|Year : 2022 | Volume
| Issue : 3 | Page : 168-170
Adenocarcinoma of the appendix
Gbemi Henry Ano-Edward1, Kehinde J Aworinde-Olufemi2, Enugwaronu A Agbakwuru3, Mathew E Lasisi1, BM Famoroti4
1 Department of Anatomic Pathology, Bowen University Teaching Hospital, Ogbomoso, Oyo State, Nigeria
2 Department of Haematology and Blood Transfusion, Bowen University Teaching Hospital, Ogbomoso, Oyo State, Nigeria
3 Department of Surgery, Bowen University Teaching Hospital, Ogbomoso, Oyo State, Nigeria
4 Gosec Medical Centre Ilorin, Kwara State, Nigeria
|Date of Submission||27-Jan-2022|
|Date of Decision||28-Mar-2022|
|Date of Acceptance||18-Apr-2022|
|Date of Web Publication||21-Sep-2022|
Gbemi Henry Ano-Edward
Department of Anatomic Pathology, Bowen University Teaching Hospital, Ogbomoso, Oyo State
Source of Support: None, Conflict of Interest: None
Rationale: Adenocarcinoma of the appendix is a rare disease which is often diagnosed after surgery by a pathologist. Patient concerns: This case is that of a 50 year old man who presented with an acute abdomen. Diagnosis: A diagnosis of acute appendicitis was made. Interventions: He had an appendectomy and a subsequent right hemicolectomy performed. In the laboratory, the diagnosis of moderately differentiated adenocarcinoma of the appendix and chronic granulomatous inflammation of lesions within the abdomen was made after surgery. Outcome: The patient did well after surgery and was followed up for three years in the outpatient clinic. Lessons: Although, a simple appendectomy may be sufficient for incidental adenocarcinoma of the appendix but for optimal outcome right hemicolectomy is advised for a suspicious mass or lesions. Furthermore, adenocarcinoma of the appendix is a very rare disease in our environment, surgeons are encouraged to submit appendectomy specimens for histopathological diagnosis.
Keywords: Adenocarcinoma of appendix, moderately differentiated adenocarcinoma, right hemicolectomy
|How to cite this article:|
Ano-Edward GH, Aworinde-Olufemi KJ, Agbakwuru EA, Lasisi ME, Famoroti B M. Adenocarcinoma of the appendix. Hamdan Med J 2022;15:168-70
| Introduction|| |
Adenocarcinoma of the appendix is a rare disease and is often diagnosed after appendectomy by the pathologist. It is usually seen between the 6th and 7th decades of life with a male preponderance. Adenocarcinoma of the appendix is the least common tumour of the appendix, accounting for 10%, followed by cystadenocarcinoma 20% and carcinoids 66%. We present this case which was diagnosed post-appendectomy and subsequent right hemicolectomy.
| Case Report|| |
KI is a 50-year-old man who presented with right iliac fossa pain of 10-day duration. There was a 3-day history of associated abdominal swelling with four episodes of non-projectile, non-bilious vomiting containing recently ingested food. He had constipation and anorexia and weight loss. There was no history of the passage of pellet-like or bloody stool and no diarrhoea. He had no history suggestive of diabetes mellitus, hypertension or peptic ulcer disease. There was no history of previous surgery.
On examination, he was in painful distress, with a fever of 38.1°C, respiratory rate was 24 cycles/min and pulse rate was 92 beats/min. There was moderate abdominal distension and guarding which prevented palpation of the abdominal organs. The heart sounds were normal, and blood pressure was 130/90 mmHg; breath sounds were vesicular bilaterally with clear lung fields. Bowel sounds were hyperactive. Digital rectal examination revealed poor perianal hygiene, normal sphincteric tone, with little faeces in the rectum. The prostate was not enlarged, and the gloved finger was stained with brownish non-bloody stool.
An assessment of adynamic intestinal obstruction secondary to peritonitis from perforated viscus was made pre-operatively. Haematologic indices showed packed cell volume as 30% and total white blood cells − 6.0 × 109/dl (neutrophils = 60% and lymphocytes = 40%). Other patient's parameters include blood Group A rhesus positive, potassium − 3.0 mmol/dl, sodium − 3.45 mmol/dl, urea − 50 mg/dl and creatinine − 1.4. The patient's plain abdominal X-ray showed dilated loops of bowel and multiple air-fluid levels in the abdomen. The abdominal ultrasound performed suggested an inflamed appendix.
Intraoperative findings revealed free serous intraperitoneal fluid, an appendiceal mass walled off with omentum attached to the anterior abdominal wall. The intraoperative diagnosis was intestinal obstruction secondary to appendiceal mass. An initial emergency exploratory laparotomy with concurrent appendectomy and omentectomy was carried out.
The histopathology report of the appendiceal mass was invasive adenocarcinoma. The post-operative period was uneventful, and the patient was discharged to the outpatient clinic, where he was informed of the disease and counselled on the need for a right hemicolectomy. Colonoscopy performed before revision surgery did not reveal any other lesion in the large bowel. Thus, a right hemicolectomy was performed successfully 1 month after the first surgery. Intraoperative findings at revision surgery revealed multiple grey-white lesions attached to the urinary bladder, umbilical region, serosa of the intestine and part of the mesentery. There was no mass seen or palpated but mild spillage of mucin into the abdomen was noted. Hence, there was a need to rule out carcinomatosis peritonei.
At the histopathology laboratory, we initially received an appendectomy specimen that measures 12 cm × 6 cm with a grossly distended tip, covered by haemorrhagic necrosis. On dissecting, the lumen was dilated and a 1.5 cm greyish mass was seen arising from the wall of the appendix [Figure 1]. Microscopically, there was an infiltration of hypertrophied muscular wall and mucosa by malignant epithelial cells disposed of in a glandular pattern and no extension of the malignant cells to the serosa or the mesentery. Also seen were areas of haemorrhagic necrosis and mixed inflammatory cells [Figure 2]. Diagnosis of invasive adenocarcinoma of the appendix was therefore made.
|Figure 1: Gross specimen of the appendix showing tumour (1.5 cm) arising from the wall|
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|Figure 2: H and E section showing infiltration of mucosa and muscular layer of the appendix by moderately differentiated malignant glands (×40)|
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The second specimen received in the laboratory was a right hemicolectomy bowel segment, 163 cm in length with a rough serosa surface covered by fibrinous exudate and haemorrhagic necrosis; there were greyish white lesions on the serosa of the colon and the mesentery [Figure 3]. The cut surface of the intestine showed preserved mucosa with faeces; no obvious mass was seen. Samples were taken from the lesions for histology. The report of histopathology did not show any tumour in another part of the hemicolectomy specimen. The lesions on the urinary bladder, umbilicus, intestine and mesentery were chronic granulomatous inflammation [Figure 4].
|Figure 4: H and E section from the omentum showing fibrosis and poorly formed granuloma (×40)|
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| Discussion|| |
Adenocarcinoma of the appendix is a difficult diagnosis to make pre-operatively or intra-operatively, even when the patients present with an appendicular mass and sepsis. It should be considered in middle-aged and elderly patients and also in excised samples sent for histopathology diagnosis. No specific symptom is associated with the disease. However, it may present as acute appendicitis, chronic or recurrent appendicitis, appendicular abscess, intestinal obstruction, pseudomyxoma peritonei, primary bladder cancer, haematuria, hydronephrosis and pelvic mass., If patients pr esent early, tumour markers such as carcinoembryonic antigen and computerised tomography scans should be performed. However, as in most cases in our environment, the patient presented late with acute abdomen and intestinal obstruction. Thus, an emergency laparotomy had to be performed on him.
Adenocarcinoma of the appendix accounts for 10% of cancer of the appendix and treatment remains controversial. Right hemicolectomy has been the general procedure agreed upon by surgeons following the diagnosis and the prognosis is slightly better. The peak age of incidence of adenocarcinoma of the appendix is the 5th and 6th decades with slightly more males affected than females., There are three subtypes: mucinous (55%), colonic (34%) and adenocarcinoid (11%) with mixed morphology. The case being presented is that of the colonic type [Figure 2] with moderately differentiated malignant epithelial cells infiltrating the mucosa and muscular layer in a glandular pattern. Adenocarcinoma of the appendix arises in pre-existing adenoma, and it could be both cystic and colonic types. The cystic type is more common, and it produces mucin, ruptures easily and is complicated by pseudomyxoma peritonei, whereas the colonic type often arises from a tubular adenoma or tubulovillous adenoma. Adenocarcinoma of the appendix easily perforates due to the anatomy of the appendix, with the colonic type of appendiceal adenocarcinoma; the perforated cells have a low survival potential and less tendency to peritoneal implantation. It could have been the situation in this case as the deposits found on the urinary bladder, umbilicus, mesentery, intestine and peritoneum showed chronic granulomatous inflammation.
Murphy et al. are of the opinion that simple appendectomy is sufficient for adenocarcinoma with a diameter <2 cm and confined to the appendix without extension to the mesoappendix or base of the appendix and found incidentally at the surgery. This is what was done in this case, as the tumour was 1.5 cm and confined to the appendix. Thus, for optimal outcome, a right hemicolectomy was performed after the histopathology result of the initial appendectomy specimen showed an invasive moderately differentiated adenocarcinoma. At the time of writing this article, more than 3 years later, the patient was still clinically stable and haematological indices are within normal limits.
| Conclusion|| |
Primary appendiceal adenocarcinoma is a rare disease of the appendix; the colonic type is even rarer. Literature review of this disease in our environment is extremely rare. Right hemicolectomy, which offers the patient a better prognosis, should be performed as soon as possible. It is good for surgeons to consider the disease as a differential diagnosis of acute appendicitis in older patients, so as to get a proper informed consent from patients and offer right hemicolectomy, thus avoiding a two-stage surgical procedure. We also encourage surgeons to submit all appendectomy specimens for histopathological review, as the diagnosis would have been missed if histology was not done.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]