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Cecal adenocarcinoma

Case contributed by Bruno Di Muzio
Diagnosis certain

Presentation

Right iliac fossa pain.

Patient Data

Age: 60 years
Gender: Female

Abdomen and pelvis

ct

Mural thickening and enhancement involving the terminal ileum and part of the cecum is associated with soft tissue extension along the adjacent vasa recta and regional mesenteric prominent lymph nodes. There are structuring and upstream small bowel dilatation. Small amount of ascites with equivocal tiny nodularity at the peritoneal surface adjacent to the liver. 

Solid abdominal viscera are normal. 

Macroscopy: "Right hemicolectomy". Excision of the terminal ileum, cecum, and ascending colon. Mesocolon is attached to the length of the specimen. The specimen is received fixed in formalin and is unable to be longitudinally opened up through the cecum due to severe fixation of underlying pathology, impeding macroscopic assessment. The serosal surface is shiny and intact, with fatty tissue attached to the cecum, 50 mm in greatest dimension, with an erythematous and fibrotic appearance. A stenosing near-circumferential cecal lesion is identified, approximately 60 mm in greatest dimension. The lesion extends to and surrounds the appendix, with firm fibrofatty tissue surrounding it. The mesocolon adjacent to the tumor contains fibrous bands extending entirely through it, making a lymph node search difficult. There is no evidence of obstruction or perforation. No other focal lesions are identified.

Multiple lymph nodes between 2 to 4 mm are dissected from the mesocolic adipose tissue. The proximal resection margin is inked blue, distal resection margin is inked green, nonperitonealised mesenteric margin is inked black and fatty tissue attached to cecum orange.

Microscopy:  The sections from the cecum show a poorly differentiated adenocarcinoma comprising scattered irregular glands as well as solid nests, trabeculae and cords of markedly atypical cuboidal to columnar epithelial cells, infiltrating within a desmoplastic fibrous stroma. Carcinoma invades through the full thickness of the colonic wall into pericolic fat. Multiple foci of serosal invasion are identified. Tumor invades and involves the appendiceal wall. Extensive lymphovascular space and intramural and extramural venous invasion are identified, with vascular invasion within 2mm of the apical mesenteric margin. Multiple isolated tumor deposits are also identified. Focal perineural invasion is also identified. Carcinoma is clear of excision margins. Metastatic carcinoma is present within 10 of 11 mesenteric lymph nodes including the apical node. A separate tumor deposit is also present which is 5mm from the apical mesenteric margin following removal of the staple line.

Conclusion:  Right hemicolectomy and separately submitted right upper quadrant peritoneal biopsy: Poorly differentiated adenocarcinoma of the cecum; invasion to the serosal surface; extensive lymphovascular and venous invasion; focal perineural invasion; negative resection margins; metastases to 10 of 11 lymph nodes; metastases to separate right upper quadrant peritoneum; pT4a, N2b, M1c.

 

Case Discussion

Case of extensive cecal adenocarcinoma extending into the terminal ileum and causing small bowel obstruction. There is an advanced disease with clear venous invasion on CT and early peritoneal disease, which has been further confirmed with progression on follow-up scans (not shown). 

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