POLSKI
PRZEGLĄD CHIRURGICZNY
2014, 86, 3, 147–150
10.2478/pjs-2014-0027
Synchronous occurrence of colon and appendiceal
adenocarcinoma
Tomasz Goryń, Monika Meszka, Jacek Pawlak
Department of General Surgery, Specialistic Hospital in Grodzisk Mazowiecki
Ordynator: dr hab. J. Pawlak
The study presented two cases of synchronous occurrence of colon and appendiceal adenocarcinoma.
Both patients required surgical intervention, due to acute peritonitis during the course of acute appendicitis. In case of one patient we performed abdominal CT confirming the presence of sigmoid
cancer. The patient was subjected to appendectomy and Hartmann’s operation. The second patient
underwent an appendectomy, and colonoscopy performed two months later revealed the presence of
rectal adenocarcinoma. The patient was subjected to low anterior rectal resection. The histopathological results considering both patients revealed the presence of synchronous colon and appendiceal
adenocarcinoma.
Key words: appendiceal cancer, synchronous tumors, colon cancer
Primary appendiceal adenocarcinomas are
rarely diagnosed constituting < 6% of appendiceal neoplastic lesions, and < 0.5% of all
gastrointestinal neoplastic lesions (1, 2). Beger
was the first to describe a case of appendiceal
adenocarcinoma in 1882. The most common
neoplastic lesions of the appendix include carcinoid tumors, cystic adenocarcinoma, and
adenocarcinomas. Carcinoid tumors of the appendix are diagnosed ten times more often
than adenocarcinomas (3). Diagnostics of appendiceal lesions is extremely difficult, since
most patients arrive to the ER with symptoms
of acute appendicitis, and final diagnosis is
established on the basis of the histopathological examination of the excised appendix (4, 5).
In very few patients (<30%) one may observe
gastrointestinal occlusion, loss of body weight,
anemia, and unspecific abdominal pain. The
physical examination in case of patients without acute appendicitis might reveal the presence of a tumor located in the right iliac fossa.
However, only in selected cases is elective
surgery performed, after previous endoscopic
confirmation (6, 7).
The histopathological classification of appendiceal adenocarcinoma distinguishes the
intestinal type and the mucogenic type, which
is characterized by a more favorable prognosis.
In case of the mucogenic adenocarcinoma one
may observe rupture to the peritoneum and
occurrence of peritoneal pseudomyxoma (8).
Imaging examinations in the diagnostics of
appendiceal adenocarcinoma are not very useful, since they do not allow the differentiation
of cecal adenocarcinoma from acute appendicitis. Treatment of appendiceal adenocarcinoma mainly consists in surgery, and depending on the stage of the disease and location of
the appendix includes appendectomy with or
without right-sided hemicolectomy (9, 10). In
selected cases treatment is complemented by
adjuvant chemotherapy and radiotherapy.
The problem of multiple neoplastic lesions
has been present in medicine for over a hundred years. Billroth was the first who defined
the problem, followed by Warren and Gates
(11), providing grounds for the current definition and diagnostic criteria of multiple neoplastic lesions, established by the International Agency for Research on Cancer (12).
Synchronous tumors are distinguished when
the time elapsed between the diagnosis of two
neoplastic lesions is less than 6 months, while
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T. Goryń et al.
that of metachronous tumors when the period
exceeds 6 months. Despite the enormous progress in abdominal imaging techniques, both
radiological and endoscopic, the diagnosis of
synchronous colon tumors is extremely rare.
This is associated with the frequency of occurrence, which for synchronous colon cancer
ranges between 0.6-1.4%, while in case of metachronous lesions, between 1- 8% (13). Usually, during surgery performed because of a
neoplastic lesion, the surgeon identifies the
existence of a second gastrointestinal tumor.
Such a situation requires a change in the management strategy and extends the duration of
the operation, increasing the risk of complications. In case of a synchronous tumor, both
lesions should be excised. In case of emergency surgery, thorough evaluation of the remaining part of the colon is required, including
intraoperative colonoscopy in doubtful cases.
Postoperative colonoscopy is also acceptable,
in order to evaluate the remaining part of the
colon.
However, synchronous occurrence of appendiceal and colon adenocarcinoma is extremely rare, being diagnosed in less than 1%
of all synchronous tumors (14). In our study,
we presented two patients diagnosed with
synchronous appendiceal and colon adenocarcinoma.
Case report
During the period between 2006 – 2012, 327
colon resections were performed, due to neoplastic lesions at the Department of General
Surgery, Specialistic Hospital in Grodzisk
Mazowiecki. In 2012, 79 appendectomies were
performed.
Two patients were diagnosed with synchronous appendiceal and colorectal adenocarci-
noma. Table 1 presented the characteristics of
the operated patients.
Both patients underwent emergency surgery, due to acute appendicitis. Laboratory
results of both patients performed before the
operation showed leucocytosis. The physical
examination showed peritoneal irritation located in the right iliac fossa with muscular
defense.
In case of the first patient (J. F-history
numer- 15377/2012), the inconclusive medical
history (periodic bloating and hypogastric
pain) prompted the Authors to perform emergency abdominal CT, which revealed the
presence a sigmoid tumor, thickening of the
appendix wall, and suspicion of metastatic
lesions in the liver. The patient underwent
appendectomy and Hartmann’s operation.
Lymph nodes and the liver were free of neoplastic lesions (preoperative abdominal CT
did not confirm the presence of focal lesions).
The exploration of abdominal cavity lesions
showed no other pathologies. The postoperative course was complicated by heart failure,
paroxysmal AF, and wound eventration requiring suturing. Further postoperative
course was uneventful. Upon improvement of
the patients’ general condition he was referred to the outpatient oncological clinic for
adjuvant treatment.
The histopathological result (nr-100451484)
of the removed colon revealed the presence of
colorectal adenocarcinoma (G2T3N0) and appendiceal adenocarcinoma. The sample
showed 7 lymph nodes without metastatic
lesions.
The second patient (R.K- history number
5319/2012) underwent emergency surgery, due
to symptoms of acute appendicitis, in whom
preoperative ultrasonography confirmed the
initial diagnosis. During surgery the gangrenous appendix was removed. The remaining
Tabela 1
Table 1
No
Data
Sex
Age
1
2
K.R
J.F
M
M
77
82
Cause of operation
acute appendicitis
acute appendicitis
Risk factors
Location of the
synchronous tumor
COPD
rectum
sigmoid
coronary heart disease, PAF,
obesity, hyperthyroidism,
chronic renal failure, RICA and
LICA stenosis, gout, COPD
Synchronous occurrence of colon and appendiceal adenocarcinoma
Fig. 1. Thickening of the appendix wall and
synchronous sigmoid tumor visualized in abdominal CT
abdominal cavity organs were within normal
limits. Lymph node and liver metastatic lesions were not observed. The histopathological
result (nr 100451484) confirmed the presence
of appendiceal adenocarcinoma, which was
completely excised. In order to expand diagnostics, colonoscopy and abdominal CT were
performed two months after the operation
demonstrating the presence of rectal adenocarcinoma. The patient underwent low anterior rectal resection. The histopathological
result (nr 100451484) confirmed the presence
of colorectal adenocarcinoma – G2T3N0. The
postoperative course was uneventful. The patient was referred for adjuvant treatment
(Outpatient Oncology), remaining to this day
under their control.
Discussion
The synchronous occurrence of appendiceal
and colorectal adenocarcinoma is very rare.
However, in case of an unclear picture of the
appendix the surgeon should consider the possibility of the above-mentioned. Preoperative
diagnostics is extremely difficult, due to the
unspecific symptoms, and fact that more than
70% of patients’ with appendiceal adenocarcinoma present with clinical and biochemical
symptoms of acute appendicitis. In case of our
patients acute appendicitis symptoms predominated. Considering imaging diagnostics
149
of appendiceal adenocarcinoma abdominal
ultrasound and CT examinations are used.
However, due to significant inflammation and
presence of an abscess in case of appendiceal
perforation, differentiation between neoplastic
disease and inflammatory process is extremely difficult. In case of patients operated in our
department imaging examinations showed no
signs of appendiceal adenocarcinoma. In case
of patient J.F in whom preoperative abdominal
CT was performed, the examination revealed
the presence of acute appendicitis signs, as
well as sigmoid tumor. In case of the second
patient preoperative abdominal ultrasonography showed lesions characteristic of acute
appendicitis. It is often difficult to differentiate, even intraoperatively, between acute appendicitis and appendiceal adenocarcinoma.
In case of mucogenic appendiceal adenocarcinoma the presence of a peritoneal pseudomyxoma might be helpful in establishing the diagnosis. In both of our cases gangrenous appendicitis was diagnosed, intraoperatively.
Due to significant inflammatory lesions it was
impossible to differentiate between inflammatory and neoplastic disease. In both cases,
the clinical picture did not pose any doubts
requiring consideration, whether to perform
right-sided hemicolectomy. Due to the possibility of synchronous tumors after histopathological confirmation of appendiceal adenocarcinoma, it is necessary to complement
diagnostics by endoscopy or abdominal CT.
In case of our patients CT was performed,
before surgery and after histopathological
confirmation. In both patients synchronous
tumors were diagnosed: sigmoid and rectal
adenocarcinomas. The synchronous tumors
were surgically excised in both cases. Due to
patient age, concomitant diseases, and lack
of local and distant metastases, right-sided
hemicolectomy was not performed. Both patients were referred for oncological adjuvant
treatment.
Based on the presented clinical material,
one may come to the conclusion that in case of
an unclear picture of acute appendicitis, one
should consider the possibility of appendiceal
adenocarcinoma. However, in the presence of
colorectal adenocarcinoma and acute appendicitis symptoms, one should consider synchronous presence of appendiceal adenocarcinoma.
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T. Goryń et al.
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Received: 14.04.2013 r.
Adress correspondence: 05-825 Grodzisk Mazowiecki, ul. Daleka 11
e-mail: [email protected]