Int J Colorectal Dis (2004) 19:397–398 DOI 10.1007/s00384-004-0599-z
Tahsin Colak Gurkan Yazici Zekai Ogetman Ozlem Aydin Suha Aydin
Accepted: 17 February 2004 Published online: 3 April 2004 Springer-Verlag 2004
T. Colak ()) · Z. Ogetman · S. Aydin Department of Surgery, Mersin Medical Faculty of Mersin University, Tip Fakultesi Hastanesi Zeytinlibahce C, 33079 Mersin, Turkey e-mail:
[email protected] Tel.: +90-324-3374300 Fax: +90-324-3374305 G. Yazici Department of Obstetrics and Gynecology, Mersin Medical Faculty of Mersin University, Mersin, Turkey O. Aydin Department of Pathology, Mersin Medical Faculty of Mersin University, Mersin, Turkey
LETTER TO THE EDITOR
Primary adenocarcinoma of vermiform appendix
Dear Editor: Appendiceal adenocarcinoma is a rare malignancy. Therefore, there is no specific diagnostic symptom and this diagnosis is frequently described at the histopathological evaluation of the surgical specimen. This report presents two cases of primary adenocarcinoma of the appendix, which is clinically misdiagnosed as acute perforated appendicitis and left ovarian mass. A 33-year-old man presented to our hospital in April 2001 with a history of 3-day lower abdominal pain associated with nausea and vomiting. The patient said that the pain was localized in right iliac fossa in the first 2 days; however, when the patient was admitted to the hospital, the pain was in the entire lower abdomen. Physical examinations revealed lower abdominal peritonism together with a body temperature of 37.5C. Laboratory investigations including a complete blood count and all biochemical parameters were within normal limits, except for leucocytosis of 14,900 cells/ml and a higher erythrocytes sedimentation rate (51 mm/h). Chest and abdominal radiography were normal. However, USG examination confirmed a perforated, retrocecal appendicitis with pericecal fluid. The patient proceeded to surgery with a working diagnosis of acute
perforated appendicitis and appendectomy was performed. Subsequently, histological examination of the resected specimen revealed perforated adenocarcinoma in distal appendix with serosal invasion. After this unexpected outcome, the diagnostic tests were extended to find the spread of the tumor. The endoscopic examinations of upper gastrointestinal tract and colon were normal. However, the computed tomography revealed dissemination of the tumor around the cecum. This diagnostic effort and the decision to perform a second laparotomy take a long time and the second laparotomy was performed 1 month after the appendectomy. At laparotomy, dissemination of tumor was found from Treitz ligament to rectum on the serosa of the bowels. Therefore, right hemicolectomy was performed. Subsequent histopatalogic examination revealed sero-muscular invasion of adenocarcinoma in the resected specimen, but mucosa was intact and there was no lymph node metastasis. The medical oncologist advice was administration of six-cure chemotherapy with Irinotecan hydrochloride, 5-fluorouracil and Calcium-leucoverin. Despite the fact that chemotherapy was administrated, dissemination of the tumor continued and in November 2001 relaparotomy had to be performed due to tumor obstruction of the bowel and only loop ileostomy could be done. In
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March 2002, liver metastasis and, in May 2002, pulmonary metastasis was indicated by computer tomography (CT); in June 2002, the patient died. The second case, a 75-year-old woman, was referred to the gynecologic department of our institution due to a mass in the left ovary in September 2002 for further investigation. However, the medical history of the patient was unremarkable, without any gynecological, gastrointestinal symptoms or weight loss. The ovarian mass was diagnosed by USG during routine postmenopausal control in state hospital and the patient was referred to our institution because of malign suspicion of the mass. Physical examination including abdomen, breast and thyroid were normal. However, pelvic examinations determined an adnexial solid mass of 33 cm. A complete blood count and routine biochemical tests were normal. However, elevation in carcinoembryonic antigen (CEA:
17.6 ng/ml; normal value:
