ABSTRACT
Melanosis, the aberrant deposition of melanin pigment in the absence of melanocytes, is very rare in the genitourinary tract. We report a case of a 74-year-old male with symptomatic benign prostatic hyperplasia. Diagnostic cystourethroscopy demonstrated bladder mucosa remarkable for numerous flat, velvety, and brown-black lesions. The patient underwent cystolitholapaxy, transurethral resection of the prostate, and bladder biopsy. Microscopic examination of the bladder biopsy demonstrated urothelium with granular, black pigmentation within the mucosa and histiocytes in the lamina propria; a Fontana Masson stain was positive for melanin. Microscopic examination of the transurethral resection of the prostate demonstrated nodular hyperplasia with focal, black pigmentation of the stroma. The rarity of bladder and prostate melanosis highlights the need for further investigation to elucidate its clinical significance and provide assurance of its benignity. Despite its rarity, melanosis should be kept in the differential diagnosis when melanotic lesions are encountered during cystoscopy.
ABSTRACT
INTRODUCTION: Incidence of low grade appendiceal mucinous neoplasm is increasing. Preoperatively, it may present similarly to primary ovarian malignancy. This case report describes a case of presumed ovarian malignancy with final pathologic diagnosis of low grade appendiceal mucinous neoplasm. We also propose several surgical strategies to approach this conundrum. PRESENTATION OF CASE: A postmenopausal woman with abdominal pain was found to have a 30 cm abdominopelvic mass with elevated CA-125 and CEA presumably a primary ovarian malignancy. During surgical staging, intraoperative findings were notable for an appendiceal mass. Intraoperative surgical oncology consultation recommended appendectomy for diagnostic purposes. Following primary surgery and final pathologic diagnosis, she underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. DISCUSSION: Low grade appendiceal mucinous neoplasm should be within the differential diagnosis of gynecologic surgeons when presented with a patient with large volume ascites and biopsy of acellular mucin. Intraoperatively, an abnormal appearing appendix with normal appearing gynecologic structures should trigger suspicion for appendiceal rather than ovarian origin. Preoperative symptoms, imaging studies, tumor markers, and frozen section pathology may not be able to differentiate between appendiceal and epithelial ovarian malignancies. CONCLUSION: A recognition of mucinous material and abnormal appearing appendix should prompt the surgeon to consider performing an appendectomy to obtain primary pathologic diagnosis. A high level of suspicion could better optimize the patient for a joint case with the appropriate surgeons. Given the documented disguise of low grade appendiceal mucinous neoplasm as primary ovarian cancer and its increasing incidence, diagnosis and general understanding of treatment should be understood.