant pathological processes. Intraoperative diagnosis is also tricky because the inflammation of the appendix often hides the tumor. The preoperative diagnosis is essential to differentiate appendiceal mucocele from acute appendicitis as the treatment varies from open surgical versus laparoscopic surgical approach and for decreasing intraoperative and postoperative morbidity and mortality rate. We present three cases of appendiceal mucocele. The purpose of this paper is to make the physicians aware of the entity, its associations and the effect on management. This review will provide radiologic and pathologic correlation for the preoperative diagnosis of benign and malignant causative processes and differential diagnostic considerations.

Surgical treatment of mucocele of the appendix: a systematic review and case report

Introduction

Appendicular mucocele is a rare well-described clinico-pathological occurrence. It denotes an obstructive dilatation of the appendicular lumen by mucinous secretions.

Case report

A 60-year-old patient presented with right lower abdominal pain and nausea for 2 years. Abdominal CT scan suggested a diagnosis of a appendicular mucocele. Following informed consent, surgical exploration revealed a cystic mass arising from the body of the appendix with inflamed walls with no evidence of perforation. Simple appendectomy was performed as the caecum and the mesenteric nodes were free of pathological involvement. The final diagnosis of mucinous cystadenoma was confirmed by histopathology. Postoperative course was uneventful. The patient was in good health during a four years regular follow-up.

Discussion

Appendicular mucocele is a rare disease with vague symptoms. Abdominal imaging is an important diagnostic tool, but histopathology is the standard for definitive diagnosis. Surgery for benign appendicular mucoceles has an excellent long-term prognosis.

Clinicopathological Features and Management of Appendiceal Mucoceles: A Systematic Review

Appendiceal mucoceles (AMs) are rare mucin-containing neoplasms with malignant potential. Lack of evidence-based data exists defining clinicopathological features for management. MEDLINE search between 1995 and 2015 was performed using search criteria “Appendix mucocele.” Systematic review of patient-, pathologic-, and treatment-related characteristics was performed and data analyzed. Among 276 cases of non-perforated AMs, 163 (59%) patients were female, with variable and nonspecific presentation. Patients were treated with appendectomy (52.1%), right hemicolectomy (17.6%), partial cecectomy (17.2%), and ileocecetomy (13.1%). Pathologic evaluation revealed the following: cystadenoma/low-grade appendiceal mucinous neoplasm (54%), unspecified/benign (25%), retention cyst (14.1%), cystadenocarcinoma (4.2%), and mucosal hyperplasia (2.9%). All 11 (4.2%) patients with cystadenocarcinoma were female ( P = 0.004), odds ratio for malignancy 1.07 times higher for women. Synchronous colonic malignancy was reported in three patients (27%) with cystadenocarcinoma ( P = 0.007), odds ratio of 12.1. AMs have low risk for malignancy. Treatment should begin with appendectomy-only and subsequently guided by pathologic diagnosis.

Long-Term Outcomes after Surgery for Appendiceal Mucinous Tumours

Background

Appendiceal mucinous tumour (AMT) is a very uncommon disease. We aimed to evaluate preoperative and postoperative characteristics as well as long-term outcomes of patients with appendiceal mucinous adenomas and peritoneal pseudomyxoma (PMP).

Methods

A consecutive cohort of patients diagnosed with AMT were included in the study. Tumour recurrence and the development of PMP was diagnosed based on the patients' complaints, physical examination, imaging studies, and biopsy results. The calculation of survival rates was performed using the Kaplan-Meier method.

Results

Between January 2003 and February 2013, 25 patients had AMT. 15 patients underwent appendectomy only (60%), 5 patients (20%) right hemicolectomy, 4 patients (16%) cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC), and 1 patient (4%) appendectomy with caecal resection. Another 2 patients underwent CRS and HIPEC 4 days and 3 years, respectively, following initial appendectomy. In the histopathologic examination, adenoma was diagnosed in 12 patients (48%); among these, low-grade PMP was found in 1 patient (4%). Low-grade appendiceal mucinous adenocarcinoma (AMCa) was diagnosed in 11 patients (44%); among these, low-grade PMP was found in seven cases (28%) and high-grade AMCa was diagnosed in 2 patients (8%). 2 of 8 PMP patients did not undergo CRS ± HIPEC because of comorbidities. The 5-year overall survival was 100% for the adenomas and 62% for PMP patients.

Conclusion

AMT is a very rare entity with a considerably good outcome even in disseminated disease. CRS and HIPEC is a gold standard treatment for PMP with excellent prognosis. However, our results could still be improved in the future.

Appendiceal mucinous neoplasms: an uncertain nosological entity. Report of a case

INTRODUCTION

Appendiceal mucocele is a relatively rare condition characterized by progressive dilation of the appendix caused by intraluminal accumulation of mucoid substance. Its incidence is 0.07 - 0,63% of all appendectomies performed.

CASE REPORT

We report the case of a 70-year-old man who came to our observation with gravative pain in right lower abdominal region. A computed tomography abdominal scan revealed a cystic/tubular structure like an appendicular mass with wall enhancement but without calcifications suggestive of a mucocele. Into peritoneal cavity we found profuse mucinous material with a 1,5 cm size parietal nodule. We also identified a free perforation of the cecum with consensual spillage of gelatinous material mimicking a pseudomyxoma peritonei. We decided to perform a right hemicolectomy with excision of peritoneal lesion.

DISCUSSION

The controversy in the pathologic terminology can give rise to a clinical dilemma in terms of the management and follow-up plans. For mucosal hyperplasia and cystadenoma simple appendectomy is curative. Only in case of large base of implantation it may be necessary the resection of the ileum and caecum or right hemicolectomy. In case of mucinous cystoadenocarcinoma authors perform a right hemicolectomy.

CONCLUSION

Appendiceal mucinous neoplasms are different pathological entities. The correct surgical management depends on size and location of lesion. A preoperative diagnosis is obviously needed in order to perform the correct treatment. CT abdominal scan is the better diagnostic tool, but different authors show their inability to reach a preoperative diagnosis in the larger majority of cases.

Necrotizing Fasciitis Arising From an Enterocutaneous Fistula in a Case of an Appendiceal Mucocele

An appendiceal mucocele (AM) is a rare tumorous condition of the appendix. Many patients with AM are admitted to the hospital with abdominal pain or discomfort, and many cases are found incidentally. Although the rate of complications in patients with AM is very low, if left untreated, a mucocele may rupture and produce a potentially fatal entity known as pseudomyxoma peritonei. In this paper, we report a case of an 80-year-old man with necrotizing fasciitis arising from an enterocutaneous fistula caused by AM.

Mucocele of the Appendix: Dilemmas in Differential Diagnosis and Therapeutic Management

Mucocele of the appendix (AM) is a descriptive term for mucinous distension of the appendiceal lumen. It refers to the progressive retrograde dilatation of the vermiform appendix. Because of a lack of specific signs or due to its sometime quiet presentation, this condition is frequently diagnosed only at an advanced stage. We present three isolated cases of AM complicated by the development of acute inflammation of the appendix. Currently, the assessment of appendiceal lesions relies heavily on Ultra Sonography (US) as the primary diagnostic tool. This however may not always identify the origin of such a tumour. Therefore, additional investigative modalities are implemented. Despite recent research on the therapeutic strategies against appendiceal neoplastic disorders, surgical resection appears the only potentially curative approach. Accepted management includes appendectomy, right hemicolectomy, partial colectomy with debulking or palliative resection combined with additional chemotherapy. Even if laparoscopy has been successfully used to perform appendectomy, some concerns exist regarding its use in dealing with mucinous secreting lesions because of possible spillage of mucin intra-operatively. The aim of this investigation was to analyze all cases of AM complicated by the development of acute inflammation of the appendix presented in our institution. The relevant literature is briefly reviewed. Clinical features, diagnostic approach and management algorithm for appendiceal lesions are also discussed.

Mucus containing cystic lesions "mucocele" of the appendix: the unresolved issues

Background. Mucocele of the appendix is a rare condition, the pathological classification and management strategy of which have not been standardized yet. Aim. To report on our management of appendiceal mucocele, highlighting the pitfalls and possible means for avoiding them. Materials and Methods. Our registries were reviewed to retrieve cases of appendiceal mucocele, encountered in the period from July 2008 to May 2013. Results. We had 9 cases, three males and sex females, with a median age of 62 years. Abdominal ultrasound (US) and computerized axial tomography scan (CT) suspected the diagnosis in only one case each. Open appendectomy was done in two cases of mucinous cystadenoma with no further surgery performed, despite the positive margin in one. Laparoscopic appendectomy was done in three cases: mucinous cystadenoma in one case which needed no further surgery, mucinous cystadenocarcinoma with pseudomyxoma peritonei in another, and low grade mucinous tumour in a third case, and all needed subsequent right hemicolectomy. Exploratory laparotomy was done in three cases: of these, synchronous right hemicolectomy was done in one case of mucinous cystadenoma/?mucinous tumour of uncertain malignant potential; in the other two cases, appendectomy only was done for mucinous hyperplasia with carcinoid tumour of the appendix in one case and mucinous cystadenoma/?mucinous tumour of uncertain malignant potential in another. The 9th case was discovered upon laparoscopy for cholecystectomy; when pseudomyxoma peritonei arising from an appendiceal mucocele was found, laparoscopic appendectomy with peritoneal biopsy was then performed instead. Histopathologic diagnostic uncertainty was present in two cases of mucinous cystadenoma where mucinous tumour of uncertain malignant potential was an alternative possibility. Perioperative colonoscopy was performed in only one case and our follow-up programme was defective, with the longest period being 180 days. Conclusion. Mucocele of the appendix should be considered in the differential diagnosis of cystic lesions in the right lower abdomen. Owing to its rarity, it continues to intrigue the surgeon as well as the radiologist and pathologist alike. For mucinous cystadenocarcinoma, right hemicolectomy is usually needed, whereas for hyperplasia and cystadenoma, appendectomy usually suffices if the resection margins are free. For mucinous tumours of uncertain malignant potential and low grade mucinous tumours as well as pseudomyxoma peritonei, the decision is not as simple. As for laparoscopic surgery, no solid proof exists with or against its safety. Although not yet standardized, perioperative colonoscopy and regular follow-up to detect early recurrences should probably be part of the management plan.

Incidental mucocele of the appendix in a 15-year-old girl

Mucocele of the appendix is an exceedingly uncommon pathology in the pediatric population that may present with abdominal pain or represent an incidental finding after routine abdominal imaging. Etiologies may be inflammatory or neoplastic, but all share the commonality of chronic appendiceal obstruction. Early diagnosis is critical for positive long-term outcomes because the operative management will differ from that of a dilated appendix secondary to acute appendicitis.

Mucocele of the appendix: case report and review of literature

Appendiceal mucocele is a rare disease. Sometimes it is discovered accidentally and sometimes it resembles acute appendicitis. Correct diagnosis before surgery is very important for the selection of adequate surgical treatment to avoid intraoperative and postoperative complications. Ultrasonography, and particularly computed tomography, should be used extensively for this purpose. If mucocele is treated incorrectly pseudomyxoma peritonei, which is characterized by malignant process, may develop. We present a case of a 54-year-old man who was admitted to the emergency department with the signs of acute appendicitis. Open surgery was performed. At the time of surgery, a cystic mass of the appendix with dimensions 7 × 4 ×3 cm, with inflamed walls, but without perforation was discovered in the right iliac fossa. No discharge was found in the peritoneal cavity. Diagnosis of mucocele was suspected. Only appendectomy was performed because no pathologic process was found in the base of the appendix and lymph nodes were not increased in size. Hystopathologic diagnosis was mucinous cystadenoma. After 2 years, the patient is feeling well.

Low-grade appendiceal neoplasm presenting as a volvulus of the cecum

Mucocele of the appendix is an uncommon disorder that is often asymptomatic, but can present similarly to acute appendicitis. Timely diagnosis and treatment is imperative due to the many complications that can result from the mucocele, such as perforation. Appendiceal mucoceles (AM) were previously thought to be either benign or malignant; however, a different pathological classification of AM is currently favored. Also, only a few cases of volvulus of a benign AM have been reported. Here, we present the first reported case of a low-grade appendiceal mucinous neoplasm resulting in a volvulus of the cecum.

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.

Appendiceal mucocele mimicking urolithiasis

Appendiceal mucocele is a rare clinical condition that results from distension of the appendix lumen with mucus. It is only found in 0.1-0.3% of all appendectomy specimens. Twenty-five per cent of these cases are asymptomatic and are incidentally discovered either during surgery or upon radiological examination. The treatment of appendiceal mucocele is surgical, and while appendectomy is usually sufficient in some cases right hemicolectomy may be considered as a treatment option. Mucoceles are histologically subdivided into four types: retention cysts, mucosal hyperplasia, cystadenomas and cystadenocarcinomas. Herein, we present a case of appendiceal mucocele clinically mimicking urolithiasis in a 62-year-old female patient with a complaint of colicky right flank pain and a single episode of macroscopic hematuria. The patient's abdominal ultrasonography and abdominal CT scan showed a mass consistent with mucocele in the right lower quadrant of the abdomen. Colonoscopy gave the impression of a mass lesion exerting pressure from the outside. The patient was electively operated. Histopathological diagnosis was reported as mucinous cystadenoma. Appendiceal mucocele or mucinous cystadenomas are usually seen in patients undergoing surgery with a diagnosis of appendicitis but, as in our case, these lesions may rarely occur with a clinical picture that mimics urological disease.

Endoscopic therapy of colonic liver flexure mucocele

Colorectal mucoceles usually arise in the appendix, and colonic disease is very rare. We report the first case of a mucocele of the colonic liver flexure that was treated successfully with endoscopy. A 36-year-old man was admitted to our hospital because of abdominal distension persisting for 3 days. Colonoscopic examination revealed a round polyp in the hepatic flexure, and we performed hot snare polypectomy with argon plasma coagulation. Histologically, the polypectomy specimen was confirmed to be a mucocele, with no neoplastic changes. Follow-up examinations at 6 and 12 months showed no evidence of recurrence.

Incidental diagnosis of appendiceal mucocele with vaginal ultrasonography and computed tomography

BACKGROUND

Appendiceal mucocele is an uncommon entity that may be encountered at the time of abdominal surgery performed for an unrelated indication. The diagnosis may be suggested by imaging with ultrasonography or computed tomography of the abdomen and pelvis. Whereas early resection is curative, failure to recognize the disorder may lead to rupture and the devastating consequences of pseudomyxoma peritonei.

CASE

Following an annual gynecologic checkup in a healthy 63-year-old woman, vaginal ultrasonography along with a subsequent computed tomographic study raised the possibility that an incidental appendiceal mucocele was present. At laparoscopy, this diagnosis was confirmed and the lesion was resected using minimally invasive techniques.

CONCLUSION

Early diagnosis and treatment of appendiceal mucocele facilitates the successful management of this rare disorder.

Mucinous cystic neoplasms of the mesentery: a case report and review of the literature

Background

Mucinous cystic neoplasms arise in the ovary and various extra-ovarian sites. While their pathogenesis remains conjectural, their similarities suggest a common pathway of development. There have been rare reports involving the mesentery as a primary tumour site.

Case presentation

A cystic mass of uncertain origin was demonstrated radiologically in a 22 year old female with chronic abdominal pain. At laparotomy, the mass was fixed within the colonic mesentery. Histology demonstrated a benign mucinous cystadenoma.

Methods and results

We review the literature on mucinous cystic neoplasms of the mesentery and report on the pathogenesis, biologic behavior, diagnosis and treatment of similar extra-ovarian tumors. We propose an updated classification of mesenteric cysts and cystic tumors.

Conclusion

Mucinous cystic neoplasms of the mesentery present almost exclusively in women and must be considered in the differential diagnosis of mesenteric tumors. Only full histological examination of a mucinous cystic neoplasm can exclude a borderline or malignant component. An updated classification of mesenteric cysts and cystic tumors is proposed.