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One case of primary adenocarcinoma of the vermiform appendix is presented. The patient, a 55-year-old man, showed non specific symptoms and the diagnosis was made after surgery. Surgical treatment was right hemicolectomy. The patient is still alive and disease-free 12 months after the operation. The Authors review the literature and discuss some clinical aspects of this rare tumor.
The authors present a case-review of a patient with a large retroperitoneal tumor. A right-sided hemicolectomy with a removal of a large retroperitoneal cyst extending behind the liver up to the diaphragm on the right side, was conducted. Histology confirmed a mucous cystadenocarcinoma of the appendix. Furthermore, the authors discuss this fairly rare type of the GIT carcinoma. This tumor is low-invasive, mucus producing and rarely metastazing. During the tumor progression, the tumorous cells enter the peritoneal cavity and cause, so called, pseudomyxoma peritonei. The treatment principle is to complete a radical surgical removal of the tumor and, furthermore, in case of the pseudomyxoma periotenei, also application of the local peroperative chemotherapy.
Adenocarcinoma of the vermiform appendix is rare. It usually produces signs of acute appendicitis and is discovered only on pathological examination. The treatment of choice is right hemicolectomy, usually performed as a secondary operation. 2 cases of appendiceal carcinoma, in a 59-year-old man and in a 70-year-old woman, are described.
Bradycardia is commonly seen in high spinal anesthesia, however, evolution of cardiac arrest from sudden onset of severe bradycardia is infrequent. Prompt recognization and resuscitative measures are of paramount importance because they may insure a complete recovery without sequela as an aftermath. We report herein a case of severe sinus bradycardia induced by clipping of the appendix during appendectomy under spinal anesthesia with the sensory block up to T5 dermatome. Prompt intravenous atropine failed to regain normal sinus rhythm, and cardiac arrest ensued. Cardiac massage, manual ventilation with oxygen and low-dose epinephrine successfully resuscitated the patient. The possible mechanisms and management of this complication are also discussed.
Acute apendicitis rarely presents with a clinical picture of mechanical small-bowel obstruction. The Authors report a case of this inusual clinical occurrence, arised like a complication of a common disease, characterized by a chronically inflamed appendix (mucocele) wrapping around the last loop of ileum that produced volvolus and strangulation. The few similar cases reported in the literature are moreover reviewed.
The paper reports two cases of adenocarcinoma of the appendix. Following a review of the literature on this neoplasia, it concludes that prognosis is poor on account of the early spread of the disease, the low ratio of suspected disease, and difficulties of diagnosis prior to surgery. The preferred surgical treatment is right hemicolectomy which consents a 5-year survival rate of 50% in comparison to 20% achieved with appendectomy alone. The authors also stress the importance of carrying out histological tests after any type of appendectomy.
In an eleven part series published in Pathologica, we have presented various tumoral, quasitumoral and pseudotumoral lesions of the superficial and somatic soft tissue (ST), which emerged as new entities or as variants of established entities during the last quarter of a century. Detailed clinicomorphological and differential diagnostic features of approximately sixty entities were chosen on the basis of their clinical significance and morphologic distinctiveness. The series included fibrous and myofibroblastic tumors (e.g. solitary fibrous tumor, high grade classic and pigmented dermatofibrosarcoma protuberans, inflammatory myofibroblastic tumor and myofibrosarcomas), fibromyxoid and fibrohistiocytic neoplasms (e.g., Evans' tumor, phosphaturic mesenchymal tumor, inflammatory myxohyaline tumor), special adipocytic/vascular/and smooth muscle lesions (e.g., chondroid lipoma, Dabska's tumor, ST hemangioblastoma, lipoleiomyosarcoma), epithelioid mesenchymal malignancies of diverse lineages (e.g., epithelioid liposarcoma, proximal-type epithelioid sarcoma, neuroendocrine extraskeletal chondromyxoid sarcoma), ST Ewing's tumor and peripheral nerve sheath tumors (perineuriomas and pigmented and rosetting tumors of the schwannoma/neurofibroma group), extranodal dendritic or histiocytic proliferative processes (follicular dendritic cell sarcoma, Rosai-Dorfman disease, Castleman's disease, and plexiform xanthomatous tumor), and tumors with myoepithelial differentiation. The section devoted to selected pseudotumoral entities considered representatives of the hamartoma group (neural fibrolipomatous hamartoma, ectopic hamartomatous thymoma, rudimentary meningocele), metabolic diseases (amyloid tumor, nephrogenic fibrosing dermopathy, tophaceous pseudogout, pseudoinfiltrative parathyromatosis), stromal tissue reactions to trauma (fibroosseous pseudotumors of digits) and infections (bacillary angiomatosis), and normal organs (glomus coccygeum). To conclude the descriptive phase, supplementary material has now been collected and appended in an attempt to provide a quick digest of essential knowledge both for comparison and differential diagnosis. The data have been tailored to synthesize diverse sources, integrating clinical elements and references to articles that previously appeared in Part I ("Introduction"), Part II ("The List and Review of New Entities") and Parts III to XI ("Excerpta"). At the very least we hope this final part ("Appendix") will provide the reader with a useful tabular organization of ST lesions and a reference resource.
We describe a case of acute appendicitis precipitated by human immunodeficiency virus-related Kaposi's sarcoma of the appendix. This presentation in an otherwise asymptomatic homosexual man led to the establishment of a diagnosis of acquired immunodeficiency syndrome. Immediate follow-up revealed multicentric gastrointestinal involvement by Kaposi's sarcoma, and skin involvement ensued in 2 months. Salient features of this case and two other similar reports in the literature are highlighted.
A case of mucinous cystadenocarcinoma discovered into a voluminous benign mucocele of the appendix, is presented. The clinical feature is a tumor of the right iliac fossa. The identification of a limited area of epithelial degenerescence in the cyst wall--by peroperative microscopic examination--permits immediate enlargement of the cystectomy by a right hemicolectomy. The prognosis of the tumor is generally excellent as soon as the diagnosis is early and the removal large enough.
The decision to do an appendectomy for a patient with right lower abdominal pain has been analysed. We have described a simple decision tree model of the tradeoffs. The three critical variables can be measured quantitatively. The probability of appendicitis has been predicted. The probability that an inflamed appendix will perforate during observation can be estimated. It can be projected that the rate of perforation is increased in the very young and old. Therefore, the minimal threshold probability of appendicitis justifying an appendectomy is lower at the extremes of age. The decision must consider not only the probabilities of outcomes, but their utilities as well. The utility of appendectomy is discussed. Experience measuring the personal utilities of appendectomy in a group of surgeons using a standard gamble technique is presented. The variation in utilities was greater than expected. The perceived ratio of the magnitude of the increased risk of an avoidable perforation compared to that of an unnecessary operation ranged from over 30:1 to less than 1:3, with a median of about 3.5:1. The ratio predicted from mortality and morbidity rates had a median range from 20:1 to 2:1. Other factors may be influencing the utility assessments. The individual's utility for appendectomy could be shown to have a large influence on the decision to operate or observe.
A review of cases of primary adenocarcinoma of the appendix seen at the Hines VA Hospital (1950-1987) and Loyola University Medical Center (1977-1987) revealed a total of 14 cases. All patients presented with a clinical picture suggesting acute appendicitis or a right lower quadrant mass. Malignancy was not suspected in any of the patients prior to surgery. The age group ranged from 25 to 66 years (mean, 51.8 years) with 29% of the patients under 45 years old. The presence of carcinoma should be carefully looked for in middle-aged and elderly patients presenting with acute appendicitis.
A patient is described with a primary mucous adenocarcinoma of the appendix with bilateral Krukenberg tumours. On the basis of the available literature the value of diagnosing a Krukenberg tumour of the ovaries is elucidated. Finally the question is raised whether this matter should influence policy as regards colorectal tumours.
A structurally impaired appendix observed during laparotomy in a woman of 62, suffering from gall stones with stenosis of the papilla, was removed. Histological examination showed carcinoma. Right hemicolectomy was performed later.
An observation of a mucinous cystadenocarcinoma of the appendix, in the tumor form, revealed by a painful syndrome of the right iliac fossa in a 62-year man is reported. It is a rare malignant tumor as less than 0.5% of the appendicectomy parts present a malignant mucosecreting tumor. In our observation, the diagnosis was allowed by pre-operation imaging. An increase of the serous amount in the tumor markers (carcinoembryonic antigen) (CEA) and CA 19-9 was found before the intervention and the immunodetections performed on the operation part were positive for CEA and CA 19-9. The serous amounts of these markers were normalized after operation. To the author's knowledge, the interest of dosing the serous tumor markers in the observation of such a type of tumor is not mentioned in the literature. The recurrences are frequent and sometimes late even when the initial excision has been macroscopically satisfactory. A new increase of the serous amount of the markers could allow for an earlier detection of a recurrence during the patient follow-up. At present, the prognosis of these malignant forms remains very poor as the 5-year survival does not exceed 25%.
A case of pseudomyxoma peritonei originating in a malignant mucocele of the appendix, a very rare clinical entity, is presented. The cytologic findings in the gelatinous ascitic fluid of epithelial clusters with minimal nuclear atypia suggested a diagnosis of pseudomyxoma peritonei. Both routine stains and special stains for mucus assisted in making the cytologic diagnosis. Histologic examination of the laparotomy specimen confirmed the presence of a well-differentiated mucinous cystadenocarcinoma, with an apparent appendiceal origin. The origins and relationships of appendiceal mucocele and pseudomyxoma peritonei are discussed.
Acute appendicitis is among the most common indications for exploratory laparotomy during pregnancy. Although usually pyogenic in origin, parasitic infections account for a small percentage of cases. We report here the association of pregnancy and appendicitis caused by Schistosoma japonicum. Schistosomiasis is a very common complication of pregnancy, with 250,000,000 persons infected worldwide, including 20% of pregnant women living in hyperendemic areas. Schistosome egg masses can lodge throughout the body and cause acute inflammation of the appendix, fallopian tube, liver, and spleen. Congestion of pelvic vessels during pregnancy facilitates passage of eggs into the villi and intervillous spaces, causing an inflammatory reaction. Fetal anoxia and subsequent death has been attributed to heavy infestation of the placenta. Tourism, far-ranging military actions, and immigration make this disease a potential challenge for practitioners everywhere.
Urokinase and tissue-type plasminogen activators (u-PA and t-PA) were identified immunohistochemically in normal and inflamed human appendices by means of polyclonal and monoclonal antibodies. In addition, extracts of the tissues were analyzed for u-PA and t-PA by ELISA. Twelve appendices (five normal and seven with acute inflammation) were analyzed. In the normal appendices, there was a strong staining of the endothelial cells for t-PA, whereas there was negative staining for u-PA. In contrast, the endothelial cells in the inflamed appendices showed u-PA immunoreactivity, and negative or very weak reactions for t-PA. In the inflamed appendix, there was also a labeling of u-PA in fibroblast-like cells and in interstitial areas. The specificity of the staining was supported by a variety of staining controls and also by analysis of tissue extracts with ELISA, showing that on the average the inflamed appendices contained more than twice as much mu-PA per mg of protein as the normal appendices and less than one third of the amount of t-PA.
Appendicectomy was performed at the time of primary definitive surgery in 60 of 102 patients with epithelial ovarian cancer at Johannesburg Hospital over a 9-year period (January 1979-December 1987). Metastases were present in 37 of the 46 (80.4%) appendices removed from patients with advanced disease (stage III or IV) and in only 1 of the 14 patients (7.1%) with early disease. Metastases were not limited to serosal implants and included vascular and lymphatic space involvement, chronic obliterative appendicitis and almost complete replacement of the appendix by adenocarcinoma. The role of appendicectomy in the surgical management of epithelial ovarian cancer is discussed.