A chance diagnosis of appendiceal goblet-cell adenocarcinoma in acute appendicitis being treated by ileocecectomy plus partial right-hemicolectomy: A case report

Abstract

Introduction and importance: Appendiceal Goblet Cell Adenocarcinoma (GCA) is a renamed subtype of appendiceal adenocarcinoma. A proper management is required to improve the outcomes of the patients. We hereby reported a chance diagnosis of GCA presenting as acute appendicitis being treated by ileocecectomy plus partial right-hemicolectomy.

Case presentation: A 59-year old male complained of a right lower abdominal pain for 17 h on admission with a history of acute appendicitis. Physical examination revealed hyperactive bowel sound and right lower quadrant tenderness. CBC showed WBC and neutrophil elevation. Abdominal CT demonstrated an enlarged appendix with surrounding fat-stranding. A laparoscopic appendectomy was performed with the unexpected finding of GCA in the surgical specimen. Enhanced CT and colonoscopy were further performed to rule out metastasis. An ileocecectomy plus partial right-hemicolectomy was operated to resect the distal ileum and the proximal ascending colon both about 10 cm with the cecum. The pathology revealed that the ileocecal subserosa was invaded. The patient was then referred to the oncology department for 5-FU-based chemotherapy.

Clinical discussion: GCA requires proper treatment. The diagnosis can be challenging due to the unspecific clinical manifestations, and is depending on pathology in the cases of appendicitis after appendectomy. Though right-hemicolectomy should remain as the standard treatment, the enhanced CT and colonoscopy are necessary for further evaluation. Our case has chosen the ileocecectomy plus partial right-hemicolectomy based on the enhanced CT and colonoscopy ruling out metastasis.

Conclusion: The case highlights the ileocecectomy plus partial right-hemicolectomy to treat GCA on the specific preoperative evaluation ruling out metastasis and followed by the recommendation of 5-FU-based chemotherapy.

Keywords: Appendiceal neoplasms; Chance diagnosis; GCA; Ileocecectomy; Partial right-hemicolectomy; Prognosis.

Fig. 1

Abdominal CT scans showing enlarged and inflamed appendix with fat stranding around the appendix and ileocecum marker out by the arrow (⇨).

Fig. 2

Incidental pathological diagnosis of appendiceal (GCA) in the appendiceal specimen after appendectomy. A. HE showed adhesive cluster of goblet-like tumor cells invading the appendiceal subserosa with abundant mucin (AB-PAS stain) without tubule and stromal reaction, and the grade of tumor cells being grade I and II; B. IHC showed strong immunoreactivities of CK, CEA, CDX-2 and Villin, with syn and CgA being mildly stained.

Fig. 3

Pathological examination showing GCA invading the complete wall of the appendix stump and ileocecum. A. HE showed the same goblet-like tumor cells invading the complete wall of the appendix stump and ileocecum, with perineural invasion marked out by the circle; B. IHC showed positive staining of S100 and negative of BRAF and HER2.

Fig. 4

Surgical diagram of the ileocecectomy plus partial right-hemicolectomy and illustration of the surgical gross specimen. A. A surgical diagram was drawn to show the ligation of the pivotal and major arteries of right colic artery and the ileocolic artery, the regional lymph nodes dissection and the proximal right colon and the distal end of ileum both about 10 cm from the stump of appendix; B. The gross specimens of dissected partial ascending colon and the distal ileum both about 10 cm long were illustrated and cut longitudinally to show the orifice of the appendix marked out by the white arrow (⇦).