A 50-year-old female presented with a 10-day history of pain in the lower right abdomen. Examination revealed an 8x10cm mass in the right iliac fossa. Imaging showed an appendicular mass and abscess. The mass did not resolve with conservative treatment over 15 days. Exploratory laparotomy found a mucinous adenocarcinoma of the appendix that had spread. A right hemicolectomy was performed. Histopathology confirmed a well-differentiated mucin-producing adenocarcinoma with lymph node metastases. Appendiceal adenocarcinoma is a rare and often delayed diagnosis that requires surgical resection.

1. Non-resolving appendicular mass
By
Dr.K.Priyatham 2nd year P.G
Dr.Y.Prabhakar Rao, M.S, M.Ch
Professor, 2nd unit chief
Department of General Surgery

2. • A 50 year old female(I.P no- 15/958188) presented on
14/1/15 with complaint of pain in the lower abdomen since
10 days.
• Pain in right lower quadrant, insidious in onset, gradually
progressive in nature, no radiation of pain, no aggravating
factors
• H/o of fever for 2 days, continuous, high grade
• Pain & fever subsided on medication after 2 days of onset of
symptoms.
• The patient was initially treated by a R.M.P for 10 days.
• As there is recurrence of pain after 10 days, she was referred
to NRIGH for further management.

3. • No H/o loss of weight & appetite.
• No h/o of vomiting, diarrhea, constipation,
clay stools, mucus in stools, distension
• No h/o jaundice, malena, bleeding per
rectum,
• No h/o tuberculosis

4. • History of past illness:
No history of similar complaint in the past
H/o caesarian done 20 years back
• Personal history:
Takes mixed diet, bowel and bladder habits
are normal, sleep and appetite are normal
• Family history:
Not significant

5. General condition:
• Patient is conscious, oriented, moderately
built & moderately nourished.
pallor+, no icterus, no cyanosis ,no clubbing ,
no significant lymphadenopathy.
• Vitals stable

6. Systemic examination
• Per Abdomen –
• Inspection- fullness noted in the right lower
quadrant.
• Lower midline vertical scar is present.
• Abdominal striae are present.
• Umbilicus is central in position & inverted.
• No visible pulsations, no dilated veins, no visible
peristalsis.
• Renal angles are normal.
• Hernial sites & external genitalia are normal.

7. • Palpation-
• Palpable mass of size 8 × 10cms in the right iliac
fossa, minimal tenderness is present, surface is
smooth , margins are well defined , firm in
consistency, intra abdominal, no mobility with
respiration, no intrinsic mobility.
• Hernial orifices- normal
• Percussion – dull over the swelling, no free fluid
• Auscultation -Bowel sounds -normally heard

9. • CVS- normal
• RS- bilateral normal vesicular breath sounds
heard
• CNS-no neurological deficits

10. Differential diagnosis
1) Appendicular abscess
2) Ileocaecal tuberculosis
3) Carcinoma of ileocaecal junction

11. Investigations
• U/S abdomen – 4.4 cms × 5.4 cms irregular
collection in right iliac fossa.
• Another well defined hypoechoic lesion
measuring 4.4cms × 3.8 cms is seen in right
iliac fossa with thickening of adjacent
mesentery.
• Impression – Appendicular mass with abscess
formation.
• U/S guided aspiration of 20 ml pus was done

13. • Hemoglobin: 5.5 gms%
• White blood cell count: 18,000 cells/mm3
• Differential count: 82(N),10(L),02(E),03(M)
• PCV – 18%
• ESR – 140 mm/ 1st hour
• RBC- 2.4 millions/Cu mm
• Platelets – 6.8 lakhs/ mm3
• MCV – 73 fl
• MCH – 22 pg
• MCHC – 30%
• Peripheral smear – microcytic hypochromic anemia,
neutrophilic leucocytosis, thrombocytosis.

14. • Serum urea: 20 mg/dl
• Serum creatinine: 1.0 mg/dl
• Sodium: 132 mmol/l
• Potassium : 3.1 mmol/l
• Blood Grouping: O +ve
• Viral Markers : negative

15. • Conservative management was done with
• Inj Magnex forte 1.5gms IV BD
• Inj Metrogyl 500 mg IV TID
• Tab Pantop 40 mg OD
• Tab Aceclo P BD
• Blood transfusions were given to improve
Hb%

16. • Review U/S on 17/1/15 – (3 days after
admission)
• Size of collection 3 × 1.3 cms (from 4.4cms ×
5.4 cms)
• Significantly reduced in size
• Mass in right iliac fossa is same as previous
scan.

17. • As there is no evidence of pus formation,
conservative management was continued.
• Despite following conservative management
for 8 days, appendicular mass did not
decrease in size.
• Therefore CECT abdomen was done on
22/1/15 ( 8 days after admission)

18. Cect abdomen
• Ill defined heterogeneously enhancing lesion
measuring approximately 6.1 × 5.1 cms noted in the
right iliac fossa.
• The lesion shows cystic areas. Inflammatory changes
with fat stranding is noted around the lesion.
• The inflammation is seen extending in to the
anterolateral wall of urinary bladder, caecum & rectus
abdominus muscle.
• Few enlarged lymph nodes are noted in right iliac
fossa.
• Appendix is not visualised.

19. Cystic
Solid
Bladder
Caecum
Mass

22. Caecum
Ileum

23. • Impression - ? Appendicular abscess with
mass formation.
• Conservative management was continued for
6 more days.
• Case was posted for exploratory laparotomy in
view of non resolving mass of appendix on
29/1/15. (duration of hospital stay – 15 days,
duration of symptoms – 25 days)

24. Surgery
• Procedure – Exploratory laprotomy
• Intra-operative findings –
1) Firm solid mass noted posterior to the
terminal ileum (8 × 5 cms)
2) Uterus along with right ovary adherent to the
mass
3) Omental adhesion are noted to the left of the
mass & previous scar site.

25. • Lower midline incision from umblicus to symphis
pubis.
• On reaching the peritoneal cavity, omental
adhesions are noted.
• Omental adhesions were seperated
• Firm mass of size 8 × 5cms beneath the terminal
ileum.
• Uterus & right ovary separated from the mass
• Right colon is mobilized by incising white line of
toldt.

26. Uterus
Terminal ileum
Omental adhesions
Ovaries

27. Mucin from the mass

28. • Right hemi-colectomy done after ligation of ileocolic
artery, right colic artery, right branch of middle colic
artery.
• Specimen was sent for HPE.
• Ileum & transverse colon are anastomosed by using
PDS sutures
• Hemostasis secured, drain placed in the morisson’s
pouch.
• Abdomen closed in layers.
• Cut section of tumor showed mucinous like substance.

30. Anastamosis
Ileum
Transverse colon

31. Terminal
Ileum
Ascending Colon

32. Biopsy
• Sections studied shows a well differentiated
mucin producing adenocarcinoma exhibiting
transmural infiltration, serosal nodular
extension, lympho vascular embolization,
surface ulceration & secondary inflammation.
• The adjacent colonic mucosa shows features
suggestive of inflammatory bowel disease
with mucosal ulceration

33. • Both the cut margins & small intestinal
segment seperately received show mild
chronic ileocolitis changes with sub mucosal
edematous widening.
• There is no tumor extension
• All the 4 lymphnodes identified in the
mesenteric fat show metastatic deposits from
colonic carcinoma.
• Appendix is not seen.

34. • Opinion – histological appearances are in
favor of well differentiated mucin producing
adenocarcinoma with metastatic deposits in
lymph nodes.

35. Final diagnosis
1) Mucinous adenocarcinoma of the appendix.
(per-operative diagnosis)
2) Well differentiated mucin producing
adenocarcinoma with metastatic deposits.
(pathological diagnosis)

36. Normal colonic mucosa- 1
Infiltrating mucin secreting adenocarcinoma-2
1 2

37. Large mucous distended tumorous gland with lining-1 &
Lymphovascular emboli-2
1 2

38. Appendiceal Tumours

39. • Primary appendicular tumors occur in 0.9% to
1.4% of all appendectomies.
• <50% of cases are recognized pre-operatively.
• Almost 85% are carcinoids.
• Adenocarcinomas of the appendix are a
category of rare tumors of the gastrointestinal
tract, with a frequency of 0.2% - 0.5% of all
intestinal malignancies and 4% - 6% over
neoplastic lesions of the appendix

40. • The first case of a primary adenocarcinoma of the
appendix was reported by Berger on 1882
• Their main presentation is that of an acute
appendicitis or as a palpable mass, mainly in the right
lower quadrant.
• Approximately 30%–50% of patients present clinically
with signs and symptoms of acute appendicitis, most
often due to occlusion of the appendiceal lumen by
tumor.
• Although at present they are a well studied pathologic
entity, the crucial issue of their preoperative diagnosis
remains unsolved.

41. • Diagnosis of underlying tumor is usually made
only at the time of surgery or even later,
during pathologic examination of the surgical
specimen.
• This delay in diagnosis often necessitates
modification of the surgical approach or a
second surgical procedure such as right
hemicolectomy.

44. Adenocarcinoma
• A malignant epithelial neoplasm of the appendix
with invasion beyond the muscularis mucosae.
• 0.12 cases per 1,000,000 appendicectomies annually.
• F=M
• Occurs 6th decade of life
• Rarer but more aggressive type.
• It is of 2 types – 1) Mucin secreting adenocarcinoma
2) Non-mucin secreting
adenocarcinoma

45. • Patients with chronic ulcerative colitis (UC) have an increased
susceptibility to formation of epithelial dysplasia and
malignancy in affected segments of bowel;
• Inflammatory involvement of the appendix is seen in
approximately half of UC cases with pancolitis.
• Both adenoma and adenocarcinoma of the appendix have
been described in patients affected by long-standing
ulcerative colitis
• Spread to the peritoneal cavity may produce large volume of
mucin causing psuedomyxoma peritonei – abdominal
distension.

46. • Treatment
–Appendectomy + right hemicolectomy.
–Simple appendectomy for adenocarcinomas
that are confined to the mucosa or well-
differentiated lesions that invade no deeper
than the submucosa.
–Role of adjuvant chemotherapy/RT is
unclear.
–Adjuvant chemotherapy – 5 FU

47. • Prognosis – poorer than carcinoid.
• Because of similarities with colon carcinoma,
appendiceal adenocarcinomas are classified
as-
 Duke’s stage A – 100% 5 year survival rate
B – 67%
C – 50%
D – 6%
• Mucinous adenocarcinoma has better 5 year
survival rate of 70% over 40% of colonic type
of adenocarcinoma

48. Carcinoid - Argentaffinoma
• Carcinoids account for 50-77% of all
appendiceal neoplasms.
• They arise from argentaffin tissue.
• 45% of carcinoids occur in the appendix.
• Other sites of carcinoids – ileum(25%),
rectum(15%), others- pancreas, biliary tract,
bronchus & testis.

49. • It is found 1 in 300-400 appendicectomies
subjected to H.P.E.
• It is 10 times more common than any other
neoplasm of appendix.
• The mean age at presentation is 32-43 years
(range, 6 to 80 years)
• Appendiceal carcinoids occur more frequently
in females than in males

50. • Majority of carcinoids are located at the tip of
the appendix.
• The carcinoid mass is the cause of appendicitis
in 25% cases only.
• About 75% of cases are less than 1cm in size.
• 5-10% are over 2cms.
• Lymph node invasion & distant metastases are
exceedingly rare except in tumors above 2cms.

51. • Carcinoid syndrome ( flushing, SOB, diarrhea, Right
sided heart valve disease) caused by an appendiceal
carcinoid is extremely rare and almost always related
to widespread metastases, usually to the liver and
retro-peritoneum.

52. Treatment
• Treatment appendiceal carcinoids is dictated mainly by
tumor size.
• Simple appendecectomy is sufficient for tumors less
than 2cm & tumors at the tip of the appendix because
of low likelihood of lymphnode involvement.
• For masses greater than 2cms right hemicolectomy is
recommended.
• For carcinoids involving the base of the appendix –
right hemicolectomy is advised.
• Carcinoids are less aggressive & carry a much favorable
prognosis 0f 90% 5 year survival rate

53. Pseudomyxoma peritonei (PMP)
• Pseudomyxoma peritonei refers to intraperitoneal accumulation of a
gelatinous ascites secondary to rupture of a mucinous tumour. The most
common cause is a ruptured mucinous tumour of the appendix /
appendiceal mucocoele. Other sources are colon, rectum, stomach,
gallbladder, bile ducts, small intestine, urinary bladder, lung, breast,
fallopian tubes and pancreas.
• Usually has metastased at time of presentation.
• Spread
– direct
– rarely through bloodstream or lymphatics.
• Sypmtoms
– Bowel obstruction
– Increase in abdominal size (Jelly Belly abdomen)
– Pelvic discomfort
– Ovarian masses

55. • If pseudomyxoma peritonei is noted during the
operation, cytoreductive surgery plus intraperitoneal
chemotherapy with or without hyperthermia therapy
should be done.
• With traditional debulking surgery, the over-all five
year survival rates is about 30-50% according to the
literature, which is similar to our result.
• However, when cytoreductive surgery and
hyperthermia intraoperative intraperitoneal
chemotherapy is performed, five year survival rate can
be improved to 52-96% by authors around the world.

57. Summary
• Appendicular mass should be the top of the
differential diagnosis with RIF mass.
• Appendicular cancer is a rare, usually an incidental
finding & should be suspected in any elderly person
presenting with appendicitis like symptoms and
signs.
• Non resolving appendicular mass should be explored.
• All appendicectomy specimen should be sent for
HPE.

58. Leonid Rogozov

60. References
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appendix with particular reference to mucocele and pseudomyxoma peritonei. J
Clin Pathol 1973. 26 (6):413–421. [CrossRef]
• 3. Higa, E. , J. Rosai , C. A. Pizzimbono , and L. Wise . Mucosal hyperplasia,
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evaluation of appendiceal “mucocele.”. Cancer 1973. 32 (6):1525–1541. [CrossRef]
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radiologic spectrum of disease with pathologic correlation. Radiographics. 2003;23
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61. Thank you