Journal of Crohn's and Colitis (2014) 8, 334–335
Available online at www.sciencedirect.com
ScienceDirect
LETTER TO THE EDITOR Appendiceal adenocarcinoma in a patient with chronic ulcerative colitis: What is the appropriate surgical procedure?
Dear Sir,
Restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) is the surgical therapy of choice for patients with chronic ulcerative colitis (CUC).1 The association between appendiceal cancer and CUC with long-standing disease and pancolitis was reported.2–5 However, there were no established surgical intervention strategies for these patients. We report a case of CUC associated with an appendiceal adenocarcinoma undergoing a limited right sided hemicolectomy. A 68 year old male with a 35-year history of ulcerative colitis (UC) in remission on 5-aminosalicylic acid (5-ASA) developed right lower quadrant abdominal pain. An abdominal/pelvic CT scan noted a distended and inflamed appendix consistent with acute appendicitis, and the distal colon wall thickening. Recent colonoscopy showed no colonic dysplasia. He underwent laparoscopic appendectomy with caput cecectomy and preservation of ileocecal valve. Pathology revealed a T2 adenocarcinoma of the appendix that extended to the cecectomy staple line. The patient refused the preferred proctocolectomy with J-pouch reconstruction and underwent a right sided hemicolectomy. At 4-year follow up, he is free of malignancy, and in remission on oral 5-ASA with only one mild flare which was controlled after a course of corticosteroid enemas and 5-ASA. RP/IPAA has become the standard surgical intervention of chronic ulcerative colitis since 1978. However, the incidence of complications remains relatively high in contrast to the low mortality rate.1 In 1994, Odze et al.3 reported the first case of appendix adenocarcinoma in a patient with a 20-year history of CUC with pancolitis but no dysplasia. The patient underwent a total colectomy, appendectomy and ileostomy. Zannoni et al.4 in 1997 described a female patient with a 20-year history of CUC with slightly active pancolitis but no dysplasia and with a cystadenocarcinoma of the appendix who underwent a right hemicolectomy. Appendix adenocarcinoma associated with CUC of a 60-year-old with a 5-year history of left colon CUC without dysplasia who underwent an elective total proctocolectomy with ileostomy after the failure of medical treatment was published by Villanueva
Saenz et al. in 2006.5 Appendix adenocarcinoma was then detected during the surgery. Unfortunately, there were no follow up data for any of these cases. This is the first report with a 4-year follow up after a right sided hemicolectomy for an appendiceal adenocarcinoma involved with CUC. Our patient would only accept a right sided hemicolectomy and has minimal disease activity with no malignancy recurrence after 4 years. Considering the high complication rate of RP/IPAA or ileostomy, the right sided hemicolectomy could be a conservative option for the patients with appendiceal adenocarcinoma with CUC and no colonic dysplasia. However, lifelong colonoscopic surveillance is required for any patient with less than total proctocolectomy. Ultimately, these patients must recognize that they may need completion proctectomy or restorative proctectomy.
Conflict of interest The authors declare that they have no conflict of interest.
References 1. Gorgun E, Remzi FH. Complications of ileoanal pouches. Clin Colon Rectal Surg 2004;17(1):43–55. 2. Orta L, Trindade AJ, Luo J, Harpaz N. Appendiceal mucinous cystadenoma is a neoplastic complication of IBD: case-–control study of primary appendiceal neoplasms. Inflamm Bowel Dis 2009;15(3):415–21. 3. Odze RD, Medline P, Cohen Z. Adenocarcinoma arising in an appendix involved with chronic ulcerative colitis. Am J Gastroenterol 1994;89(10):1905–7. 4. Zannoni U, Masci C, Bazzocchi R, Gandolfo F, Pezzi A, Alampi G, et al. Cancer of the appendix in long-standing ulcerative colitis: a case report. Tumori 1997;83(6):958–9. 5. Villanueva Saenz E, Pérez-Aguirre J, Belmonte MC, Martínez PH, Márquez RM, Carranza RJ. Appendix adenocarcinoma associated with ulcerative colitis: a case report and literature review. Tech Coloproctol 2006;10(1):54–6. Huafeng Shen Department of Medicine, Nassau University Medical Center, East Meadow, NY, United States Seth Lipka Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
1873-9946/$ - see front matter © 2013 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.crohns.2013.11.005
Letter to the Editor
335 Seymour Katz⁎
New York University School of Medicine, New York, NY, United States North Shore University Hospital-Long Island Jewish Health System, Manhasset, NY, United States St. Francis Hospital, Roslyn, NY, United States ⁎Corresponding author at: 1000 Northern Boulevard, Great Neck, NY, United States. 11021. Tel:. 516-466-3240; Fax:. 516-829-6421. E-mail address: [email protected].
6 November 2013
Available online at www.sciencedirect.com
ScienceDirect
LETTER TO THE EDITOR Appendiceal adenocarcinoma in a patient with chronic ulcerative colitis: What is the appropriate surgical procedure?
Dear Sir,
Restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) is the surgical therapy of choice for patients with chronic ulcerative colitis (CUC).1 The association between appendiceal cancer and CUC with long-standing disease and pancolitis was reported.2–5 However, there were no established surgical intervention strategies for these patients. We report a case of CUC associated with an appendiceal adenocarcinoma undergoing a limited right sided hemicolectomy. A 68 year old male with a 35-year history of ulcerative colitis (UC) in remission on 5-aminosalicylic acid (5-ASA) developed right lower quadrant abdominal pain. An abdominal/pelvic CT scan noted a distended and inflamed appendix consistent with acute appendicitis, and the distal colon wall thickening. Recent colonoscopy showed no colonic dysplasia. He underwent laparoscopic appendectomy with caput cecectomy and preservation of ileocecal valve. Pathology revealed a T2 adenocarcinoma of the appendix that extended to the cecectomy staple line. The patient refused the preferred proctocolectomy with J-pouch reconstruction and underwent a right sided hemicolectomy. At 4-year follow up, he is free of malignancy, and in remission on oral 5-ASA with only one mild flare which was controlled after a course of corticosteroid enemas and 5-ASA. RP/IPAA has become the standard surgical intervention of chronic ulcerative colitis since 1978. However, the incidence of complications remains relatively high in contrast to the low mortality rate.1 In 1994, Odze et al.3 reported the first case of appendix adenocarcinoma in a patient with a 20-year history of CUC with pancolitis but no dysplasia. The patient underwent a total colectomy, appendectomy and ileostomy. Zannoni et al.4 in 1997 described a female patient with a 20-year history of CUC with slightly active pancolitis but no dysplasia and with a cystadenocarcinoma of the appendix who underwent a right hemicolectomy. Appendix adenocarcinoma associated with CUC of a 60-year-old with a 5-year history of left colon CUC without dysplasia who underwent an elective total proctocolectomy with ileostomy after the failure of medical treatment was published by Villanueva
Saenz et al. in 2006.5 Appendix adenocarcinoma was then detected during the surgery. Unfortunately, there were no follow up data for any of these cases. This is the first report with a 4-year follow up after a right sided hemicolectomy for an appendiceal adenocarcinoma involved with CUC. Our patient would only accept a right sided hemicolectomy and has minimal disease activity with no malignancy recurrence after 4 years. Considering the high complication rate of RP/IPAA or ileostomy, the right sided hemicolectomy could be a conservative option for the patients with appendiceal adenocarcinoma with CUC and no colonic dysplasia. However, lifelong colonoscopic surveillance is required for any patient with less than total proctocolectomy. Ultimately, these patients must recognize that they may need completion proctectomy or restorative proctectomy.
Conflict of interest The authors declare that they have no conflict of interest.
References 1. Gorgun E, Remzi FH. Complications of ileoanal pouches. Clin Colon Rectal Surg 2004;17(1):43–55. 2. Orta L, Trindade AJ, Luo J, Harpaz N. Appendiceal mucinous cystadenoma is a neoplastic complication of IBD: case-–control study of primary appendiceal neoplasms. Inflamm Bowel Dis 2009;15(3):415–21. 3. Odze RD, Medline P, Cohen Z. Adenocarcinoma arising in an appendix involved with chronic ulcerative colitis. Am J Gastroenterol 1994;89(10):1905–7. 4. Zannoni U, Masci C, Bazzocchi R, Gandolfo F, Pezzi A, Alampi G, et al. Cancer of the appendix in long-standing ulcerative colitis: a case report. Tumori 1997;83(6):958–9. 5. Villanueva Saenz E, Pérez-Aguirre J, Belmonte MC, Martínez PH, Márquez RM, Carranza RJ. Appendix adenocarcinoma associated with ulcerative colitis: a case report and literature review. Tech Coloproctol 2006;10(1):54–6. Huafeng Shen Department of Medicine, Nassau University Medical Center, East Meadow, NY, United States Seth Lipka Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
1873-9946/$ - see front matter © 2013 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.crohns.2013.11.005
Letter to the Editor
335 Seymour Katz⁎
New York University School of Medicine, New York, NY, United States North Shore University Hospital-Long Island Jewish Health System, Manhasset, NY, United States St. Francis Hospital, Roslyn, NY, United States ⁎Corresponding author at: 1000 Northern Boulevard, Great Neck, NY, United States. 11021. Tel:. 516-466-3240; Fax:. 516-829-6421. E-mail address: [email protected].
6 November 2013
