Intraoperative predictors of appendiceal abnormalities in patients with mucinous ovarian neoplasms.

OBJECTIVE: To evaluate intraoperative factors predicting appendiceal pathology during gynecologic oncology surgery for suspected mucinous ovarian neoplasms. METHODS: We conducted a retrospective study on 225 patients with mucinous ovarian neoplasms who underwent surgery for an adnexal mass with concurrent appendectomy between 2000 and 2018. Regression analyses were used to evaluate intraoperative factors, such as frozen section of the ovarian mass and surgeon's impression of the appendix in predicting appendiceal pathology. RESULTS: Most patients (77.8%) had a normal appendix on final pathology. Abnormal appendix cases (n = 26) included: metastasis from high-grade adenocarcinoma of the ovary (n = 1), neuroendocrine tumor of the appendix (n = 4), and low-grade appendiceal mucinous neoplasms (n = 26; 23 associated with a mucinous ovarian adenocarcinoma, 2 with a benign mucinous ovarian cystadenoma, and 1 with a borderline mucinous ovarian tumor). Combining normal intraoperative appearance of the appendix with benign or borderline frozen section yielded a negative predictive value of 85.1%, with 14.9% of patients being misclassified, and 6.0% having a neuroendocrine tumor or low-grade appendiceal neoplasm. CONCLUSION: Benign or borderline frozen section of an ovarian mucinous neoplasm and normal appearing appendix have limited predictive value for appendiceal pathology. Appendectomy with removal of the mesoappendix should be considered in all cases of mucinous ovarian neoplasm, regardless of intraoperative findings.

Case 295: Pseudomyxoma from Mucinous Adenocarcinoma of the Appendix Extending from the Retroperitoneum into the Thigh.

History A 57-year-old man with no remarkable past medical history presented to an outside institution with painless swelling in his right thigh of 6 months duration. He denied any trauma to the site. At that time, physical examination demonstrated swelling in his right upper thigh. All other work-up, including complete blood count and chest radiography, yielded negative results. The initial diagnosis was lymphangioma of the thigh. He continued to experience worsening swelling in his right upper thigh with no other symptoms over the next year. He was referred to our facility, where he underwent US evaluation of the thigh lesion, an MRI scan encompassing the entire extent of his thigh lesion, and a CT scan of his abdomen and pelvis.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal and appendiceal peritoneal metastases - The Hong Kong experience and literature review.

INTRODUCTION: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly used to treat peritoneal metastases from appendiceal or colorectal origin. We evaluate our institution's experience and survival outcomes with this procedure, and its efficacy in symptom relief. METHODS: This is a single-centre retrospective observational study on patients with peritoneal metastases (PM) from appendiceal neoplasm or colorectal cancer who underwent CRS/HIPEC in Queen Mary Hospital. Our primary endpoints were overall survival (OS) and morbidity and mortality of this procedure; secondary endpoints included disease-free survival (DFS) and symptom-free survival. RESULTS: Between 2006 and 2018, thirty CRS/HIPEC procedures were performed for 28 patients - 17 (60.7%) had appendiceal PM while 11 (39.9%) had colorectal PM. The median peritoneal cancer index was 20; complete cytoreduction was achieved in 83.3% patients. High-grade morbidity occurred in 13.3% cases. There was no 30-day mortality. Two-year OS were 71.6% and 50% for low-grade appendiceal PM and colorectal PM patients (p = 0.20). Complete cytoreduction improved OS (2-year OS 75.4% vs 20%, p = 0.04). Median DFS was 11.8 months. Median symptom-free duration was 36.8 months; patients with complete cytoreduction were more likely to remain asymptomatic (82.9% at 1 year, vs 60% in incomplete cytoreduction group, p < 0.01). 91.7% low-grade appendiceal PM patients and 58.4% colorectal PM patients remained asymptomatic at post-operative one year (p = 0.31). CONCLUSION: CRS/HIPEC is beneficial to appendiceal PM and selected colorectal PM patients - improving survival and offering prolonged symptom relief, with reasonable morbidity and mortality. Complete cytoreduction is key to realising this benefit.

Missed Gastric Cancer Metastasis to the Appendix: Case Report and Literature Review.

BACKGROUND Gastric cancer metastasis to the appendix is a rare condition that might present with symptoms of acute appendicitis or remain asymptomatic and be diagnosed incidentally. This report summaries 6 previously reported cases in addition to the presented case. CASE REPORT We report a 54-years-old female patient who presented with gastric cancer metastasis to the appendix that was found incidentally in the second surgery when she underwent bowel resection due to bowel entrapment in internal hernia, a complication of her primary gastric cancer surgical intervention. Six case-reports on gastric cancer metastasis to the appendix were reviewed. The metastasis was symptomatic in 4 cases, and solitary in 3 cases. The diagnosis was delayed in 4 cases as there was no evidence of metastasis at the diagnosis of the primary tumor; appendectomy was performed in all cases. The prognosis of the cases varied considerably. CONCLUSIONS We question the real incidence of appendiceal metastasis in gastric cancer, and the benefit-risk ratio of appendectomy in every gastrectomy. Guidelines on management of similar cases is also needed.

Unusual Pattern of Invasive Lobular Carcinoma Metastasis: A Case Report.

BACKGROUND Metastasis of breast cancer to the gastrointestinal (GI) tract is not common, however, invasive lobular carcinoma is more likely to metastasize to the GI tract than ductal carcinoma. The simultaneous metastasis of invasive lobular carcinoma to the GI tract and ovaries is an extremely uncommon presentation, which may mimic another rare entity that is peritoneal carcinomatosis secondary to breast cancer. Diagnosis of this entity is difficult as it can masquerade as a primary disease process instead of a secondary one. Treatment is even more difficult due to the sparsity of guidelines regarding this presentation. CASE REPORT A 58-year-old female with a history of invasive lobular carcinoma of the left breast treated 5 years prior to presentation with GI symptoms. Workup revealed a stenosis of the sigmoid colon; however, colonoscopy and biopsy did not show signs of malignancy. The patient was initially diagnosed with diverticulitis and given appropriate treatment which mildly improved her symptoms but did not eradicate them. Continued symptoms and failed attempts at diagnosis prompted the decision to perform an exploratory laparotomy which revealed metastasis of invasive lobular carcinoma to the sigmoid colon, appendix, and ovaries. CONCLUSIONS GI metastasis of breast cancer is a difficult entity to diagnose and treat. Concomitant metastasis to the GI tract and genitourinary system is even more challenging to diagnose and treat. These variable metastasis presentations of breast cancer indicate a need for more specific modalities for follow-up of breast cancer patients especially those with the invasive lobular subtype which tends to metastasize to unusual distant sites and present years after diagnosis and treatment of the primary disease.

Anti-angiogenesis treatment in a patient with appendix metastasis of small cell lung cancer: A case report.

RATIONALE: Small-cell lung cancer (SCLC) is a common pathological type of lung cancer, but appendiceal metastasis of SCLC was rare. At present, clinical studies on the maintenance therapy of SCLC have not reached a significant conclusion. PATIENT CONCERNS: We reported on a 52-year-old man who diagnosed as extensive stage SCLC with abdominal pain for 2 months, aggravated for 2 days. DIAGNOSES: The patient was diagnosed with extensive-stage SCLC, relapsed with appendix metastasis after treatment by emergency abdominal surgery. INTERVENTIONS: The patient received systemic treatments, including surgery, bevacizumab in combination with chemotherapy and bevacizumab alone was continued as maintenance therapy. OUTCOMES: The patient had an overall survival would more than 23 months, and he gained another 8 months of progression-free survival after first-line radiochemotherapy. LESSONS: Although SCLC appendix metastasis is rare, continuous anti-angiogenic therapy combined with bevacizumab maintenance therapy after surgical treatment can prolong survival.

[Surgery in early-stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. / Chirurgie des stades précoces des cancers ovariens. Article rédigé sur la base de la recommandation nationale de bonnes pratiques cliniques en cancérologie intitulée « Conduites à tenir initiales devant des patientes atteintes d'un cancer épithélial de l'ovaire ¼ élaborée par FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY sous l'égide du CNGOF et labellisée par l'INCa.

Early stage ovarian epithelial cancer (stage I according to the FIGO classification, i.e. limited to ovaries) affects 20% to 33% of patients with ovarian cancer. This chapter only describes data on these presumed early stages. The rate of occult epiploic metastases varies from 2% to 4%, and leads to over-staging in stage III A of 3% to 11% of patients. Performing an omentectomy does not result in a change in survival in this situation (NP4). The rate of appendix metastasis ranges from 0% to 26.7% (NP4). In the mucinous subtype, this rate can reach 53% if the appendix is macroscopically abnormal (NP2). The rate of positive peritoneal cytology ranges from 20.9% to 27%. Positive peritoneal cytology is responsible for over-staging of patients in 4.3% to 52% of cases and appears as a poor prognostic factor on survival (NP4). The rate of occult peritoneal metastases varies from 1.1% to 16%. Performing these peritoneal biopsies results in over-staging of 4% to 7.1% (NP4). In the management of ovarian cancers at a presumed early stage, it is recommended to perform: omentectomy, peritoneal biopsies, cytology, appendectomy (grade C). In case of incomplete or incomplete initial staging, restaging including omentectomy, peritoneal biopsies and appendectomy (if not explored) is recommended; especially in the absence of a reported indication of chemotherapy. The lymph node invasion rate ranges from 6.3% to 22%. It is 4.5% to 18% for stages I and 17.5% to 31% in stages II. Between 8.5% and 13% of patients with suspected early stage ovarian cancer are reclassified to stage IIIA1 following the completion of lymphadenectomy (NP3). Pelvic and lumbo-aortic lymphadenectomy improves the survival of patients with ovarian cancer at a presumptive early stage (NP2). Pelvic and lumbo-aortic lymphadenectomy is recommended for presumed early ovarian stages (grade B). In case of initial treatment of early-stage ovarian cancer without lymph node staging, restadification including lymphadenectomy is recommended; especially in the absence of a stated indication of chemotherapy (grade B). No studies have shown any laparoscopic disadvantage compared to laparotomy for feasibility, safety, or postoperative rehabilitation (NP3) in surgical staging of patients with early-stage ovarian cancer. For the initial surgical management of these patients, the choice between laparoscopy or laparotomy depends on local conditions (tumor size) and surgical expertise. If complete surgery without risk of tumor rupture is possible, the laparoscopic approach is preferred (grade C). In the opposite case, median laparotomy is recommended. As part of surgical restadification, the laparoscopic approach is recommended (grade C). Intraoperative tumor rupture leads to a decrease in disease free survival (hazard ratio=2.28) and overall survival (hazard ratio=3.79) (NP2). It is recommended that all precautions be taken to avoid perioperative ovarian tumor rupture, including the intraoperative decision of laparoconversion (grade C). There is no specific study to answer the question of the feasibility of a one-time or two-time surgery during an extemporane diagnosis of an early stage ovarian cancer. The high sensitivity and specificity of this extemporane examination in this situation makes it possible to consider a surgical management of staging during the same operating time.

Endometrioid Adenocarcinoma With Solitary Metastasis to the Appendix, Mimicking Primary Appendiceal Adenocarcinoma: A Case Report and Literature Review.

Metastatic tumors of the appendix are rare. Endometrial cancer tends to metastasize by directly invading neighboring structures; the lung, liver, bones, and brain are common sites of distant metastasis. Herein, we present a case of a solitary endometrial metastatic tumor in the appendiceal mucosa without serosal involvement that mimicked a primary adenocarcinoma of the appendix. The patient who had undergone a radical hysterectomy for an endometrioid adenocarcinoma 3 years earlier presented to the hospital with a history of persistent right-lower abdominal pain. Physical examination showed tension of the abdominal muscles, tenderness, and rebounding pain on the McBurney's point. Open appendectomy for suspected appendicitis revealed a perforation of the distal appendiceal tip. Opening of the surgical specimen showed a mass that was located in the mucosa of the appendix near the appendicular root and resembled a primary tumor of the appendix. Microscopically, the adenocarcinoma of the appendiceal mucosa showed a transitional relationship with the normal mucosa, involving the submucosa and muscle but not invading the serosa. Based on the patient's medical history and the results of immunohistochemical staining, we made a diagnosis of metastatic endometrioid adenocarcinoma. The gross anatomy and histologic features of solitary metastatic tumors can mimic those of primary tumors. A correct diagnosis should be made by combining the patient's medical history with morphologic and immunohistochemical test results.

Prostate cancer with an unusual metastatic affinity for the appendix, inducing acute appendicitis.

Acute appendicitis induced by metastatic disease is uncommon. We present the case of an 82-year-old man with known bony metastases secondary to prostatic cancer who presents with a short history of acute abdominal pain. A CT scan was indicative of acute appendicitis and the patient underwent a laparoscopic appendicectomy; a phlegmonous mass seen intraoperatively was suspicious for malignancy, and histopathology confirmed acute appendicitis as well as metastases of prostate cancer. Metastatic disease should be considered as an important differential in all patients with a known history of malignancy, as this may in turn complicate their presenting surgical complaint.

A Case of Carcinoid Syndrome Due to Malignant Metastatic Carcinoid Tumor with Carcinoid Heart Disease Involving Four Cardiac Valves.

BACKGROUND Carcinoid tumor, benign, low-grade malignant, and high-grade malignant, can be associated with the release of vasoactive substances that cause symptoms including cutaneous flushing, diarrhea, and bronchospasm. In 50-60% of patients with carcinoid syndrome, the vasoactive substances cause fibrosis of the pulmonary and tricuspid heart valves which lead to regurgitation and right-sided heart failure. The right side of the heart is usually affected because monoamine oxidases in the lungs usually inactivate the vasoactive substances. CASE REPORT A 62-year-old woman presented with a four-month history of diarrhea and abdominal discomfort. The patient had bilateral pelvic masses and elevated serum CA125 and an elevated urinary 5-hydroxyindoleacetic acid (5-HIAA). Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) identified a primary appendiceal carcinoid tumor with bilateral ovarian metastases. Post-operatively, a computed tomography (CT) scan showed cardiomegaly. Transthoracic echocardiography showed morphologic changes that affected all four heart valves, consistent with carcinoid heart disease but without a patent foramen ovale (PFO). The patient was evaluated for valve replacement surgery, but surgery was not performed due to the degree of heart failure. CONCLUSIONS This report describes a rare case of carcinoid heart disease with involvement of all four cardiac valves, but without the presence of a PFO, possibly due to a large amount of vasoactive substances in the patient's circulation, as supported by the patient's elevated urinary 5-HIAA. This rare presentation highlights the importance of early diagnosis and treatment with tumor resection and, if possible, Cardiac valve replacement to prevent irreversible heart failure.

Rate of Appendiceal Metastasis with Non-Serous Epithelial Ovarian Cancer in Manitoba.

OBJECTIVE: This study sought to evaluate the rate of appendiceal involvement in non-serous mucinous and endometrioid-associated epithelial ovarian cancers. METHODS: The Manitoba Cancer Registry and CancerCare database were used to find all women with non-serous epithelial ovarian, fallopian tube, or primary peritoneal cancer between 1995 and 2011. All patients with an appendectomy were then identified, and their final pathology findings were reviewed. Women who did not receive treatment or lacked follow-up were excluded. RESULTS: We identified 338 patients from 1995-2011 with no prior appendectomy. Of these, 16.6% received an appendectomy, and 22.8% were clinically evaluated. Most cases within this cohort were mucinous (62%) and stage 1 (63%). Four appendiceal metastases were identified (7.2%), and one half appeared clinically normal at the time of surgery (3.6%). Within the mucinous histologic type, 32.7% of patients received an appendectomy, with a metastatic rate of 5.7%. Of the 127 endometrioid cases, only 10 patients received an appendectomy, and 2 were found to have metastases. No metastases were found in the 85 patients in the clear cell cohort, only 5 of whom received an appendectomy. CONCLUSION: Routine appendectomy or clinical assessment of the appendix is valuable for all non-serous ovarian cancers. The rate of involvement for endometriosis-associated ovarian cancers may be significantly higher than expected, and further studies need to be conducted.

Metastasis of esophageal small cell carcinoma to the appendix: A case report and literature review.

Primary small cell carcinoma (SCC) of the esophagus is characterized by high malignancy with a tendency to metastasize early through lymph and blood circulation. Metastasis of esophageal SCC frequently occurs to distant organs such as liver and lung. However, few cases of appendiceal metastasis have been reported. This paper first presents a pathologically confirmed case with metastasis of esophageal SCC to the appendix. This particular case highlights the importance of pathological diagnosis and provides new evidence of appendiceal metastasis from esophageal SCC.

Metastasis to the appendix from adenocarcinoma of the ascending colon: A case report.

RATIONALE: Metastasis of cancer cells involves shedding from the primary tumor through various means to distant tissues and organs with continued growth and formation of new metastatic tumors of the same cancer type as the original tumor. The common sites for colon cancer metastases include the pelvis, retroperitoneal lymph nodes, liver, and lungs; Colon cancer metastases to the appendix are rare, as reported in this case. PATIENT CONCERNS AND DIAGNOSES: A 45-year-old man was admitted to our department with a 24-hour history of abdominal distension and incomplete obstruction. Colonoscopy showed an elevated lesion in the ascending colon and the pathologic diagnosis was adenocarcinoma. INTERVENTIONS AND OUTCOMES: This patient underwent a radical right hemi-colectomy. The post-operative pathologic examination revealed metastatic adenocarcinoma in all layers of the appendix, especially the muscularis mucosae. The diagnosis was adenocarcinoma of the ascending colon (pT4bN2bM0 stage IIIC) with metastatic adenocarcinoma of the appendix. LESSONS: An absent right colic artery with lymph node fusion might increase the risk of appendiceal cancer metastasis.

Pulmonary toxicity after intraperitoneal mitomycin C: a case report of a rare complication of HIPEC.

BACKGROUND: Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has become a common treatment approach for disseminated appendiceal neoplasms. Systemic absorption of intraperitoneal chemotherapeutics may lead to drug-induced toxicity, most commonly neutropenia. Mitomycin C has been the most commonly used chemotherapeutic in HIPEC for the past several decades. CASE PRESENTATION: Here, we describe a rare pulmonary complication secondary to intraperitoneal administration of mitomycin C. CONCLUSIONS: While rare, intraperitoneal mitomycin C has the potential to cause serious pulmonary toxicity that should be considered with administration. To our knowledge, this report represents only the second case described in the literature.