|Year : 2019 | Volume
| Issue : 2 | Page : 187-189
Appendicular lump misdiagnosed as ovarian tumor
Pratibha Kumari1, Pravin Kumar2, Satya Kumari1, Sangeeta Pankaj3
1 Senior Resident, Dept. of Gynecological oncology, IGIMS, Patna, Bihar, India
2 PG Student, Department of general surgery, JLNMC, Bhagalpur, India
3 Professor & Head, Dept. of Gynecological oncology, IGIMS, Patna, Bihar, India
|Date of Submission||08-May-2019|
|Date of Acceptance||10-Jun-2019|
|Date of Web Publication||12-Aug-2019|
Professor & Head, Gynecological Oncology, IGIMS, Patna
Source of Support: None, Conflict of Interest: None
Appendiceal mucocele is a rare entity which occurs due to cystic dilatation because of abnormal accumulation of mucus in the lumen of the appendix. Patients are often diagnosed incidentally during abdominal surgery for other causes. When the patient is symptomatic,the most common symptom of appendix mucocele is pain in the right lower quadrant of the abdomen. Mucocele may present as acute or chronic appendicitis. This is a study done on a 52-year-old female for whom surgical intervention for ovarian tumor was planned, but who instead underwent laparotomy for appendicular lump.
Radiologic assessments showed large sized right adenexal cystic lesion with mild enhancing wall thickening infero-medially. The test for serum tumor markers showed normal level of CA-125. The patient underwent a laparotomy and appendicular lump was found. We conducted frozen section biopsy of mass for confirming malignancy before performing staging surgery. The result of frozen section biopsy confirmed appendicular lump. Subsequently total hysterectomy and B/L salpingo-oopherectomy were performed. Appendicular Mass was removed. It should be taken into consideration that the possibility of malignancy is low in post menopausal woman with normal CA-125 Level. Instead of performing staging surgery,it is appropriate to carry out surgery based on result of intra-operative frozen section biopsy so that we were able to avoid unnecessary surgical procedures. Gynecologists should routinely consider this disease in the differential diagnosis of right lower dumbbell abdominal cysts. Eleven percent to 20% of mucoceles are caused by mucinous cystadenocarcinomas.
Keywords: Appendicular lump, ovarian mass,CA-125,Frozen section
|How to cite this article:|
Kumari P, Kumar P, Kumari S, Pankaj S. Appendicular lump misdiagnosed as ovarian tumor. J Indira Gandhi Inst Med Sci 2019;5:187-9
| Introduction :|| |
Rarely, mucocele of the appendix is caused by mucinous cystadenoma and is thus considered as a “diagnostic dilemma. Gynecologists often do vaginal ultrasound examinations as a standard procedure to evaluate pelvic tumors originating from the ovaries, the tubes, and the uterus. Masses that are found in the pelvis, but are not associated to these structures, often can be mis-diagnosed . Consequently, a definite diagnosis may not be made until surgery and which may then force the surgeon to make important decisions quickly resulting in error in diagnosis of pathology. On transvaginal ultrasound which is often used as a screening tool for adnexal tumors, malignancy can be suspected when the size of an ovarian mass is larger than 10 cm or the tumor has papillary projections or solid components. In postmenopausal women with these imaging findings, bilateral salpingo-oophorectomy and hysterectomy are typically performed considering that a mass is malignant.,, Appendiceal mucocele is a rare entity that is characterized by cystic dilatation in the lumen of the appendix. The diagnosis is often made based on clinical signs and symptoms of acute appendicitis or coincidentally via imaging methods when it is asymptomatic. However, it may rarely receive a definitive diagnosis before surgery in spite of all technical possibilities, and it may be encountered during abdominal surgery performed with another indication. This study presents a 52-year-old female patient who was operated on with the pre-diagnosis of complicated ovarian mass but during laparotomy , it was found to be appendicular mucocele.
| Case Report:|| |
A 52 year old married menopausal woman visited the department of Gynaecological oncology, state cancer institute , IGIMS , Patna, with chief complain of lower right abdominal pain on and off since 3 months. Her obstetrics history was that the patient had 2 term birth, both by LSCS . At the time of visit, her systemic condition was favourable , vital signs were normal. On abdominal palpation there was no tenderness or rebound tenderness. On pelvic examination no vaginal bleeding or discharge was noted. Abdominal and pelvic CT Scan revealed a large 10.1x6.4x6.9cm size right adenexal cystic lesion with mild enhancing wall thickening(5.9cm) infero-medially. Residual right ovary appeared adhered to it. Malignancy was suspected. In addition there was a finding of lateral deviation and compression of the right distal Ureter by the cyst causing significant proximal hydroureteronephrosis. There was no finding of pleural effusion, ascites and lymph node enlargement . CBC, Blood Coagulation, LFT, KFT, Urine analysis, chest x ray, ECG were normal. The test for serum tumor markers showed normal level of CA 125 (4.80), CA 19-9(24), CEA(3.13).The patient was suggested for USG guided FNAC to rule out malignancy but she denied . The patient underwent exploratory laparotomy with a suspicion of borderline tumor or malignancy of an adenexal mass. On opening abdomen the uterus and both adenexa showed no features of pathologies .However, in fact the cystic lesion was distended appendix with inflamed walls but without perforation . A mucocele was suspected. Ascites was not found in abdominal cavity. The organized mass was dissected and appendectomy was performed without compromising mucocele integrity with the help of team of oncosurgeons. Frozen section biopsy was done and it confirmed the mass to be mucocele only. Total abdominal hysterectomy with b/l salpingectomy was done and tissue were sent for histopathological biopsy. The patient was discharged on seventh post operative day without any complication and further follow up was scheduled after 3 month.HPE was also consistent with mucocele .
| Discussion :|| |
Appendiceal mucocele is a descriptive term referring to distention of the appendix with mucus, which develops secondary to mucinous cystadenoma (63%), mucosal hyperplasia (25%), mucinous cystad-enocarcinoma (11%) and retention cysts (1%) of the appendix lumen. Mucocele can also occur when the lumen is obstructed due to endometriosis or carcinoid tumors. It is reported that the incidence of appendiceal mucocele in appendectomy specimens is 0.2-0.3%. Patients are generally above the age of 50, and it is 4 times more common among women. The malignancy incidence of ovarian tumors is known to range between 6% and 11% in premenopausal women, whereas the risk increases up to about 30% in postmenopausal women, especially in women greater than 40 years of age.,
Tumor marker test and ultrasound are relatively easy diagnostic methods of screening for ovarian tumors. CA- 125 is a tumor marker used in differentiating malignant from benign ovarian tumors and CA-125 levels raise in women with epithelial ovarian tumors. Although reproductive age women with elevated levels of CA-125 are more likely to develop malignant ovarian tumors, the usefulness of elevated CA-125 levels decrease in discriminating malignant from benign ovarian tumors in women of childbearing age because an increase in CA-125 can be associated with benign conditions such as endometriosis, uterine leiomyoma, and pelvic inflammatory disease, pregnancy, and menstruation. CA- 125 level and ultrasonography have been shown to have a low positive predictive value when used in a screening test fo r a d n e x a l t u m o rs i n p o s t m e n o p a u s a l women. Malignancy can be suspected when the size of an ovarian mass is larger than 10 cm or the tumor has papillary projections or solid components on ultrasound. Because of the nonspecific nature the disease , preoperative diagnosis is often difficult. Pelvic masses are generally diagnosed by ultrasound preoperatively, in which mucoceles of the appendix frequently mimic like adenexal masses and thus may easily be misdiagnosed .Thus it is essential to raise gynecologists’ awareness about the pattern of this disease .
| Conclusion :|| |
Appendiceal mucocele is a rare entity which does not have a specific clinical presentation. Therefore, mucocele is not considered as a part of the differential diagnosis of lower right quadrant abdominal pain, and it is often difficult to achieve a pre-operative diagnosis. Appendiceal mucocele must be considered particularly in cases where an elderly woman is found to have a mass with atypical appearance in ultrasound identified in the right iliac fossa. Appendiceal mucoceles are usually found in middle-aged patients with a higher occurrence in women than in men. Thus gynecologists should routinely consider this disease in the differential diagnosis of right lower dumbbell abdominal tumor.
| References|| |
Bartlett C, Manoharan M, Jackson A. Mucocele of the appendix - a diagnostic dilemma: a case report. J Med Case Reports. 2007;1:183. [PMC free article] [PubMed]
Cohen A, Solomon N, Almog B, et al. Adnexal torsion in postmenopausal women: clinical presentation and risk of ovarian malignancy. J Minim Invasive Gynecol 2017;24:94-7. [PubaMed]]
Ganer Herman H, Shalev A, Ginath S, et al. Clinical characteristics and the risk for malignancy in postmenopausal women with adnexal torsion. Maturitas 2015;81:57-61. [PubMed]]
Practice Bulletin No. 174 summary: evaluation and management of adnexal masses. Obstet Gynecol 2016;128:1193-5. [PubMed]]
K?l?c K, Arac M, Ozer S, Ozakp?nar E. Mucinous cystadenoma of the appendix. Tan?sal ve Giri?imsel Radyoloji. 2001;7:128-130.]
Bartlett C, Manoharan M, Jackson A. Mucocele of the appendix-a diagnostic dilemma: a case report. J Med Case Rep. 2007;1:183. [PMC free article] [PubMed]]
Dachman AH, Lichtenstein LE, Friedman AC. Mucocele of the appendix and pseudomyxoma peritonei. Am J Roentgenol. 1985;144:923-929. [PubMed]
Minni F, Petrella M, Morganti A, Santini D. Giant mucocele of the appendix. Dis Colon Rectum. 2001;44:1034-1036. [PubMed]
Webb PM, Jordan SJ. Epidemiology of epithelial ovarian cancer. Best Pract Res Clin Obstet Gynaecol 2017;41:3-14. [PubMed]]
Kinkel K, Lu Y, Mehdizade A, et al. Indeterminate ovarian mass at US: incremental value of second imaging test for characterization: meta-analysis and Bayesian analysis. Radiology 2005;236:85-94. [PubMed]
Van Calster B, Timmerman D, Bourne T, et al. Discrimination between benign and malignant adnexal masses by specialist ultrasound examination versus serum CA-125. J Natl Cancer Inst 2007;99:1706- 14. [PubMed]
Fung MF, Bryson P, Johnston M, et al. Screening postmenopausal women for ovarian cancer: a systematic review. J Obstet Gynaecol Can 2004;26:717-28. [PubMed]
American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins-Gynecology. Gynecologists’ Committee on Practice, Practice Bulletin No. 174: evaluation and management of adnexal masses. Obstet Gynecol 2016;128:e210-26. [PubMed]