Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1998  |  Volume : 4  |  Issue : 1  |  Page : 31-33
Appendiceal adenocarcinoma simulating primary bladder carcinoma: A case report and review of the literature


1 Department of Urology, Riyadh Medical Complex, Riyadh, Saudi Arabia
2 Department of Pathology, Riyadh Medical Complex, Riyadh, Saudi Arabia

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Date of Submission15-Feb-1997
Date of Acceptance06-Nov-1997
 

How to cite this article:
Tarsin MS, Giangreco AB, Afzal M. Appendiceal adenocarcinoma simulating primary bladder carcinoma: A case report and review of the literature. Saudi J Gastroenterol 1998;4:31-3

How to cite this URL:
Tarsin MS, Giangreco AB, Afzal M. Appendiceal adenocarcinoma simulating primary bladder carcinoma: A case report and review of the literature. Saudi J Gastroenterol [serial online] 1998 [cited 2021 Oct 17];4:31-3. Available from: https://www.saudijgastro.com/text.asp?1998/4/1/31/33905


Primary adenocarcinoma of the appendix is rare [1] and its presentation as a bladder tumor is by far the rearest [2],[3],[4],[5],[6],[7],[8] . We report a patient with family history of gastrointestinal malignancy, who developed adenocarcinoma of the appendix penetrating the external wall of the urinary bladder therefore clinically mimicking a primary carcinoma of urinary bladder. To our knowledge, this is the 12th case reported of an adenocarcinoma of appendix simulating primary adenocarcinoma of urinary bladder and the second to be associated with strong family history of gastrointestinal malignancy.


   Case Report Top


A 35-year-old Lebanese woman was admitted to the Riyadh Medical Complex due to suprapubic tenderness and hematuria. She had no other symptoms and specifically, no gastrointestinal complaints. Family history revealed that her mother died of uterine carcinoma at the age of 35 and a sister died of colonic carcinoma at the age of 30. A brother is under treatment of colonic carcinoma and a younger sister has colonic polyps and stomach lesion.

Physical examination was essentially normal except the suprapubic tenderness that was centrally located with some radiation to the right side. The laboratory investigations, including complete blood count, electrolytes, urea, creatinine, liver function test, and serum amylase, were all within normal limits. Urine analyziz showed abundant red cells with no bacteria.

Abdominal ultrasound and intravenous pyelogram revealed normal liver and kidneys with no upper tract abnormalities, however, a filling defect occupying the region of the dome of urinary bladder with smooth outline was noted. Cytoscopy showed bullous edema of the mucosa covering the mass occupying the right lateral and superior part of the posterior wall. With the clinical diagnosis of a bladder tumor, multiple random biopsies were performed. Histopathological examination revealed congestions, edema but no evidence of a neoplasm.

A CT scan performed with contrast enhancement demonstrated an extrinsic mass involving the posterolateral wall of the bladder [Figure - 1]. Colonoscopic examination was normal with no evidence of polyp, ulceration or mass. Exploratory laparotomy showed a 5 cm large mass in the right posterior urinary bladder wall attached to the tip of the appendix. The uterus, colon and ovaries were normal. Partial cystectomy and appendectomy was performed. Postoperative recovery was uneventful and the patient was discharged two weeks postoperatively.

Gross pathologic examination of the specimen revaled product of partial cystectomy with a tumor measuring 5 cm in diameter. An appendix measuring 7.0 x 1.2cm was attached to the specimen. The tip of the appendix was totally embedded within the tumor mass but the rest of the appendix appeared to be grossly normal [Figure - 2]. Histologic examination revealed a moderately differentiated adenocarcinoma of the tip of the appendix, [Figure - 3], infiltrating the whole thickness of the appendiceal wall and penetrating the muscular wall of the urinary bladder but not reaching the mucosa [Figure - 4]. The base of the appendix was free of the tumor. The corresponding urinary bladder mucosa was ulcerated and edematous. The tumor was surrounded by marked fibrous reaction.


   Discussion Top


In practice, most primary and secondary bladder tumors are clinically easy to separate. The presence of hematuria associated with a mass involving the posterolateral wall of the urinary bladder, and the absence of signs or symptoms from the surrounding organs such as intestinal tract, uterus, ovaries, suggested that the patient had a tumor of the urinary bladder. Secondary neoplasms that invade the bladder are usually quite evident and their site of origin can be identified by physical examination, sigmoidoscopy or standard radiographic means. However, appendiceal neoplasms usually challenge preoperative recognition. Rarely they can be suspected clinically because they are uncommon and it is usually impossible to evaluate the appendix preoperatively [3] . Appendiceal carcinoma is observed in I of 1,500 to 1 of 30,000 appendectomy specimens [1] . It comprises 0.2 to 0.5 percent of all gastrointestinal neoplasm, occurs in a 3:1 male to female ratio and makes up 6 percent of all appendiceal neoplasms [9],[10] .

The majority of appendiceal carcinomas originate at the base of the organ [11] . In this case, the tumor was located at the tip with infiltration of the whole thickness of the appendiceal wall and extended to the external muscular coat of the urinary bladder wall. The proximal appendix also showed adenocarcinoma but only involving the mucosa and submucosa, however the base of the appendix was free.

Although four primary appendiceal carcinomas have been identified preoperatively by barium enema [12] these are the exceptions. Diagnosis of an appendiceal neoplasm generally is made at operation in patients treated for appendicitis. Right lower quadrant mass, intestinal obstruction, or the lesion may be recognized incidentally in an appendectomy specimen removed for some other indications.

In this particular case when cytoscopic biopsy result was negative, the possibility of a secondary tumor was entertained, however the diagnosis of primary tumor of the urinary bladder could not be ruled out since the CT scan revealed mass involving the bladder wall. The possibility of a ureteral carcinoma was ruled out due to posterolateral location of the tumor clinically and finding of appendiceal carcinoma invading the bladder histologically.

Primary adenocarcinoma of the urinary bladder is unusual. It constitutes only 2% of the malignant tumors of this organ. They particularly arise through metaplastic changes initiated by chronic inflammation, and through sequential changes from Brunn's glands, to cystitis glandularis and cystica to adenocarcinoma. Others arise in extrophied bladder and urachal remnants. These adenocarcinomas may closely mimic those of colonic origin, but they usually tend to occur in much younger patients and involvement of the mucosa is mostly evident [13],[14] .

During the surgical procedure, a mass involving the bladder wall and adherent to the tip of the appendix was discovered. Because the remaining proximal appendix was essentially normal, a block resection of the tumor bearing bladder and appendectomy was done. Histologic examination of the mass revealed moderately differentiated adenocarcinoma of the appendix infiltrating the whole thickness of the appendiceal wall at the tip and extending directly to the urinary bladder wall.

From 11 cases reported in the literature of adenocarcinoma of appendix mimicking carcinoma of the urinary bladder, it is interesting to mention that in seven cases the tumor was reaching the mucosa of the urinary bladder and in two cases [2],[3],[15] the neoplasm was only infiltrating the muscular coat as in the present case. Only one of these cases had family history of other gastrointestinal malignancy similar to our patient.

This case and review of the similar cases reported in the literature would suggest that when in a case presenting as bladder tumor, or an extrinsic bladdler mass is detected, and cystoscopic biopsies are negative or show an adenocarcinoma, the possibility of an appendicial primary or an extravesical primary site such as colon or appendix should always be considered [15],[16],[17],[18] .

Stiehm and Seaman described barium enema finding in four patients. In three a mass impression on the cecum with failure to fill the appendix. In the fourth case, barium enema revealed no mass effect and partial filling of the appendix. Hence, the inability to reflux barium into the appendix is a nonspecific finding [15] .

Adenocarcinoma of the appendix should be considered in the differential diagnosis of hematuria, especially when an extrinsic mass invades the bladder. Computed tomography and magnetic resonance imaging are valuable methods to demonstrate expanding appendiceal tumor when clinical data, histological examination and conventional radiological studies were nondiagnostic [16],[17],[18] .

 
   References Top

1.Anderson A, Bergdahl L. Primary carcinoma of the appendix. Ann Surg 1975;183:53-7.  Back to cited text no. 1    
2.Richie JP, Smith RB. Primary adenocarcinoma of the appendix masquerading as a bladder tumor. Arch Surg 1977;112:266-7.  Back to cited text no. 2    
3.Henry R, Bracken RB, Ayala A. Appendiceal carcinoma mimicking primary bladder cancer. J Urol 1980; 123:590-1.  Back to cited text no. 3    
4.Bischoff W, Bohnm N. Adenocarcinoma of the appendix penetrating the bladder. J Urol 1980;123:123-4.  Back to cited text no. 4    
5.Bartholomew LG, Farrow GM, Dc Weerd JH. Adenocarcinoma of the appendix simulating primary bladder carcinoma. 1984;29:371-5.  Back to cited text no. 5    
6.Nataf R. Lefakis P. Endovesical perforation of an appendiceal adenocarcinoma. J Urol Nephrol, Paris. 1974;80:306-12.  Back to cited text no. 6    
7.Skaane P, Isachsen MM, Hoiseth A. Computed tomography of mucin producing adenocarcinoma of the appendix presenting as a bladder tumor. J Comput Assit Tomogr 1985;9:566-7.  Back to cited text no. 7    
8.Chen KT, Spaulding RW. Appendiceal Carcinoma Masquerading as Primary Bladder Carcinoma. J Urology 1991;145:821-2.  Back to cited text no. 8    
9.Delgado RR Jr, Mullen JT, Ehrlich RE. Primary adenocarcinoma of the appendix. South Medical J 1975;68:976-8.  Back to cited text no. 9    
10.Wolf M, Ahmed N. Epithelial neoplasms of the vermiform appendix (exclusive of carcinoid) I. Adenocarcinoma of the appendix Cancer 1976;37:2493-5 10.  Back to cited text no. 10    
11.Appeiman HH. Epithelial Neoplasia of the Appendix In Norris H. Thomas (Ed.) Pathology of the colon, small intestine and anus. In Contemporary issues in Surgical Pathology 1983;2:233-65.  Back to cited text no. 11    
12.Stiehm WD, Seaman WB. Roentgenographic aspects of primary carcinoma of the appendix. Radiology 1973; 108:275-8.  Back to cited text no. 12    
13.Thomas DG, Ward AM, Williams JK. A study of 62 cases of adenocarcinoma of the bladder. Brit J Urol 1971;43:4-15.  Back to cited text no. 13    
14.Friedman NB, Ash JE. Tumors of the Urinary Bladder. In Atlas of Tumor Pathology, Washington DB. Armed Forces Institute of Pathology 1989, section 8, fascicle 31.  Back to cited text no. 14    
15.Fish B, Smulewicz JJ, Barek L. Role of computed tomography in diagnosis of appendiceal disorders. NY State J Med 1981;81:900-4.  Back to cited text no. 15    
16.Tripoidi J, Perlmutter S, Rudansky S, Kim DK, Burakoff R. Primary Adenocarcinoma of the Appendix. An unusual presentation. Am J Gastroenterol 1995;90:661-2.  Back to cited text no. 16    
17.Ikeda L, Miura T, Kondo L. Case of Vesico-appendiceal Fistula Secondary to Mucinous Adenocarcinoma of the Appendix. J Urol 1995;153:1220-1.  Back to cited text no. 17    
18.Dahms SE, Hohenfellner M, Eggersmann C, Lampel A, Golz R, Thuroff JW. Appendix Carcinoma Invading the Urinary Bladder. Urologia Inter 1997;58:124-7.  Back to cited text no. 18    

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Correspondence Address:
Mahmoud S Tarsin
P.O. Box 92025, Riyadh 11653
Saudi Arabia
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PMID: 19864784

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