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Acute appendicitis: an unusual cause

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Q1: Describe the histological features

Histopathological examination of the appendix (fig 1) shows deposits of adenocarcinoma associated with acute inflammation. Examination of the ovary (fig 2) and omentum (fig 3) confirm the presence of papillary adenocarcinoma of the ovary with spread to the omentum as well as the appendix.

Figure 1

Histological section of appendix (haematoxylin and eosin stain, original magnification × 100).  

Figure 2

Histological section of right ovary (haematoxylin and eosin stain, original magnification × 100).

Figure 3

Histological section of omentum (haematoxylin and eosin stain, original magnification × 200).  

Q2: What further treatment is indicated?

Total abdominal hysterectomy and left salpingo-oophorectomy (right salpingo-oophorectomy and omentectomy having already been performed) to “debulk” the tumour mass, followed by cytotoxic chemotherapy (with cisplatin and either paclitaxel or cyclophosphamide)1 is indicated.

Discussion

Epithelial cancer of the ovary is characterised by exfoliation of malignant cells and early dissemination throughout the peritoneal cavity. The appendix is a common site of such metastasis, both macroscopically apparent and occult, and appendicectomy is performed by some gynaecologists as part of surgical staging and to reduce tumour burden before chemotherapy. In one study of women with epithelial ovarian tumours, 39% overall and 49% with FIGO stage III (disease outside the pelvis) or IV (distant metastases) had appendiceal secondaries; about one third of these were occult (that is, microscopic only).2 In three cases appendices involved with tumour were found to be acutely inflamed microscopically, but none of these was symptomatic. In another series, appendiceal metastases were found in 63% overall and in 80% with stage III or IV ovarian disease.3

Learning points

  • Ovarian cancer frequently spreads to the appendix, resulting in micrometastases.

  • Metastatic ovarian cancer is a very rare cause of acute appendicitis.

  • It is important to perform a thorough laparotomy in adult cases of acute appendicitis.

The aetiology of appendicitis is not entirely clear, but obstruction of the lumen is thought to play an important part in some cases. This may be due to lymphoid tissue, foreign body, or, in an older age group, caecal carcinoma. We have found only one previous report of a case of ovarian carcinoma presenting with acute appendicitis.4 While metastatic ovarian cancer is a very rare cause of appendicitis, these cases emphasise the importance of thorough examination of the abdomen and pelvis at appendicectomy, even in the presence of unequivocal appendicitis.

Final diagnosis

Acute appendicitis due to metastases from papillary carcinoma of the ovary.

References

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