The volcano sign of appendiceal mucocele

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.

Massive appendiceal mucinous neoplasm diagnosed after abdominal trauma: Pitfalls in imaging and diagnosis

Low grade appendiceal mucinous neoplasm (LAMN) is a rare tumor presenting typically with symptoms of acute appendicitis. A 33-year-old gentleman presented with abdominal fullness and discomfort secondary to abdominal trauma obtained during boxing training. Investigations with magnetic resonance imaging (MRI), ultrasound, and colonoscopy revealed a large cystic lesion in the ascending colon mesentery with unclear continuation with the appendix. There were no obvious features of malignancy. Laparoscopy revealed a large, firm mass connected to the appendix with enlarged lymph nodes, and the patient underwent radical resection with a right hemicolectomy. Histopathology revealed complete excision of LAMN with no lymphatic involvement. Post traumatic intra-abdominal cystic lesions pose a diagnostic challenge, and neoplastic lesions cannot be ruled out with imaging alone, even with benign appearances. Careful surgical excision and histopathological diagnosis is the only definitive method of ruling-out malignancy.

Mucinous neoplasm of the appendix: A case report and review of literature

BACKGROUND

Appendiceal mucinous neoplasms (AMNs), although not classified as rare, are relatively uncommon tumors most often discovered incidentally during colorectal surgery. Accurate identification of AMNs is difficult due to non-specific symptoms, overlapping tumor markers with other conditions, and the potential for misdiagnosis. This underscores the urgent need for precision in diagnosis to prevent severe complications.

CASE SUMMARY

This case report describes the unexpected discovery and treatment of a low-grade AMN (LAMN) in a 74-year-old man undergoing laparoscopic hemicolectomy for transverse colon adenocarcinoma (AC). Preoperatively, non-specific gastrointestinal symptoms and elevated tumor markers masked the presence of AMN. The tumor, presumed to be an AMN peritoneal cyst intraoperatively, was confirmed as LAMN through histopathological examination. The neoplasm exhibited mucin accumulation and a distinct immunohistochemical profile: Positive for Homeobox protein CDX-2, Cytokeratin 20, special AT-rich sequence-binding protein 2, and Mucin 2 but negative for cytokeratin 7 and Paired box gene 8. This profile aids in distinguishing appendiceal and ovarian mucinous tumors. Postoperative recovery was uncomplicated, and the patient initiated adjuvant chemotherapy for the colon AC.

CONCLUSION

This case highlights the diagnostic complexity of AMNs, emphasizing the need for vigilant identification to avert potential complications, such as pseudomyxoma peritonei.

Appendiceal cancer showing a submucosal tumor-like morphology in the ascending colon on colonoscopy: a case report

Few reports have described a submucosal tumor (SMT)-like colon tumor together with appendiceal cancer. Moreover, some appendiceal tumors may exhibit a cecal protuberance. Here, we report an uncommon case of appendiceal cancer with an SMT-like tumor, which was a protuberant lesion in the ascending colon. To our knowledge, this is the first report in Japan. Our case was a 50-year-old man with an ascending colon tumor presented at our hospital for further evaluation of this lesion. This was discovered as a cystic lesion near the ascending colon on colonoscopy. Our initial diagnosis was an ascending colon SMT-like tumor, and our treatment strategy was laparoscopic resection. The differential diagnosis was appendiceal cancer or mucocele. Postoperative pathological findings led to a diagnosis of adenocarcinoma of the appendix. The postoperative course was uneventful, and the patient was followed up with computed tomography and blood sampling on an outpatient basis.

Three cases of appendiceal mucocele: From diagnosis to management

Appendiceal mucocele is an appendicular dilatation secondary to the intraluminal accumulation of mucous material. Adequate pre-operative diagnosis and surgical resection remains the standard management. Here, we present three cases of appendiceal mucocele. In the first case, a 60-year-old female presented with signs and symptoms of acute appendicitis and was admitted and operated. An inflamed distended globular cystic mass of appendix measuring 10 × 6 × 4 cm with a wide base was found and the patient underwent right hemicolectomy. In the second case, a 30-year-old male with symptoms and signs of acute appendicitis was admitted to the emergency department. An open surgery was performed and a distended, tense, and inflamed appendix without perforation of size 6 × 1 × 1 cm was discovered and removed. The diagnosis of mucocele appendix was suspected and confirmed by postoperative dissection of the specimen and histopathology. In the third case, a 25-year-old female patient was subjected to diagnostic laparoscopy in view of non-specific pain abdomen. A diagnosis of mucocele of appendix was made intraoperatively and removed using a specimen bag. Appendiceal mucocele with acute presentation is a rare pathology that clinically resembles acute appendicitis. Preoperative detailed investigations to reach a definitive diagnosis are critical for adequate surgical resection and overall outcome.

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.

A Retrospective Study on Mucocele of the Appendix Presented with Acute Abdomen or Acute Appendicitis

Objective

We reported the demographic, clinical, radiologic, preoperative and postoperative characteristics and outcomes on patients of appendix mucocele that presented with or operated for acute appendicitis or acute abdomen.

Methods

A retrospective study. Patients who were presented or operated for acute appendicitis or acute abdomen and had an operative histopathological diagnosis as appendix mucocele (simple mucocele, mucinous cystadenoma, mucinous cystadenocarcinoma) were included. Demographic, clinical, radiologic, preoperative and postoperative data of eligible cases were evaluated.

Results

From January 2003 to February 2010, a total of 2120 patients with the pre-operative diagnosis of acute appendicitis were treated in our center, and nine (0.42%) patients were diagnosed to have mucocele of the appendix. Seven patients (78%) were female. Average age of the patients was 59.5 (range=25-74). Major complaint was right lower quadrant pain in eight (89%) patients. In preoperative ultrasonographic examination of the patients, appendiceal cystic masses (mucocele) were diagnosed in four (44.5%) patients. In histopathologic examination, the number of patients diagnosed to have simple mucocele was two (22%), mucinous cystadenoma was four (45%), and mucinous cystadenocarcinoma was three (33%). No postoperative morbidity or mortality was noted.

Conclusion

Appendix mucocele is a rare disease and it is usually diagnosed histopathologicaly in appendectomy specimens. When a cystic mass in appendix is seen during operation, appendiceal mucocele should be kept in mind to avoid iatrogenic perforation causing pseudomyxoma peritonei and possible concomitant malignancies should be searched.

Preoperative Diagnosis and Surgical Approach of Appendiceal Mucinous Cystadenoma: Usefulness of Volcano Sign

We report a case of appendiceal mucinous cystadenoma that was successfully diagnosed preoperatively and treated by laparoscopic resection. We could find volcano sign on colonoscopy and cystic lesion without any nodules at the appendix on computed tomography (CT). Without any malignant factors in preoperative examinations, we performed laparoscopic appendectomy including the cecal wall. We could avoid performing excessive operation for cystadenoma with accurate preoperative diagnosis and intraoperative finding and pathological diagnosis during surgery. Appendiceal mucocele is a rare disease that is divided into 3 pathological types: hyperplasia, cystadenoma, and cystadenocarcinoma. The surgical approaches for it remain controversial and oversurgery is sometimes done for benign tumor, because preoperative diagnosis is difficult and rupturing an appendiceal tumor results in dissemination. Based on our study, volcano sign on colonoscopy and CT findings were important for the preoperative diagnosis of appendiceal mucocele. Furthermore, we think that laparoscopic resection will become a surgical option for the treatment of appendiceal mucocele.

Low-Grade Appendiceal Mucinous Neoplasm Presenting as an Adnexal Mass

Appendiceal tumors are rare, late diagnosed neoplasms that may not be differentiated from adnexal masses even by advanced imaging methods and other diagnostic procedures. They may be asymptomatic and remain undiagnosed until surgery. We report a case of an 80-year-old postmenopausal woman presenting with a pelvic mass and a history of weight loss. The patient underwent laparotomy which revealed an appendiceal mucocele, for which she received a full oncological procedure. The histology report showed a low-grade appendiceal mucinous neoplasm, and the patient underwent six cycles of chemotherapy. Appendiceal tumors should be kept in mind in patients with adnexal mass.

Low-grade mucinous neoplasia in a cecal diverticulum: A case report

INTRODUCTION

Low-grade mucinous neoplasia is an uncommon benign tumor that develops in the appendix. The development of mucocele disease has never been reported in a colonic diverticulum. We present a case developing low-grade mucinous neoplasia in a cecal diverticulum.

PRESENTATION OF CASE

A tumor in the ileocecal region was found during a medical examination of a 66-year-old woman. Three months later, the tumor was still present and the patient developed abdominal pain. Laparoscopic ileocecal resection with D2 lymph node dissection was performed. Histopathological examination revealed a low-grade mucinous neoplasm in a cecal diverticulum.

DISCUSSION

Colonic mucoceles reportedly originate from the appendix. There are no previous reports of mucocele disease in a colonic diverticulum worldwide. This report reviews and discusses the management of the appendiceal mucoceles.

CONCLUSION

The incidence of colonic diverticula has recently begun to increase in Japan. The possibility of a mucocele within a colonic diverticulum should be considered in patients with submucosal colonic tumors.

Giant mucocele of the appendix in pregnancy: A case report and review of literature

INTRODUCTION

Mucocoele of the appendix is an obstructive dilatation of the appendix by intraluminal accumulation of mucoid material. Mucocoeles may develop by one of four processes: Retention cysts, Mucosal hyperplasia, Cystadenomas, and Cystadenocarcinomas. The clinical presentation of a mucocele is nonspecific and often an incidental finding at operation for acute appendicitis. If mucocoele is allowed to rupture either spontaneously or during surgery, the escape of mucin and epithelial cells into the peritoneal cavity - Pseudomyxoma Peritonei - may occur.

PRESENTATION OF CASE

We present the case of a 35 years old pregnant woman, who was admitted to the accident and emergency department with history and ultrasound findings suggestive of acute appendicitis. The ultrasound scan also confirmed a viable fetus at about 23week's gestational age. She had an open appendectomy. The intra-operative findings were an enlarged, tense, cystic retro-caecal appendix which was about 14cm×5cm×3cm in dimensions. Histopathological examination confirmed mucocoele of the appendix. She had normal vaginal delivery at term and postoperative follow up for 1 year was uneventful.

DISCUSSION

Mucocele of the appendix is an uncommon disorder with nonspecific presentation ranging from asymptomatic disease diagnosed incidentally to clinical features of appendicitis. The treatment is surgery.

CONCLUSION

Appendiceal mucocoele is difficult to diagnose preoperatively, and a giant size of the simple mucocoele may be connected to hormonal influence of pregnancy. In the index case, as in majority of cases, the definitive diagnosis is made at surgery.

Laparoscopic appendectomy for mucocele of the appendix

Mucocele of the appendix is an aseptic dilatation secondary to obstruction. The preoperative clinical diagnosis of appendiceal mucoceles can therefore be difficult because of this lack of clinical symptomotology. Surgical excision is the treatment of choice in benign mucocele. We report a case presenting to the surgeons where initial clinical findings and investigations suggested a cyst in the right adnexa. Diagnostic laparoscopy revealed mucocele of the appendix and laparoscopic appendicectomy was done.

Mucinous cystadenoma of the appendix presenting with an elevated carcinoembryonic antigen (CEA): Report of two cases and review of the literature

INTRODUCTION

Despite the fact the mucocoele of the appendix is a rare entity it has been the subject of much interest in the literature. The term mucocoele refers to cystic dilatation of the appendix filled with mucin resulting from proximal obstruction of the appendix lumen.

PRESENTATION OF CASE

We report two patients presenting with mucinous cystadenoma of the appendix with elevation of serum carcinoembryonic antigen (CEA), which has rarely been reported. Both patients had mild symptoms and a normal colonoscopy preoperatively. The diagnosis was not suspected in one patient prior to surgery. The elevated CEA prompted additional diagnostic radiologic investigations including ultrasonography, and computed tomography scans. The patients had uneventful appendicectomies with subsequent normalization of their CEA levels.

DISCUSSION

Mucinous cystadenoma of the appendix is a rare pathological entity characterized by a dilated mucous filled appendix. The presence of an elevated CEA associated with the presence of this entity is a rare presentation.

CONCLUSION

Because the diagnosis is rarely suspected prior to surgery patients with an enlarged appendix with associated elevated CEA levels should have careful investigations to exclude malignancy.

Mucinous neoplasms of the appendix: a current comprehensive clinicopathologic and imaging review

Mucinous neoplasms of the appendix are a heterogeneous group of neoplasms ranging from simple mucoceles to complex pseudomyxoma peritonei. Considerable controversy exists on their pathologic classification and nomenclature. Clear understanding of the histopathologic diversity of these neoplasms helps in establishing proper communication between the radiologist, the pathologist and the surgeon. In this article, we present a brief discussion of the current taxonomy and nomenclature of mucinous neoplasms of the appendix followed by a review of their imaging features. Important points including the significance of identifying extra-appendiceal mucin at imaging, the new classification of pseudomyxoma peritonei into low- and high-grade varieties and the significance of simultaneous ovarian and appendiceal neoplasms are highlighted.

Rupture of appendiceal mucocele due to endometriosis: report of a case

We report a rare case of a mucocele of the appendix due to endometriosis which accidentally ruptured prior to surgery. A 56-year-old woman was referred to our institution for further evaluation of a cecal tumor. Colonoscopy showed a submucosal tumor at the appendiceal orifice in the cecum. Computed tomography and magnetic resonance imaging showed a well-circumscribed mass measuring 4 cm in diameter in the right lower quadrant. A preoperative diagnosis of a simple mucocele of the appendix was established. At laparotomy, a mucocele was identified in the right side of the abdomen; however, part of the mucocele had ruptured and yellow mucin was seen around the cecum. An ileocecal resection was performed. Histopathological examination was consistent with a mucocele of the appendix due to endometriosis. Cytology specimens from the yellow mucin showed few proliferating epithelial cells with a mild degree of cytological and architectural atypia. Mechanical pressure due to excess anteflexion during administration of epidural anesthesia may have contributed to the rupture of the mucocele. It is important to handle a mucocele of the appendix with great care to avoid rupture at the time of operation, including during the administration of epidural anesthesia.

Perforated mucinous cystadenoma of the vermiform appendix: an overview in reasoning clinical decisions

Recent advances in the management of appendiceal mucinous neoplasms (AMN) such as peritonectomy combined with hyperthermic intraperitoneal chemotherapy have introduced new standards of care. However, many dilemmas are encountered in decision making as in the following patient. A 74-year-old woman was admitted with an appendiceal cystadenoma found in a preadmission CT scan. However, the tumour was not documented by the in hospital investigation due to its perforation and its reduction in size. Consequently, a series of management dilemmas were encountered that were solved by cautious evaluation of the pre and peroperative findings. She was submitted to a right hemicolectomy. A spontaneous perforation was suspected, but the accurate diagnosis was documented postoperatively by histopathology. This paradigm motivated this review which concluded that reasoning clinical decisions in the light of recent advances and appropriate care based on the disease-stage are essential for an optimal outcome in the management of AMN.

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.

[Laparoscopic treatment of appendiceal mucocele]

Mucocele is a mucin-filled cavity, which can be multi-loculated as well. Mucocele is relatively rarely found in the appendix. The disease does not cause any symptoms in most cases, and it is usually an accidental finding. A thorough investigation should be carried out to exclude malignancy. Depending on the operative findings and the full histological report, the spectrum of surgery extends from appendectomy to right hemicolectomy. In this paper, we discuss the presentation, diagnostical options, and the possible surgical treatment--based on our experience with five cases. In three cases a non-tender mass was palpable in the right lower quadrant of the abdomen, while another patient presented with right lower quadrant abdominal pain and one with abdominal pain and diarrhoea. Abdominal and pelvic ultrasound and CT scans raised the possibility of mucocele, however colonoscopy was negative. After laparoscopic exploration, laparoscopy assisted partial caecum resection was carried out in two cases, in further two cases laparoscopic appendectomy, and in one case laparoscopic partial caecum resection was done. The hystological examinations showed appendiceal mucocele with no malignancy demonstrated. All patients recovered without complications, they were discharged from hospital on postoperative day five. The patients have been disease free after a 6-30 month follow-up period. We concluded that laparoscopy is a recommended method for the surgery of appendiceal mucocele.

Mucocele of the appendix - a diagnostic dilemma: a case report

Introduction

Mucocele of the appendix secondary to mucinous cystadenoma is a rare clinical finding. Clinical presentation is varied with more than half being asymptomatic.

Case presentation

We report such a case presenting to the surgeons where initial clinical findings and investigations suggested an ovarian cyst. The patient was subsequently referred to the Gynaecologists for further management. In spite of extensive preoperative investigations, the diagnosis was only made at the time of surgery.

Conclusion

In women presenting with a right iliac fossa mass and clinical features not indicative of gynaecological pathology, an appendiceal origin should be considered in the differential diagnosis.

[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.

Mucinous cystadenocarcinoma of the appendix invading the ascending colon with fistula formation: report of a case

Based on colonoscopy findings, we made a preoperative diagnosis of primary mucinous cystadenocarcinoma of the appendix with features of a submucosal tumor (SMT) in the ascending colon. A 59-year-old woman who presented with right lower quadrant abdominal pain underwent colonoscopy, which revealed an SMT with three nodules covered with mucus in the ascending colon. Examination of colonoscopic biopsy specimens indicated "very" well-differentiated adenocarcinoma with mucus lakes. Abdominal computed tomography showed irregular wall thickness from the cecum to the ascending colon. The adjacent appendix had an enhanced wall and unclear border against the ascending colon. Thus, we performed right hemicolectomy, with good results. Histopathological examination revealed mucinous cystadenocarcinoma of the appendix, invading the ascending colon with fistula formation. Appendiceal tumors can manifest with a variety of colonoscopic features, and curative surgical resection should be attempted even if there is fistula formation.

Mucocele of the appendix: an important clinical rarity

Mucocele is an uncommon pathology of the vermiform appendix that can be confused with acute appendicitis. We present a case of an appendiceal mucocele associated with subacute, intermittent right lower quadrant discomfort. The diagnosis of appendiceal mucocele is an important one in that it can be associated with malignancies and other serious gastrointestinal, ovarian, and urological complications.

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.

Giant appendiceal mucocele: Report of a case and brief review

Mucocele of the appendix is a rare lesion, characterized by distension of the lumen due to accumulation of mucoid substance. This disease is often asymptomatic and pre-operative diagnosis is rare. If untreated, one type of mucocele may rupture producing a potentially fatal entity known as pseudomyxoma peritonei. The type of surgical treatment is related to the dimensions and to histology of the mucocele. Appendectomy is used for simple mucocele or for cystadenoma. Right hemi-colectomy is recommended for cystadenocarcinoma. In this paper, we report a case of a 51-year-old woman with a mobile, painless mass in the right lower quadrant of abdomen caused by a giant appendiceal mucocele. Imaging showed a large, tubular, cystic structure extending below from the inferior wall of the cecum. Surgery revealed a giant retro-cecal appendix measuring 17 cm in length and 4 cm in diameter. The final pathologic diagnosis was mucocele caused by mucinous cystadenoma.

Laparoscopic resection of an appendiceal mucocele

A 78-year-old man was incidentally discovered to have an asymptomatic right lower quadrant abdominal mass during physical examination for influenza. CT scan of the abdomen revealed a cystic sausage-shaped lesion arising from the cecum. Diagnostic laparoscopy revealed an appendiceal mucocele. There was no ascites or metastatic peritoneal nodules. Laparoscopic excision of the unruptured appendiceal mucocele was achieved. Histopathologic examination of the mucocele showed epithelial dysplasia, a feature diagnostic of a mucinous cystadenoma. The patient was discharged on postoperative day one and recovered uneventfully. No analgesic was required after surgery. The patient remained well and symptom-free during the follow-up period. The laparoscopic approach allows diagnostic laparoscopy and appendectomy to be performed, and confers the advantages of minimal-access surgery, including the avoidance of a large incision, a better cosmetic outcome, and a short convalescent period.

Laparoscopic treatment of an appendiceal mucocele

Appendiceal mucocele is a rare entity with a nonspecific preoperative presentation and is diagnosed intraoperatively in a majority of cases. The emphasis lies in accurate pathologic diagnosis, as the final treatment can differ depending on the malignant potential. The case presented was correctly diagnosed preoperatively. Laparoscopic exploration was both diagnostic and therapeutic. This case demonstrates the utility and safety of laparoscopy in the treatment of appendiceal masses.

Neoplastic lesions of the appendix

Neoplasms occur in 0.5 per cent of appendices. Ultrasonography or computed tomography is beneficial, but preoperative detection is rare. At operation, the diagnosis is considered in under half of cases. Mucocele, localized pseudomyxoma peritonei, benign tumours and most appendiceal carcinoids are cured by appendicectomy alone. Right hemicolectomy is indicated for: (1) invasive adenocarcinoma; (2) tumours close to the caecum; (3) lesions larger than 2 cm; (4) mucin production; (5) invasion of the lymphatics, serosa or mesoappendix; and (6) cellular pleomorphism with a high mitotic rate. Tumours of 1-2 cm, small mucinous carcinoids, adenocarcinoma confined to the mucosa, and tumours in children may be treated by appendicectomy alone at the surgeon's discretion. The 5-year survival rate associated with classical carcinoid is more than 90 per cent. The prognosis of mucinous carcinoid is intermediate between that of classical carcinoid and well differentiated adenocarcinoma. The prognosis of adenocarcinoma is determined by Dukes' stage and is similar, stage for stage, to that of colorectal carcinoma.