Limited, local, extracolonic spread of mucinous appendiceal adenocarcinoma after perforation with formation of a malignant appendix-to-sigmoid fistula: Case report and literature review

Abstract

A 68-year-old man presented with progressive right lower quadrant abdominal pain and tenderness without rebound tenderness, and with constipation during the prior 9 mo. Abdomino-pelvic computed tomography and magnetic resonance imaging demonstrated a dilated appendix forming a fistula to the sigmoid colon. Open laparotomy revealed a bulky abdominal tumor involving appendix, cecum, and sigmoid, and extending up to adjacent viscera, without ascites or peritoneal implants. The abdominal mass was removed en bloc, including resection of sigmoid colon, cecum (with preservation of ileocecal valve), appendix, right vas deferens, testicular vessels, and minimal amounts of anterior abdominal wall; and shaving off of small parts of the walls of the urinary bladder and small bowel. Gross and microscopic pathologic examination revealed an appendix-to-sigmoid malignant fistula secondary to perforation of mucinous adenocarcinoma of the appendix with minimal local spread (stage T4). However, the surgical margins were clear, all 13 resected lymph nodes were cancer-free, and pseudomyxoma peritonei or peritoneal implants were not present. The patient did well during 1 year of follow-up with no clinical or radiologic evidence of local recurrence, metastases, or pseudomyxoma peritonei despite presenting with extensive stage T4 cancer that was debulked without administering chemotherapy, and despite presenting with malignant appendiceal perforation. This case illustrates the non-aggressive biologic behavior of this low-grade malignancy. The fistula may have prevented free spillage of cancerous cells and consequent distant metastases by containing the appendiceal contents largely within the colon.

Keywords: Mucinous adenocarcinoma; Appendicitis; Appendix; Malignant fistula; Pseudomyxoma peritonei; Colon cancer; Metastases

Core tip: A patient with mucinous appendiceal adenocarcinoma had appendiceal perforation that was locally contained by a malignant appendix-to-sigmoid fistula. The patient presented with right lower quadrant pain and tenderness and constipation. Abdomino-pelvic computed tomography and magnetic resonance imaging revealed a bulky peri-appendiceal mass containing an appendix-to-sigmoid-fistula. Pathologic analysis after debulking surgery revealed a locally extensive cancer involving appendix, sigmoid, and cecum and extending up to adjacent viscera with clear surgical margins and benign lymph nodes. The patient remained free of local recurrence/metastases during 1 year of follow-up despite not receiving chemotherapy/radiotherapy. This apparently favorable outcome is due to this cancer’s nonaggressive biology, and the fistula which likely largely contained cancer cell spillage within the colon and prevented free cancer cell spillage.