Tumors of the appendix and colon

Colonoscopy in the diagnosis and management of appendiceal disease

In this editorial, we comment on the article published in the recent issue of the World Journal of Gastrointestinal Endoscopy. We focused on the understanding of appendiceal disease, and the various options for diagnosis and treatment via endoscopy. Some factors affecting the diagnosis and management of appendiceal diseases are also discussed. The existence of any organ has its natural rationality, and the appendix is such a magical organ. A growing number of experts and scholars have gradually come to a consensus that the appendix is not a useless evolutionary relic. There are many lymphocytes and lymph nodes in the appendix wall, which has a strong immune function, and this function is particularly important for children and adolescents. Many intestinal probiotics in the appendix are very helpful for maintaining the balance of the intestinal flora. With the continuous progress of endoscopic technology, endoscopic treatment involving preservation of the appendix has shown great advantages over surgery. In the diagnosis of appendiceal inflammation and neoplasms, colonoscopy, endoscopic retrograde appendicography and choledochoscopy help assess conditions of the appendix. Endoscopic retrograde appendicitis therapy, abscess drainage under colonoscopy, fenestration of abscess under colonoscopy, and endoscopic or natural orifice transluminal endoscopic surgery resection of appendiceal neoplasms are safe and effective endoscopic treatments for appendiceal disease. New breakthroughs in the application of endoscopy in the appendix are expected to occur in the near future.

Colonic leiomyoma mimicking a liver tumor: an unusual diagnosis after en-block robotic resection

Colonic leiomyomas are rare. Their clinical presentation ranges from asymptomatic polyps detected on endoscopy to large symptomatic abdominopelvic masses. Imaging findings are usually non-specific, and percutaneous biopsy might help with differential diagnosis. However, radical surgery with negative margins is ultimately needed to rule out malignancy. We describe an uncommon presentation of a colonic leiomyoma mimicking a right hepatic lobe tumor on preoperative imaging. The robotic approach allowed a precise abdominal exploration with confirmation of colonic and hepatic infiltration and subsequent oncological en-block resection. Surgeons operating on hepatic tumors close to the right colic flexure should be aware of this diagnosis.

Leiomyosarcoma mimicking acute appendicitis: a cautionary tale!

Appendiceal neoplasms are rare, occurring in <1.4% of all appendicectomy specimens. Carcinoid tumours and adenocarcinomas comprise the majority of cases, however, lymphomas or sarcomas may also arise within the appendix. Appendiceal leiomyosarcomas are rare and to date, there remains a relative dearth of cases reported in the literature. Leiomyosarcomas are derived from the smooth muscle cells or mesenchymal stem cells committed to this line of differentiation. However, their pathogenesis and underlying genetic mechanism remains to be fully elucidated. Unbalanced karyotypic defects are the only shared features observed across different leiomyosarcoma subtypes. Children with AIDS have a higher incidence compared with adults, where the main pathology in individuals with HIV is Kaposi's sarcoma and B-cell lymphoma. Although surgical excision with clear margins remains the treatment of choice, a good response to treatment with gemcitabine, docetaxel and trabectedin has been observed. The authors present the case of a 23-year-old female presenting to the emergency department with acute appendicitis. She underwent a laparoscopic converted to an open appendectomy. Her operation was complicated by a pelvic collection requiring percutaneous drainage and an ileus. Histopathological examination confirmed the diagnosis of a leiomyosarcoma, a rare mesenchymal tumour presenting in individuals with immune suppression. HIV serology was positive and she commenced anti-retroviral therapy. She remains under review in the Department of HIV Medicine.

An Uncommon Presentation of Leiomyoma Cecum as a Subcutaneous Abscess of the Right Flank

Cecal leiomyomas are rare benign tumors of smooth muscle arising from the colonic muscularis mucosa or muscularis propria. They are usually asymptomatic in nature and, if symptomatic, may present as pain in the abdomen, intestinal obstruction, or bleeding. In some cases, leiomyoma can cause free perforation leading to peritonitis. Contrast-enhanced computed tomography (CECT) and colonoscopy were the diagnostic modalities used for evaluation. It is extremely unusual for a benign lesion of the cecum to present as a ruptured subcutaneous abscess. A 40-year-old man presented to the surgical emergency with complaints of right loin swelling and dull aching pain for one week. The patient did not have any significant medical history. Examination revealed a 5×5 cm swelling in the right anterior lumbar region. Blood investigations revealed anemia with leukocytosis. An abdominal CECT revealed a 9×6 cm heterogeneous enhancing mass lesion arising from the cecum with hypodense areas abutting the anterior abdominal wall and tracking into the intermuscular plane. The patient underwent surgical exploration, and a 9×6 cm growth arising from the cecum with a localized abscess tracking into the intermuscular plane in the right anterior abdominal wall and forming a subcutaneous abscess was intraoperatively found. A right hemicolectomy with ileocolic anastomosis was done, with external drainage of the subcutaneous abscess. Histopathological examination of the resected specimen revealed a leiomyoma of the cecum with abscess. To the best of our knowledge, this is the first report of a case of cecal leiomyoma to rupture into the subcutaneous space and present as a flank abscess.

Cecal Leiomyoma: Can We Attempt Endoscopic Resection?

Gastrointestinal leiomyomas are smooth muscle tumors arising from the muscularis mucosae, muscularis propriae and possibly from smooth muscle of the vessel wall. Management depends on the size, location and the clinical scenario. Endoscopic snare cauterization with or without saline lift has been described in literature for tumors involving the left colon. To the best of our knowledge, endoscopic resection of right colon leiomyoma was never attempted in the past. We present a case of cecal leiomyoma which was resected endoscopically.

Giant extraluminal leiomyoma of the colon: rare cause of symptomatic pelvic mass

Leiomyomas (LMs) may appear throughout the entire gastrointestinal tract but are rarely seen in the colon-rectum and only 5 of those measured greater than 15 cm in diameter. Pain and palpable abdominal mass are the most common symptoms. Surgical resection is the treatment of choice for most LMs. We here describe a case of a 46-year-old woman who presented with a 3-month history of abdominal pain associated with worsening constipation and abdominal distension. A pelvic solid, polylobulate, left-sided mass was noted on examination. Preoperative findings revealed a dishomogeneous sigmoid mass with calcified spots compressing small intestine and bladder. At laparotomy, a large polylobulate and well-circumscribed mass arising from the descending colon mesentery and displacing small intestine, uterus, and ovaries. A segmental colon resection was performed. An extraluminal 18- × 12- × 5-cm paucicellular sigmoid colon leiomyoma was histologically diagnosed. Our case is one of the few giant (>15 cm) sigmoid colon LMs reported in the literature. Although rare and benign in nature, LMs of the colon can cause life-threatening complications that could require emergency treatment and they should be included in the differential diagnosis of large abdominopelvic masses. Follow-up after surgery is necessary for tumors with any atypia or mitotic activity.

Leiomyosarcoma of the sigmoid colon with multiple liver metastases and gastric cancer: a case report

Background

Leiomyosarcoma (LMS) of the gastrointestinal tract is an extremely rare high-grade neoplasm with poor prognosis. For advanced LMS with distant metastasis, the decision as to the choice of the most appropriate therapeutic strategy, including chemotherapy and surgery, is difficult. Here, we present an unusual case of LMS of the sigmoid colon with liver metastases and gastric cancer. The survival of this patient was prolonged by a combined modality therapy involving chemotherapy and surgery.

Case presentation

A 66-year-old woman who had been diagnosed with advanced gastric cancer and multiple liver metastases was referred to our hospital. The initial treatment with docetaxel and S-1 considerably reduced both the gastric cancer and liver tumors; consequently we performed surgical resection. Pathological examination revealed that no viable tumor cells remained in the stomach and chemotherapy resulted in complete remission of the gastric cancer. The liver tumors were immunohistochemically diagnosed as LMS. A tumor of the sigmoid colon was subsequently discovered and the liver tumors were found to have recurred. The surgically resected sigmoid colon and liver tumors were all immunohistochemically diagnosed as LMS. These findings indicated that the multiple liver metastases arose from the LMS in the sigmoid colon, and that they were accompanied by advanced gastric cancer. We performed another surgical resection and administered chemotherapy to treat the recurring liver metastases. The patient survived for 4 years and 10 months after initial presentation at our hospital.

Conclusion

Colonic LMS is rare and its joint occurrence with gastric cancer is extremely unusual. Although LMS is a high-grade neoplasm, a multimodal therapeutic approach can increase patient survival time even when multiple liver metastases are present.

Giant appendiceal leiomyosarcoma: a rare and unusual tumour

Appendiceal tumours are uncommon but may be present in 0.9-1.4% of all appendicectomy specimens. While carcinoid tumours and adenocarcinomas comprise the majority of appendiceal tumours, rarely, lymphomas or sarcomas may also present in the appendix. Appendiceal leiomyosarcomas are rare, and to date, only a handful of cases have been reported. The current paper presents a case of giant appendiceal leiomyosarcoma followed by a review of the literature.

Massive lower gastrointestinal hemorrhage caused by a large extraluminal leiomyoma of the colon: report of a case

The occurrence of leiomyoma of the colon is uncommon. Most of these lesions are clinically silent and are found incidentally during laparotomy or endoscopic procedures for unrelated conditions. Symptomatic leiomyomas of the colon are encountered less frequently, with only sporadic reports in the literatures. We describe a heretofore unreported case of a large extraluminal leiomyoma of the sigmoid colon presenting as massive lower gastrointestinal hemorrhage. Because it was extraluminal in position, it was difficult to make an accurate diagnosis endoscopically and the condition was easily misdiagnosed as angiodysplasia of the colon until CT scan results were seen. Although rare and benign in nature, leiomyoma of the colon may cause life-threatening complications that require emergency surgery and should be included in the differential diagnosis of lower gastrointestinal hemorrhage.

Therapeutic procedures for submucosal tumors in the gastrointestinal tract

This review is part three of three and will present an update on the therapeutic options and procedures concerning gastrointestinal (GI) submucosal tumors (SMTs). The aim of this paper is to investigate the treatments of GI SMTs and to present a case of a gastrointestinal stromal tumor (GIST). Literature searches were performed to find information on therapy for GI SMTs. Based on these searches, the optimal therapeutic procedures could be outlined. The choice of treatment of localized tumors is endoscopic resection if possible or, alternatively, laparoscopic resection or surgical resection by an open procedure. However, benign SMTs should only be excised if symptoms are present, and GISTs should be treated with particular precautions. Irresectable or recurrent GISTs may be successfully treated with the tyrosine kinase inhibitor, imatinib.

Gastrointestinal stromal tumor of appendix incidentally diagnosed by appendiceal hemorrhage

Gastrointestinal stromal tumor is rare, which arises from the mesenchymal tissues in the gastrointestinal tract, and it is extremely rare in the appendix. Only a few cases have been found in this location to date. Although the annual incidence of lower gastrointestinal bleeding has been increasing, bleeding related to the appendix is quite rare. We herein present a very rare case of gastrointestinal stromal tumor incidentally found by appendiceal hemorrhage.

Synchronous appendiceal tumours

Primary appendiceal neoplasms are a rare clinical and pathological entity. We report a case of synchronous appendiceal tumours of different histological types which presented as a symptomatic palpable and radiologically apparent mass in the right iliac fossa. This case demonstrates the importance of pre-operative diagnosis of these neoplasms, as it may alter the surgical approach and obviate the need for additional surgery. Furthermore, some of the controversies associated with the management of an appendix mass in the elderly population are discussed.

A population-based study of colorectal cancer histology in the United States, 1998-2001

BACKGROUND

Histology is an important factor in the etiology, treatment, and prognosis of cancer. The purpose of this study was to descriptively characterize colorectal cancer (CRC) histology in the United States population.

METHODS

Data from cancer registries in the National Program of Cancer Registries (NPCR) or Surveillance, Epidemiology and End Results (SEER) program, representing 88% of the U.S. population, were used in the study. The analysis included 522,630 microscopically confirmed CRC cases diagnosed from 1998-2001.

RESULTS

About 96% of CRCs were adenocarcinomas, approximately 2% were other specified carcinomas (including carcinoid tumors), about 0.4% were epidermoid carcinomas, and about 0.08% were sarcomas. The proportion of epidermoid carcinomas, mucin-producing carcinomas, and carcinoid tumors was greater among females. Several histologic patterns with regard to race and ethnicity existed, including a higher percentage of carcinoid tumors among most non-white populations. With respect to age, higher percentages of sarcomas, mucin-producing adenocarcinomas, signet ring cell tumors, and carcinoid tumors were found in individuals under age 40. Overall, adenocarcinomas were more likely to be diagnosed at regional stages with moderate differentiation. Compared with other adenocarcinomas, signet ring cell tumors were more often poorly differentiated and were at distant stage at diagnosis. Carcinoid tumors and sarcomas were mainly poorly differentiated and were at localized stage at diagnosis. Small cell carcinomas were more likely undifferentiated and were at distant stage at diagnosis.

CONCLUSIONS

To date, this is the largest population-based study to analyze CRC histology in the United States. Distinct demographic and clinical patterns associated with different histologies may be helpful for future epidemiologic, laboratory, and clinical studies.

Management of an unexpected appendiceal neoplasm

BACKGROUND

Appendiceal neoplasms are rare and most present unexpectedly as acute appendicitis. The classification and management are confusing, and there are few substantial reports in the literature.

METHODS

A systematic literature review was performed to access relevant publications on the presentation, pathology and management of appendiceal tumours.

RESULTS

Appendiceal tumours account for 0.4 to 1 per cent of all gastrointestinal tract malignancies and are found in 0.7 to 1.7 per cent of appendicectomy specimens. Carcinoid tumours are most common. Most are cured by simple appendicectomy if the tumour is less than 2 cm in size and does not involve the resection margin or mesoappendix. Epithelial tumours may present with, or in time develop, pseudomyxoma peritonei, the optimal management of which involves complete tumour resection and intraperitoneal chemotherapy, usually available only in specialized centres.

CONCLUSION

Suggested algorithms for the management of unexpected appendiceal tumours are provided. Recommendations are made for follow-up of patients with a perforated appendiceal epithelial tumour.

Primary neoplasms of the appendix: radiologic spectrum of disease with pathologic correlation

Although uncommon, primary appendiceal neoplasms often result in clinical symptoms that may lead to abdominal imaging. Acute appendicitis from luminal obstruction is the most common manifestation for most tumor types. Other manifestations include intussusception, a palpable mass, gastrointestinal bleeding, increasing abdominal girth (from pseudomyxoma peritonei), and secondary genitourinary complications. Asymptomatic appendiceal neoplasms may be discovered incidentally. Mucoceles from either benign or malignant mucinous neoplasms represent the majority of appendiceal tumors detected at imaging but are the least likely to manifest as appendicitis. Pseudomyxoma peritonei is a common manifestation of mucinous adenocarcinoma. Colonic-type (nonmucinous) adenocarcinoma of the appendix is much less common than mucinous tumors and typically manifests as a focal mass without mucocele formation. Carcinoid tumor is the most common appendiceal neoplasm but is less often detected radiologically because it is typically small and relatively asymptomatic. Goblet cell carcinoid tumor and non-Hodgkin lymphoma of the appendix are rare and usually infiltrate the entire appendix. Cross-sectional imaging, particularly computed tomography (CT), is effective in the evaluation of these neoplasms. CT appears to be the modality of choice whenever an appendiceal mass is suspected. CT will help rule out or confirm an appendiceal tumor and may suggest a more specific diagnosis.