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DOI: 10.2174/0250688201999200908145403, 2021, 2(1), 60-63
New Emirates Medical JournalContent list available at: https://newemiratesmedicaljournal.com
CASE REPORT
Adenocarcinoma of the Appendix in Elderly: Diagnostic Dilemma
Heba Nofal1, Hayder Al-Masari1,*, Marwan Mohammed Rashed1, Reham Ainawi1, Desh Idnani1 and Rawan Majdalawi1
1Department of General Surgery, Al-Qassimi Hospital, Sharjah, UAE
Abstract:
Acute appendicitis in elderly continue to be a diagnostic dilemma as it raises both the suspicion of malignancy and increased risk of morbidity andmortality. Cancers of the appendix are rare and most of them are found accidentally on appendectomies performed for acute appendicitis. Whenreviewed, the majority of the tumors were carcinoid, adenoma, and lymphoma. Adenocarcinomas of appendix are only 0.08% of all cancers andthe treatment remains controversial. This paper presents a case of 75-year-old female presented to the emergency (ER) with signs and symptomsmimicking acute appendicitis. Laparoscopic appendectomy was planned after a CT scan was done as it was suggesting acute appendicitis. Thespecimen then was sent for pathology lab and a diagnosis of adenocarcinoma of the appendix was made.
Keywords: Acute Appendicitis, Appendicitis in elderly, Tumor of the appendix, Adenocarcinoma of the appendix, CT scan edenoma.
Article History Received: March 22, 2020 Revised: July 27, 2020 Accepted: July 29, 2020
1. BACKGROUND
Acute appendicitis in the elderly requires special attentionbecause of variable and atypical clinical presentations,increased risk of morbidity and mortality and association witha higher incidence of suspicious malignancy.
2. INTRODUCTION
Acute appendicitis is common among adult and geriatricpatients [1]. However, some clinical conditions, such asdevelopmental abnormalities, are rarely observed in geriatricpatients. In addition, carcinoma of the appendix, carcinoids, ormucocele appendix may be observed rarely. Appendicealmalignancies are rare clinical entities and have been reported toconstitute 1% of all colorectal malignancies and 1% of allappendectomy specimens [2]. Primary neoplasms of theappendix are broadly classified as colonic-type adeno-carcinoma, mucinous adenocarcinoma, goblet cell adeno-carcinoma, or neuroendocrine carcinoma [3]. Carcinoids arethe most common tumors of the appendix (66%), followed bymucinous adenocarcinoma (20%), and colonic typeadenocarcinoma (10%) [4]. These different varieties of tumorsmay have different signs and symptoms that might requiredifferent management strategies. Preoperative diagnosis of thetumor may not be available in most of the patients. However,radiological imaging may give some clues in some of thepatients. Surgical exploration also has limitations in diagnosing
* Address correspondence to this author at the Department of General Surgery,Al Qassimi hospital, Sharjah, UAE; Tel: 0566298515;E-mail: [email protected]
appendiceal malignancies. It has been reported that thediagnosis of adenocarcinoma of the appendix is rarely madepreoperatively, and less than 50% cases are diagnosed intra-operatively during surgery, whether for acute or electiveconditions [5] but still most tumors are identified only afterhistopathological analysis of the removed specimens [6]. Inthis case report, an adenocarcinoma of the appendix in anelderly patient is presented. In addition, the natural history ofthe disease and its diagnostic difficulties are discussed.
3. CASE PRESENTATION
A 70 years old female presented to the emergencydepartment, complaining from right sided lower acuteabdominal pain for 1 day, the pain was colicky in nature,radiating to the right flank and associated with one episode ofloose motion and two attacks of undigested food vomitus, thepatient denied fever. Patient had past medical history positivefor diabetes mellitus type 2, dyslipidemia and migraine, pastsurgical history of hysterectomy for menorrhagia and familyhistory of colon cancer. On examination, patient’s weight was56 kg, vital signs were stable, she had right iliac fossatenderness with positive rebound tenderness.
Investigations showed raised inflammatory markers (Whiteblood counts of 15.28 x10(3)/mcl, Neutrophils 88%). CTabdomen was done to exclude suspicious lesions and it showeda distended appendix measuring 1 cm in size, enhancementmore at the peripheral with surrounding dirty fat smudgingsuggesting acute appendicitis and short segment luminalnarrowing (2.3 cm) (Fig. 1). The decision was taken by the
Adenocarcinoma of the Appendix in Elderly 61
oncall surgeons to perform diagnostic laparoscopy withappendectomy and to proceed accordingly if any suspiciouslesions were found.
Exploration of the peritoneal cavity showed a hugeadhesion of omentum under the umbilical region from the oldprevious surgery she did 20 years back (hysterectomy formenorrhagia), the examination of the terminal 80 cm of theileum did not show any diverticulum, or any thickening of thewall and it was normal that the appendix was retrocaecal,kinked dilated and inflamed (Fig. 2), the caecum was dissectedand sent for pathological examination, no lymph nodes orabnormal findings were seen (Fig. 3).
Fig. (1). CT scan showing dilated inflamed appendix.
Fig. (2). Acutely inflamed appendix.
Patient had uneventful post-operative hospital stay and wasdischarged home after 2 days with follow up in the outpatientdepartment.
Screening for tumor markers, like cancer antigen (CA)19.9 – high in pancreatic cancer, 15.3 – high in breast cancer,125 – high in ovarian cancer and Carcinoembryonic antigen(CEA) – high in colorectal cancer were normal. Histopathologyreport proved the diagnosis of well differentiateadenocarcinoma - intestinal type - appendix body with acuteappendicitis and the base and tip of the appendix showed insitu Adenocarcinoma limited to mucosal layer with tumorglands invading the muscular layer and serosa (Figs. 4 and 5).
The patient was referred to oncology center for furtherinvestigations and management.
Fig. (3). Nearby mesentery, free of lymph nodes.
Fig. (4). Appendix mucosa showing papillary architecture - Intestinaltype.
4. DISCUSSION
Acute appendicitis is one of the commonest surgicalemergencies in the accident and emergency unit and thediagnosis of acute appendicitis is usually based on history andclinical examination.
The classical presentation being central abdominal painthat been shifted to right lower abdomen associated with loss ofappetite, nausea, classical tenderness, and positive reboundtenderness in right iliac fossa on examination in more than twothirds of the cases.
The lifetime risk of having appendicitis in elderlypopulation above 60-year-old is between 5-10%. Thereby,acute appendicitis in the elderly needs special attention becauseof its atypical presentations, associated medical conditions, andage related physiological changes, which lead to confused andincomplete history [7].
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Fig. (5). Tumor glands invading muscular layer and serosa.
The classical signs and symptoms of acute appendicitis arepresented in less than half of elderly patients. Elderly patientsmore frequently have localized pain in right iliac fossa (RIF)without the classical migration of the pain from the epigastriumor periumbilical to the RIF, and it usually lasts longer and isassociated with abdominal distention, reduced bowel soundsand sometimes a palpable mass [8].
The most common causes of acute abdominal pain in theelderly patient are cholecystitis, bowel obstruction, acuteappendicitis, peptic ulcer disease, pancreatitis, anddiverticulitis, respectively, in order of frequency [9]. Acuteappendicitis is the main cause of acute abdominal pain in ayoung age while acute cholecystitis is the most frequent causein the elderly [7].
Malignancy should always be in consideration when itcomes to elderly people as it considers one of the frequentdiagnosis in such ages, thereby, urgent investigations areimportant and needed to reach the final definitive diagnosis assoon as possible, but on the another hand, it is time consumingand can delay the diagnosis so it can increase the risk ofperforation which results in increasing the morbidity andmortality [10, 11]. The mortality rate of elderly patients withacute appendicitis is between 4-10% and the rate increases incase of perforation to be between 25-32% due to septiccomplication from perforation associated with thecomorbidities [7].
Appendix gives rise to different histological tumor typesincluding adenocarcinoma, neuroendocrine carcinoma, andmixed tumors, which had both of these types along with gobletcells [3].
The laparoscopic approach for appendectomy is now themost common operative therapy. Studies have shown a lowerrate of complications and death in the elderly (2.4 vs. 0.5%) foropen compared to laparoscopic approach in patients over 65years of age [12]. In general, appendicular tumors mimic acuteappendicitis in presentation and can present as a palpableabdominal mass [13]. Diagnosis of malignancy should alwaysbe suspected in patients with suspicious appendicular mass [14]as there are no specific signs and symptoms for
adenocarcinoma of the appendix and it mostly resemble thesigns and symptoms of acute appendicitis and this makes thepreoperative diagnosis controversial and challenging [15]. Theemergent presentation of patients with suspected acuteappendicitis limits the range of diagnostic procedures.Preoperative abdominal computerized tomography is alwaysindicated in elderly patients to confirm the diagnosis of acuteappendicitis to limit the need for surgical exploration [16].However, the importance of routine histopathologicalexamination of appendectomy specimen should not beunderestimated [17].
Missed histopathological examination of these materialsmay result in a delay of diagnosis of primary appendicularadenocarcinoma and poor medicolegal outcomes for thesurgeon.
Surgical therapy of adenocarcinoma of the appendix is stillcontroversial. In a study conducted by Murphy et al.,appendectomy was suggested as the appropriate managementfor accidentally intraoperatively identified tumors if the tumorwas confined to the appendix, less than 2 cm in diameter andwithout infiltration of the base of the appendix [2]. While in theretrospective study of Arellano et al. right hemicolectomy wassuggested as elective treatment.
Patients diagnosed with colonic-type adenocarcinoma ofthe appendix follow appendectomy due to appendicitis or otherindication, where histological staging is important to determinethe next step in management. If the lesion is grade 1 or 2 withno angiolymphatic invasion, appendectomy alone withnegative resection margins is enough but all patients shouldhave a colonoscopy to evaluate and follow up for any possiblesynchronous colorectal lesions [3].
CONCLUSION
Primary adenocarcinoma of the Appendix is a rare clinicaldiagnosis, which should not be overlooked in elderly patients.Preoperative or intraoperative diagnosis is challenging for mostof the patients. Thus, routine histopathological examination isof extreme importance for proper diagnosis and management.
ETHICS APPROVAL AND CONSENT TOPARTICIPATE
This study was approved by the Dubai Research EthicsCommittee – Ministry of Health and Prevention Dubai, UAE.
HUMAN AND ANIMAL RIGHTS
Not applicable.
CONSENT FOR PUBLICATION
Informed consent of the patient had been obtained for thiscase report.
STANDARD FOR REPORTING
CARE guidelines have been followed in this case report.
FUNDING
None.
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Adenocarcinoma of the Appendix in Elderly 63
CONFLICT OF INTEREST
The author declares no conflict of interest, financial orotherwise.
ACKNOWLEDGEMENTS
The authors would like to thank the patient for hisparticipation and consent to the publication of the case detailsand associated images.
REFERENCES
Hardin DM Jr. Acute appendicitis: Review and update. Am Fam[1]Physician 1999; 60(7): 2027-34.[PMID: 10569505]Murphy EM, Farquharson SM, Moran BJ. Management of an[2]unexpected appendiceal neoplasm. Br J Surg 2006; 93(7): 783-92.[http://dx.doi.org/10.1002/bjs.5385] [PMID: 16775823]Kelly KJ. Management of appendix cancer. Clin Colon Rectal Surg[3]2015; 28(4): 247-55.[http://dx.doi.org/10.1055/s-0035-1564433] [PMID: 26648795]Carr NJ, Sobin LH. Adenocarcinoma of the appendix.WHO[4]classification of tumours of the digestive system. Lyon: IARC 2010;pp. 122-5.O’Donnell ME, Badger SA, Beattie GC, Carson J, Garstin WI.[5]Malignant neoplasms of the appendix. Int J Colorectal Dis 2007;22(10): 1239-48.[http://dx.doi.org/10.1007/s00384-007-0304-0] [PMID: 17447078]Aljarabah MM, Borley NR, Wheeler JM. Appendiceal[6]adenocarcinoma presenting as left-sided large bowel obstruction, acase report and literature review. Int Semin Surg Oncol 2007; 4: 20.[http://dx.doi.org/10.1186/1477-7800-4-20] [PMID: 17662117]Lunca S, Bouras G, Romedea NS. Acute appendicitis in the elderly[7]patient: Diagnostic problems, prognostic factors and outcomes. Rom JGastroenterol 2004; 13(4): 299-303.[PMID: 15624027]Telfer S, Fenyö G, Holt PR, de Dombal FT. Acute abdominal pain in[8]
patients over 50 years of age. Scand J Gastroenterol Suppl 1988;144(Suppl.): 47-50.[PMID: 3165555]de Dombal FT. Acute abdominal pain in the elderly. J Clin[9]Gastroenterol 1994; 19(4): 331-5.[http://dx.doi.org/10.1097/00004836-199412000-00016] [PMID:7876517]Sherlock DJ. Acute appendicitis in the over-sixty age group. Br J Surg[10]1985; 72: 245-6.[http://dx.doi.org/10.1002/bjs.1800720337]Lee SL, Walsh AJ, Ho HS. Computed tomography and[11]ultrasonography do not improve and may delay the diagnosis andtreatment of acute appendicitis. Arch Surg 2001; 136(5): 556-62.[http://dx.doi.org/10.1001/archsurg.136.5.556] [PMID: 11343547]Guller U, Jain N, Peterson ED, Muhlbaier LH, Eubanks S, Pietrobon[12]R. Laparoscopic appendectomy in the elderly. Surgery 2004; 135(5):479-88.[http://dx.doi.org/10.1016/j.surg.2003.12.007] [PMID: 15118584]Ko YH, Park SH, Jung CK, et al. Clinical characteristics and[13]prognostic factors for primary appendiceal carcinoma. Asia Pac J ClinOncol 2010; 6(1): 19-27.[http://dx.doi.org/10.1111/j.1743-7563.2010.01276.x] [PMID:20398034]Kalpande S, Pandya J, Sharma T. Adenocarcinoma mimicking[14]appendicular lump: A diagnostic dilemma-a case report. World J SurgOncol 2016; 14(1): 283.[http://dx.doi.org/10.1186/s12957-016-1036-9] [PMID: 27835997]Shami VM, Yerian LM, Waxman I. Adenoma and early stage[15]adenocarcinoma of the appendix: Diagnosis by colonoscopy.Gastrointest Endosc 2004; 59(6): 731-3.[http://dx.doi.org/10.1016/S0016-5107(04)00008-2] [PMID:15114326]Trivedi AN, Levine EA, Mishra G. Adenocarcinoma of the appendix[16]is rarely detected by colonoscopy. J Gastrointest Surg 2009; 13(4):668-75.[http://dx.doi.org/10.1007/s11605-008-0774-6] [PMID: 19089515]Jones AE, Phillips AW, Jarvis JR, Sargen K. The value of routine[17]histopathological examination of appendicectomy specimens. BMCSurg 2007; 7: 17.[http://dx.doi.org/10.1186/1471-2482-7-17] [PMID: 17692116]
© 2021 Nofal et al.
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New Emirates Medical Journal, 2021, Volume 2, Number 1
