International Journal of Gastrointestinal Cancer, vol. 34, no. 1, 55–58, 2003 © Copyright 2003 by Humana Press Inc. All rights of any nature whatsoever reserved. 0169-4197/03/34:55–58/$25.00
Case Report
Appendicular Metastasis From Pancreatic Adenocarcinoma Levent Filik,*,1 Sedef Ozdal-Kuran,1 Bahattin Cicek,1,2 Neslihan Zengin,2 Ozgur Ozyilkan,3 and Burhan Sahin1 1
Turkiye Yuksek Ihtisas Hospital, Gastroenterology Clinic, Ankara, Turkey, 2Turkiye Yuksek Ihtisas Hospital, Department of Pathology, Ankara, Turkey, 3Baskent University, Faculty of Medicine, Division of Medical Oncology, Ankara, Turkey
Abstract We present a 78-yr-old man with appendicular metastases from pancreatic adenocarcinoma. Barium enema X-ray showed incomplete filling of a distended appendix in a patient with abdominal discomfort. Colonoscopic evaluation revealed firm nodules in appendicular orifice. Histopathological examination of the nodule in the appendix revealed a metastatic adenocarcinoma. Abdominal computed tomography showed a low-density mass in the body of the pancreas. Endoscopic ultrasonography disclosed a hypoechoic mass in the body of the pancreas. Appendicular metastasis is extremely rare. To our knowledge, this is the second case of adenocarcinoma of the pancreas metastatic to the appendix in English language literature. A brief review of relevant literature is presented. Key Words: Appendiceal metastasis; pancreatic carcinoma; appendicitis.
Introduction
dix usually require a surgical strategy because of acute appendicitis, and the appendicular involvement is seen intraoperatively. These rare metastases must be considered in the differential diagnosis of right lower quadrant pain in cancerous patients. The main differential diagnosis includes neutropenic enterocolitis, acute appendicitis, malignant intestinal obstruction, and perforation of the bowel (14–16).
Pancreatic carcinoma rapidly metastasizes to the lymphatic system by permeation, embolization, and retrograde spread in the presence of lymphatic obstruction (1,2). Here, we report the second case of a pancreatic adenocarcinoma with appendicular metastasis in English language literature. Appendicular metastases of malignancies are very rare, and 11 well-documented cases have been reported in the medical literature (Table 1) (3–13). Appendicular metastases do not display any specific signs in cancerous patients, and therefore, diagnoses of appendiceal masses—especially in the elderly—are often difficult. Solid masses of appen-
Case Report A 78-yr-old Turkish man with a 3-mo history of abdominal discomfort and weight loss was introduced to our hospital because a Barium enema X-ray detected the incomplete filling of a distended appendix. Medical and familial history of malignancy was insignificant. Blood examinations revealed only mild anemia. The tumor marker CA 19-9 level was high.
*Author to whom all correspondence and reprint requests should be addressed: Cemal Gursel Cad., no. 52–2, Kurtulus, Ankara 06600, Turkey. E-mail:
[email protected].
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Filik et al. Table 1 Patient Characteristics of Appendicular Metastasis
Case 1 2 3 4 5 6 7 8 9 10 11
Author Moller (1984) Ohnishi (1986) Gillesse (1987) Pang (1988) Ciganak (1989) Maddox (1990) Haid (1992) Hsu (1995) Gopez (1997) Rose (1997) Sudirman (2001)
Primary tumor Gastric cancer Gallbladder carcinoma Cardia carcinoma Bronchogenic carcinoma Gastric carcinoma Breast carcinoma Gastric carcinoma Nasopharyngeal carcinoma Bronchogenic carcinoma Ovarian carcinoma Carcinoma of cervix
Colonoscopic examination revealed firm nodules in the appendicular orifice (Fig. 1). Histopathological examination of the nodule in the appendix revealed malignant epithelial cells in mucosal lymphatic vessels. These cells were characterized by intracytoplasmic mucinous material and exantric hyperchromatic nuclei. Neoplastic cell groups were located only in lymphatics, and there was not any tumoral infiltration to lamina propria or submucosa; there also was no dysplasia at colonic surface or cryptic epithelium. These histopathologic and cytologic findings were consistent with lymphatic metastasis (or spreading) of pancreatic adenocarcinoma according to the patient’s clinical and radiological test results. Abdominal computed tomography showed a lowdensity mass 6 cm in diameter in the body of the pancreas. With an endoscopic ultrasonography, a hypoechoic mass was evident in the corpus of the pancreas. Doppler ultrasonography showed splenic artery invasion of the pancreatic mass. The esophagogastroduodenoscopic examination revealed no abnormality. Laparotomy was not performed because of inoperability criteria of the patient including the splenic artery invasion and the appendicular metastasis. The clinical picture and the endoscopic ultrasonography and computed tomography findings strongly suggested pancreatic adenocarcinoma with appendicular metastasis. Therefore, histological confirmation of primary tumor was not preferred. The patient was referred for the pain palliation and consulted the medical oncology unit. International Journal of Gastrointestinal Cancer
Admission reason Appendicitis Peritonitis Appendicitis Appendicitis Peritonitis Appendicitis Appendicitis Appendicitis Appendicitis Staging laparotomy Appendicitis
Discussion Metastatic carcinoma of the appendix is extremely rare. In his analysis of 71,000 appendix specimens summarizing 40 yr of study, Collins (15) did not report any case of appendix metastasis. A review by Blair et al. (16) showed no metastatic tumor of the appendix in 2216 appendectomy specimens. Berge and Lundberg documented only 7 cases in 16,294 autopsies (17). The most common tumors metastasizing to the appendix are carcinomas of the breast, stomach, and bronchus (18). The most frequent clinical presentation of appendicular metastasis was acute appendicitis or peritonitis. Obstruction of the lumen of the appendix generally is considered the most important triggering factor in the pathogenesis of acute appendicitis. In our study, Barium enema X-ray showed incomplete filling of a distended appendix. We diagnosed the appendicular metastasis before development of appendicitis because the metastatic carcinoma partially obstructed the appendicular lumen. We believe that longer survival of persons with disseminated malignancies as well as better perioperative support will lead tot he higher frequency of appendectomies. To our knowledge, this is the second case of a pancreatic adenocarcinoma with appendicular metastasis in English language literature. The first case involved a cystic adenocarcinoma of the pancreas metastatic to cecum and the appendix (19). Colonoscopic appearance of pancreatic metastasis revealed oval, firm, solid nodules in the appenVolume 34, 2003
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Fig. 1. Colonoscopic appearence of appendiceal metastasis.
dicular orifice. Typically, malignant adenocarcinoma cells in lymphatics of a patient with a pancreatic mass is sufficient for the diagnosis of metastasis after a thorough investigation for other possible primary adenocarcinomas has been performed. The most important differential diagnosis of the metastatic lesion in our study was the primary appendix tumor. Approximately 80% of primary appendix tumors reported are carcinoid tumors; the remainder are colonic adenocarcinoma (20). In our study, histopathological examination was consistent with adenocarcinoma metastasis because the neoplastic cell groups were located only in lymphatics, and there was not any tumoral infiltration to lamina propria or submucosa; there also was no dysplasia at the colonic surface or cryptic epithelium. In conclusion, we have reported a case of appendicular metastasis from pancreatic adenocarcinoma. International Journal of Gastrointestinal Cancer
Our subject was admitted to the hospital before development of appendicitis. With better diagnostic techniques and methods, as well as earlier diagnosis, more patients with appendicular metastasis will be diagnosed before development of acute abdomen and appendicitis. We believe that physicians should consider potential metastasis in patients with probable malignant disease.
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58 3. 3 Moller P, Lohmann M. Acute appendicitis as primary symptom of gastric cancer. Ann Chir Gynaecol 1984;73(4): 241–242. 4. Ohnishi S, Hoh E, Kodama T, et al. A case of gallbladder carcinoma metastatic to the appendix associated with acute peritonitis. Nippon Shokakibyo Gakkai Zasshi 1986;83(8): 1540–1543. 5. 5 Gillesse EG, Mud HJ, Prins ME. An unusual cause of acute appendicitis. Neth J Surg 1987;39(5):153–154. 6. 6 Pang LC. Metastasis-induced acute appendicitis in small cell bronchogenic carcinoma. South Med J 1988;81(11): 1461–1462. 7. 7 Ciganak J, Florek E. Carcinoma metastasis into the vermiform appendix. Rozhl Chir 1989;68(7):511–513. 8. 8 Maddox PR. Acute appendicitis secondary to metastatic carcinoma of the breast. Br J Clin Pract 1990;44(9): 376–378. 9. 9 Haid M, Larson R, Christ M. Metastasis from adenocarcinoma of the lung producing acute appendicitis. South Med J 1992;85(3):319–321. 10. 10 Hsu KL, Wang KS, Chen L, et al. Acute appendicitis secondary to metastatic nasopharyngeal carcinoma. J Surg Oncol 1995;60(2):131–132. 11. Gopez EV, Mourelatos Z, Rosato EF, Livolsi VA. Acute 11 appendicitis secondary to metastatic bronchogenic adenocarcinoma. Am Surg 1997;63(9):778–780.
International Journal of Gastrointestinal Cancer
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