Mucinous cystadenocarcinoma in the appendix in a patient with nonrotation: report of a case

Multiple intestinal hemangioma concurrent with low-grade appendiceal mucinous neoplasm presenting as intussusception-a case report and literature review

BACKGROUND

Cases with intussusception caused by either intestinal hemangiomas or appendiceal mucinous neoplasms are extremely rare.

CASE PRESENTATION

In this study, we reported a 47-year-old male presented with paroxysmal abdominal pain and postprandial bloating for 3 days. CT results indicated a high possibility of secondary intussusception in ascending colon. Histopathology indicated a mixed type of cavernous and capillary hemangioma, combined with low-grade appendiceal mucinous neoplasms (LAMNs) and intestinal obstruction. The patient underwent laparotomy and right hemicolectomy. Finally, the patient was followed up for 4 months with no disease progression.

CONCLUSIONS

Rare studies reported the intestine hemangiomas coincided with appendix low-grade mucinous tumor. Its manifestations are not specific, which is a challenge in the preoperative diagnosis. For cases with intussusception that was not observed in time, it may lead to intestinal necrosis and diffuse peritonitis. Additionally, the ruptured mucinous tumor in the appendix may lead to pathogenesis of pseudomyxoma peritonei. Therefore, accurate diagnosis and appropriate surgery-based treatment contribute to the improvement of prognosis and severe outcomes among these patients.

Utility of computed tomography and 18 F-fluorodeoxyglucose with positron emission tomography/computed tomography for distinguishing appendiceal mucocele caused by mucinous adenocarcinoma from other pathologies

AIM

Differentiating appendiceal mucocele with mucinous adenocarcinoma from other pathologies before surgery is difficult. The objective of this study was to evaluate the utility of CT and ¹⁸ F-fluorodeoxyglucose (FDG) with positron emission tomography (PET)/CT for differentiating mucinous adenocarcinoma of appendiceal mucocele from other pathologies.

METHOD

The study included 25 patients who underwent surgery for clinically diagnosed appendiceal mucoceles detected on CT at the University of Tokyo Hospital. Among these patients, 19 underwent FDG-PET/CT preoperatively. We compared features of the CT imaging findings and maximum standard uptake values (SUV_max ) detected by FDG-PET/CT between mucocele with mucinous adenocarcinoma and other pathologies.

RESULTS

A total of 13 men (52%) and 12 women (48%) were included in this study, with a median age of 65 years (range 34-83). There were six patients (24%) with pathologically confirmed mucinous adenocarcinoma, 15 patients (60%) with appendiceal mucinous neoplasm and four patients (16%) with simple mucocele caused by chronic inflammation. On the CT findings, wall irregularity was the only significant feature for the two groups in this study (83.3% vs 0.0%, P < 0.01). There was a significant difference in the SUV_max levels on PET/CT between the two groups (100.0% vs 20.0%, P < 0.01).

CONCLUSION

Distinguishing between mucocele with mucinous adenocarcinoma and other pathologies using imaging modalities is challenging. Our results suggest that wall irregularity on CT and elevated SUV_max on PET/CT are useful factors that can be employed for such discrimination.

Perforated mucocele of the appendix in the left upper quadrant: A challenging anatomy and an improvised surgical technique

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Pseudomyxoma peritonei (PMP) is a devastating consequence of perforated appendicular mucocele. It is considered a rare disease.

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The presence of asymptomatic gut malrotation in adults can complicate the clinical picture of acute abdomen. ** (starting a new highlight point): Not considering possible anatomical variations initially during assessment could delay the diagnosis and managment.

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The introduction of Cytoreductive Surgery/Heated Intraperitoneal Chemotherapy (CRS/HIPEC) improved the outcome of many patients with PMP.

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Preserving part of the colon during challenging colorectal resection to allow a colo-rectal anastomosis offers a superior quality of life.

Introduction

Pseudomyxoma peritonei (PMP) is a feared complication of appendicular mucocele perforation. Although a rare disease, its major sequel mandates recognition and early intervention. Intestinal malrotation is mostly asymptomatic in adults. Its significance arises when it complicates another coinciding condition by confusing the presentation, leading to delay in diagnosis and treatment. PMP and incidental finding of gut malrotation in adults are two rare events, and the chance of both occurring in the same patient is very slim. This can complicate the clinical picture and lead to devastating outcomes.

Presentation of the case

We present a case of PMP in a patient with gut malrotation, managed with cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC).

Discussion

Management with CRS/HIPEC has been found to improve outcomes for patients with PMP. However, the extensive disease and abnormal anatomy of the patient in our report proposed unique intraoperative challenges. Preserving part of the colon was possible with an improvised surgical technique that we used which proved to be safe and effective.

Conclusion

Early recognition and consideration of uncommon but serious surgical conditions are essential for improved patient outcomes. To our knowledge, this is the first report in the English literature that describes the use of CRS/HIPEC for PMP in a case of intestinal malrotation. This improvised surgical technique was found to be safe and can provide a surgical solution for preserving part of the colon in selected patients.

Mucinous appendiceal neoplasms: pathologic classification, clinical implications, imaging spectrum and mimics

Mucinous appendiceal neoplasms are uncommon, but important to recognize with imaging due to malignant potential. Peritoneal seeding and pseudomyxoma peritonei can occur with both frankly malignant as well as low-grade appendiceal neoplasms. Prospective imaging identification of potential appendiceal neoplasm is paramount to clinical/surgical management. When a mucinous appendiceal neoplasm is suspected, a right hemicolectomy with lymph node dissection is the preferred surgical management. Unfortunately, accurate preoperative diagnosis can be challenging due to a wide range of clinical presentations and overlapping imaging appearances of appendiceal neoplasms with benign entities. Using the 2010 World Health Organization (WHO) pathologic classification as a framework, we provide a comprehensive multi-modality pictorial essay detailing the broad array of imaging findings of mucinous appendiceal neoplasms and common imaging mimics.

Appendiceal mucocoele with midgut malrotation

Introduction Malrotation of the midgut and appendiceal mucocoele are both extremely rare pathological conditions in adults. To our knowledge, there are only two reported cases in the English literature with a combination of both conditions. Case History A 65-year-old man presented with a 10-day history of upper abdominal pain associated with abdominal bloating and weight loss. He was otherwise fit and healthy with no significant past medical history. On examination, his abdomen was soft with tenderness and palpable fullness over the left upper quadrant. The initial blood test, chest x-ray and abdominal x-ray demonstrated no significant abnormality. Computed tomography showed a 17cm x 8cm x 6cm elongated cystic mass with possible malrotation of the intestines. Histopathology showed a low grade mucinous tumour of the appendix. At 12 months following surgery, there was no evidence of recurrence or postoperative complications and the patient was discharged from the care of the colorectal team. Conclusions We report a patient with a combination of two rare conditions. This case illustrates how a combination of pathologies can present a challenge to the unwary general surgeon.

Malrotation of the Intestine in Adult and Colorectal Cancer

Malrotation of the gut is a congenital anomaly and usually presents in childhood. Rarely, it may present in adults. Patients may be asymptomatic, and malrotation is detected during investigations, operation or autopsy. It can cause longstanding abdominal symptoms like pain, dyspepsia or acute abdomen due to volvulus. In adults, malrotation is found with different gastrointestinal malignancies like gastric, hepatobiliary, pancreatic and, in particular, colorectal neoplasms. We are reporting a case of 60-year-old female presented with carcinoma caecum along with malrotation of the gut. It is the first case report from India. We also reviewed documented cases of malrotation associated with colorectal malignancies. A large number of cases have been reported in Japan as compared to rest of the world. Malrotation in adults is probably associated with gastrointestinal malignancies. Possible causes of this association can be genetic factors or gut changes like chronic inflammation. These associations need further study to consider intestinal malrotation as premalignant lesion which may be very important in follow-up of children with malrotation.

Appendiceal mucocele: A diagnostic dilemma in differentiating malignant from benign lesions with CT

OBJECTIVE

The purpose of this study was to assess the feasibility of using CT to differentiate malignant from benign lesions in patients with pathologically confirmed appendiceal mucoceles.

MATERIALS AND METHODS

CT scans of 18 consecutively registered patients (11 men, seven women; age range, 21-78 years) with pathologically confirmed appendiceal mucocele were reviewed retrospectively. Patients were classified into three groups according to pathologic results: nonneoplastic mucocele (n = 3), mucinous cystadenoma (n = 10), and mucinous cystadenocarcinoma (n = 5). The nonneoplastic and mucinous cystadenoma groups were formed into a benign group, and the mucinous cystadenocarcinoma constituted the malignant group. Two experienced radiologists working in consensus assessed the shape, short diameter, density, contour, and wall thickness of the masses. The presence of calcifications, internal septations, soft-tissue thickening, periappendiceal fat stranding, intraperitoneal free fluid and pseudomyxoma peritonei were also evaluated. The CT results were compared for malignant and benign appendiceal mucoceles.

RESULTS

CT showed statistically significant differences in wall irregularity and soft-tissue thickening between malignant and benign cases (p < 0.05). Short diameter of mucoceles, attenuation of intraluminal contents, maximal wall thickness, calcifications, internal septations, periappendiceal fat stranding, intraperitoneal free fluid, and pseudomyxoma peritonei in the lesions did not differ significantly between the benign and malignant groups (p > 0.05).

CONCLUSION

Differentiating malignant from benign mucoceles can be difficult with CT. Irregular walls and soft-tissue thickening are features most likely to be associated with malignancy.

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.

Left-sided appendicitis: Review of 95 published cases and a case report

AIM: To give an overview of the literature on left-sided acute appendicitis (LSAA) associated with situs inversus totalis (SIT) and midgut malrotation (MM).

METHODS: We present a new case of LSAA with SIT and a literature review of studies published in the English language on LSAA, accessed via PubMed and Google Scholar databases.

RESULTS: Ninety-five published cases of LSAA were evaluated and a 25-year-old female, who presented to our clinic with left lower abdominal pain caused by LSAA, is reported. In the reviewed literature, fifty-seven patients were male and 38 were female with an age range of 8 to 82 years and a median age of 29.1 ± 15.9 years. Sixty-six patients had SIT, 23 had MM, three had cecal malrotation, and two had a previously unnoted congenital abnormality. Fifty-nine patients had presented to the hospital with left lower, 14 with right lower and seven with bilateral lower quadrant pain, and seven subjects complained of left upper quadrant pain. The diagnosis was established preoperatively in 49 patients, intraoperatively in 19, and during the postoperative period in five; 14 patients were aware of having this anomaly. The data of eight patients were not unavailable. Eleven patients underwent laparoscopic appendectomy, which was combined with cholecystectomy in two cases. Histopathological examination of the appendix specimens revealed adenocarcinoma in only two of 95 patients.

CONCLUSION: The diagnosis of left lower quadrant pain is based on well-established clinical symptoms, physical examination and physician’s experience.

Mucinous Cystadenocarcinoma of the Colon during Pregnancy

A rare case of mucinous adenocarcinoma of the cecum in a pregnant woman is described. A 32-year-old Korean woman was diagnosed as having an abdominal tumor immediately after giving birth. Abdominal computed tomography demonstrated a smooth mass measuring 10 cm in diameter on the right side of the abdomen. Acute abdomen developed 3 days after birth. At emergency surgery, volvulus of a polypoid tumor was detected at the cecum apart from the normal appendix. We successfully performed a tumorectomy; however, histopathological examination demonstrated mucinous adenocarcinoma with a massive blood clot.

Laparoscopic resection of appendiceal mucinous cystadenoma

Mucinous cystadenoma is a rare lesion of the vermiform appendix and is seldom diagnosed before surgery, although radiologic and ultrasonographic findings have been reported. We present the case of a 65-year-old female with rheumatoid arthritis who presented with general malaise, poor appetite, fever, and right upper and lower quadrant pain of about one week's duration. Abdominal sonography and computed tomography revealed an 8 x 4 x 3 cm cystic lesion of the appendix. Laparoscopic evaluation confirmed this finding and the lesion was resected without rupturing the tumor during manipulation. Laparoscopic surgery provides the advantages of good exposure and evaluation of entire abdominal cavity, as well as more rapid recovery. It is important to avoid tumor rupture during manipulation, and formation of pseudomyxoma peritonei, in case the tumor is malignant.