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Introduction:
Appendiceal adenocarcinomas are uncommon representing less than 0.5% of all gastrointestinal neoplasms1,2. We present an unusual case of metastatic recurrent appendiceal adenocarcinoma to the peritoneum diagnosed by rectal EUS. We are not aware of any similar such report in the published literature of EUS diagnosis of this condition.
Case Report:
A 70-year-old man with a history of T3,N2,MO mucinous appendiceal adenocarcinoma status post appendectomy with right hemicolectomy and adjuvant chemotherapy in 2001, was referred for EUS after surveillance CT scan seven years later demonstrated a 1.3cm nodule in the right perirectal space (Figure 1).
Colonoscopy demonstrated an unremarkable remnant colon. EUS confirmed a ~1.5cm hypoechoic perirectal lesion corresponding to CT imaging (Figure 2). EUS- FNA was performed (Figure 3) and cytopathology was consistent with adenocarcinoma in a background of mucin. Subsequently exploratory laparotomy did not show any evidence of peritoneal dissemination. The nodule was identified in the peritoneal reflection deep within the pelvis adherent to right anterior rectal wall. Simple peritonectomy was not possible and low anterior resection was performed. Metastatic poorly differentiated mucinous adnocarcinoma involving perirectal soft tissue was confirmed.
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Figure 1 |
Figure 2 |
Figure 3 |
Discussion:
In adenocarcinoma of the appendix, available evidence suggests right hemicolectomy is associated with improved survival compared with appendectomy alone for patients undergoing curative resection especially if = stage T22,3. Right hemicolectomy performed as a secondary procedure frequently results in upstaging2. Lymph nodes and intraperitoneal spread is frequent site at the time of diagnosis2. Second primary malignancies are not uncommonly encountered (up to 35%; 18% synchronous; 17% metachronous)2,4. Outcome data associated with therapies are not well characterized. The overall 5-year survival for appendiceal mucinous adenocarcinoma of 44-55% has been reported1,2. Recurrence occurred in a mean of 23 months (range 4-111) after surgery. Late recurrence as was present in our patient is not unprecedented reflecting the variable indolence of these tumors. The importance of lifetime surveillance is demonstrated. EUS with FNA was very useful in this case to demonstrate the recurrence of appendiceal carcinoma in the peritoneum in a minimally invasive manner that guided further management.
References:
1. McCusker ME, Cote TR, Clegg LX, et al. Primary malignant neoplasms of the appendix: a population based study from the surveillance, epidemiology and end-results program, 1973-1998. Cancer 2002; 94:3307-12.
2. Nitecki SS, Wolff BG, Schlinkert R, et al. The natural history of surgically treated primary adenocarcinoma of the appendix. Ann Surg 1994;219:51-7.
3. Ito H, Osteen RT, Bleday R, et al. Appendiceal adenocarcinoma: long term outcomes after surgical therapy. Dis Colon Rectum 2004;47:474.
4. Conner SJ, Hanna GB, Frizelle FA. Appendiceal tumors: retrospective clinicopathologic analysis of appendiceal tumors from 7970 appendectomies. Dis Colon Rectum 1998;41:75-80.
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