International Journal of Medical Science and Health Research

Vol. 2, No. 06; 2018

ISSN: 2581-3366

Adenocarcinoma of the Appendix with Lymph Node Metastasis: A Case

Tiago Ferrari1, Ariana Ferrari2, Guilherme Munhoz Lopes1, Juliano Fabricio dos Santos Neto 1,
Luiz Ricardo Campelo 1, Guilherme Telles Hahn1.
1
Hospital Santa Rita de Maringá
2
Centro Universitário de Maringá – Unicesumar

Abstract
Adenocarcinoma of the cecal appendix is a malignant tumor of rare affection, occurring in the
range of 0.001 to 0.2 per 100,000 person/year. Usually affects young adults. Its main clinical
manifestation is acute appendicitis, making early diagnosis difficult. It is commonly found in the
distal portion of the appendix and is most often discovered only in the anatomopathological
examination (AP) of a surgical specimen of appendectomy. We report a case of a 61-year-old
patient, presenting pain in the hypogastro region, which radiated to the right iliac fossa, when it
increased in intensity. In surgery, an appendix of Grade III was identified, with AP describing
Adenocarcinoma of the Appendix. In this way, a right hemicolectomy associated with
lymphadenectomy by laparotomy was performed, in the second time, whose AP identified lymph
node metastasis.
Keywords: Appendiceal Neoplasms. Adenocarcinoma. Appendicitis. Colectomy. Lymph Node
Metastasis.

Introduction
The adenocarcinoma of the cecal appendix is a rare affection and its incidence in anatomic part
from an appendectomy is low(1,2,3,4). The annual occurance of this type of neoplasia varies
from 0,001 to 0,2 in every 100.000 people, being part of 3% to 6% of the malignant tumors in
this segment(3,5) and making up 0,5% of all cases of malignant gastrointestinal neoplasias (4).
Besides, it is highlighted that 63,5% of the appendix tumor has benign characteristics (5).
The appendix carcinoma occurs, usually, in young adults aging around 40 years old and, less
frequently, in older people(6), being the men more affected than women(7). Commonly, the
tumors are found in the distal portion of the appendix, having, in most of the time, less than 1
cm(6). A small amount of these tumors are found in the base of this tube, therefore, it is
responsible for causing the ostium obstruction infered or for arousing its mucocele (6).
The main clinical manifestation of the adenocarcinoma of the appendix is the sharp appendicitis,
a purulent and inflammatory process, resulting, most commonly, for the difficulty to drain the
cecal appendix content (4). This way, frequently an appendectomy preceeds the diagnosis of
appendix neoplasia. From the late findings, the possibility of metastasis increases, because the
staging system, most of the time, occurs only after the appendix excision (6).
If confirmed the adenocarcinoma of the cecal appendix, the envisioned treatment does not
depend on the size of the tumor and follows with right hemicolectomy, carried out in a second
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 International Journal of Medical Science and Health Research

Vol. 2, No. 06; 2018

ISSN: 2581-3366

time (11, 12). Patients in which the tumor invaded surrounding structures must undergo a
resection in monobloc, combining the right hemicolectomy an excision of the invaded organs (8,
11, 12, 13). Adjuvant therapy, with radiotherapy and chemotherapy, are used just in cases in
which the tumour was locally progressed, using the same criteria of the colonic adenocarcinomas
(9).
The survival rate in 5 years in cases of appendicular adenocarcinoma are of 95 %(11). When
distant metastasis are present, these rates are reduced to 0 %(11). A bad prognosis is
characterized by an advanced stage of histological presence, with a a high degree dysplasia and a
tumor with not mucinous characteristics (8). Other criteria of bad prognosis are the findings of
peritoneal pseudomyxoma, abdominal distension, loss of weight and morphological evidences of
underlying structures invasion (11).

Case Report
S.A.D.G., female, 61 years old, looked for immediate attention at Santa Rita Hospital in
Maringá, having pain in the hypo gastric region lasting for 24 hours, the steady type, but with
exacerbation at wandering or coughing, with no improvement factors. She described that, with
approximately 10 hours of evolution, the pain irradiated to the right iliac nasal cavity, when it
increased the intensity.
In the clinical stage at the admission in the hospital, she also referred to epigastric discomfort
with nauseas, but with no vomits, in addition to hyporexia. She said she had no urinary symtoms
nor fever and she said she had preserved intestinal habits.
In the physical exams, the patient showed a good general state, with no sign of shock or disease
severity. The abdomen was still flaccid, but sore to superficial and deep palpation in all
hypogastric, with sign of positive blumberg.
In this initial care, it was asked laboratorial exams, CT scam of the abdomen with endogenous
contrast and the evaluation of a general surgeon, with the thoughts of a severe appendicitis in
mind.
In the laboratorial exams, the patient presented a light leukocytosis without a left deviation,
associated to a considerable increase in the C reactive protein. The other exams, as hepatic
function and aggression, besides the urine routine, were in the regular value.
The abdomen tomography showed a blurring of fat in the right iliac fossa, associated with free
liquid in the pelvis, which corroborated the diagnosis of sharp appendicitis, being the patient
directed to appendectomy.
The surgery, by open technique, occurred without complications. It was identified an
appendicitis Level III, with necrosis signs and local abscess. The surgical part was sent to
histopathological exam (AP). The patient was released on the third day after the surgery and
directed to return with the result of the AP.
In the return, the patient brought the AP that showed differentiated moderate adenocarcinoma,
measuring 1,7 centimeters, and with infiltrative aspect, invading the subserosal periappendicular
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 International Journal of Medical Science and Health Research

Vol. 2, No. 06; 2018

ISSN: 2581-3366

fatty tissue and of mesoappendix, without angiolymphatic invasion or neural, obtaining a staging
TNM of pT3 pNx pMx. It also presented a venous tubule adenoma with dysplasia of high level
associated in the part.
It was requested back up image exams with the purpose of active search of metastasis. The
patient had a CT scan in the chest and cranium, both without metastasis evidence.
This way, it was opted the execution of a Right Hemicolectomy by laparotomy associated to a
mesenteric lymphadenectomy (figure 1) with primary anatomises, procedure that occurred three
weeks after and which had no complications.

Figure 1. Surgical Part – Right Hemicolectomy with Mesenteric lymphadenectomy.

With the result of the AP of the product, the right ileocolectomy associated with the
lymphadenectomy, the patient proceeds to her health assistance. In this exam, it was described
implants of adenocarcinoma in subserosal, with mucinous standard areas. The appendicular
ostium, although, it showed free from neoplasia and the borders of the surgical part were free
from it. However, the exam showed, besides the tumor deposits in the organ surrounding fatty
tissue, also the presence of metastasis in a lymph node from the 19 dissected, lymph o vascular
invasion and perineural were not detected.
Given the findings of the AP, the patient was, consequent, directed to the Oncology Clinic
ambulatory, to continue the treatment, aiming the adjuvant treatment with chemotherapy and
radiotherapy.

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 International Journal of Medical Science and Health Research

Vol. 2, No. 06; 2018

ISSN: 2581-3366

Discussion
The adenocarcinoma of the appendxi is a rare illness and that reaches mainly the male sex and
young adults, aging on average 40 years old (6). The case presented does not endorse with the
presented epidemiology in literature, as the patient is a female sex and aging above 60 years old.
The clinical presentation of the studied patient was the classic way, in other words, as sharp
appendicitis. The clinical picture covers pain, immediate start, located in the periumbilical region
and in most of the cases; it is followed by nausea and vomits (11). After a few hours, the pain
concentrates in the right iliac fossa, next to the McBurney point, indicating the peritonitis
periapendicular impairment (11). The fever, in this case, does not usually increase, and it gets
close between 37, 5 to 38°C(11).
The main signals and sympthoms from the adenocarcinoma of the appendix, apart from the
appendicitis manifestations, include, as cites, touchable abdominal mass, peritonitis, unspecific
abdominal pain, swelling and abdominal rigidity (9,10).
It is described in the literature, clinical manifestations uncommon to the illness, such as pelvic
mass with urinary signals, hydronephrosis, bladder infiltration, vaginal bleeding, melena and
intussusception (3), although they were not found in the case.
As observed in the present study, the literature points out that from its etiology of sharp
appendicitis(1), most of the patients with these symptoms are directed to surgery without
suggesting the hypothesis of neoplasia, which forces to decide for the urgent treatment. This
occurs because its diagnosis, in most of the cases, is obtained just in the surgical part AP (2).
Being suggested the diagnosis of adenocarcinoma of the appendix, it may highlight
histologically if there were mural invasion or the presence of metastasis, including the peritoneal
cavity spread (6). The AP exam of the product of appendectomy showed and advanced tumor, in
which the neoplasia had already invaded the subserosal of the organ. The main reason of this
advance is the age of the patient, which lead to the hypothesis of being an old lesion. It is
important to emphasize that the exam also showed another tubular-villous adenoma with
dysplasia of high level, and being considered a premalignant lesion that could evolve to another
adenocarcinoma (7,10).
Since the not invasion of the surrounding structures and the absence of metastasis to distance,
described in the AP of the surgical part of appendix, it was opted for a right colectomy in a
second time, as widespread in the academic environment, as a healing treatment way of the
illness (1,2,3,4,5,6). However, with the result of the AP of the product of the right
hemicolectomy, and the presence of lymphomodal metastasis became imperative the supervision
with an Oncology Clinic, considering the stage changes of the illness and the necessity of
carrying on an adjuvant treatment (9).
Therefore, the adenocarcinoma of the appendix is a rare illness but it shows present in the
surgeon daily life. This fact rises the importance of the histopathological exam, not being
neglected at excisioning an anatomic part. It is fundamental that the surgeons have knowledge of
the characteristics of tumors that affect the cecal appendix, so that it is adopted more insightful
procedures before the situation.

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 International Journal of Medical Science and Health Research

Vol. 2, No. 06; 2018

ISSN: 2581-3366

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