Primary Appendiceal adenocarcinoma
Description
● Epidemiology & Background
Approximately 1.2 cases per 100,000 people per year is the incidence.
Male inclination, more prevalent in older adults (60–70 years).
● Risk factors:
• Not well identified.
• Frequently found by chance during surgery or in the histology following an appendectomy.
• Mucinous, colonic-type, goblet cell, and signet ring cell carcinomas are among the low-grade to high-grade histology types.
• About 60% of initial appendiceal cancers are adenocarcinomas.
• Represents less than 0.5 % of all gastrointestinal malignancies.
● Presentation of a Case (27-year-old guy)
➣Symptoms include tingling and numbness in the inguinal area and proximal thigh for two months.
One week of cramping discomfort in the right bottom quadrant that radiates to the thigh and inguinal area.
Lack of appetite, trouble walking, and a 10-kg weight drop in just five months.
➣No bleeding, nausea, vomiting, fever, bowel disruption, or family history of cancer.
➣Half a pack a day for five years.
➣Physical examination: proximal thigh/inguinal discomfort plus RLQ soreness.
➣Imaging shows a 6x4 cm necrotic retrocecal appendicular tumour that is encasing the femoral nerve and infiltrating the psoas muscle.
Colonoscopy: non-diagnostic; extra luminal bulk effect.
➣Surgery: En bloc mass resection and right hemicolectomy. Because it was difficult to resect fully, the frozen section margins were good.
➣Histology: Approximately 7 cm tumour of moderately differentiated adenocarcinoma with osseous metaplasia and no nodal metastases.
➣Postoperative course: uneventful, discharged, adjuvant chemotherapy + HIPEC subsequently administered.
● Conversation & Important Takeaways
➣Case rarity:
•Young males (27 years old) with adenocarcinoma are uncommon (average ages 62–65 years old).
•The first documented instance of psoas muscle invasion by appendiceal cancer.
➣Diagnosis challenges:
•Imaging suggested sarcoma/neurogenic tumor.
•Biopsies and colonoscopies are non-diagnostic; surgery is required to confirm the diagnosis.
➣Management:
•The mainstay is surgical resection.
•There are no general surgical guidelines.
•For early stages (less than 1 cm, mucosa-restricted, low grade), appendectomy could be enough.
•For advanced adenocarcinomas (T2 or above, high-grade, or >2 cm), a right hemicolectomy is recommended.
•HIPEC combined with cytoreductive surgery for peritoneal dissemination.
•chemotherapy used systemically for distant metastases.
➣Prognostic factors:
•Nodal status and invasion depth are crucial.
•Nodal involvement is more common in non-mucinous tumours (20–67%).
•Liver and lungs are less common metastatic sites than the peritoneum.
•For aggressive tumours, full excision improves 5-year survival.
•Nodal involvement is more common in non-mucinous tumours (20–67%).
•Liver and lungs are less common metastatic sites than the peritoneum.
•For aggressive tumours, full excision improves 5-year survival.
➣Guidelines & Staging:
•AJCC TNM staging is applicable.
•For precise staging, at least 12 lymph nodes are required.
•Adjuvant chemotherapy is frequently needed for Stage III/IV and Stage II (high-risk).
➣Trends in epidemiology (NCDB 2004–2017):
•Appendiceal tumours are more common than right-sided colon cancers.
•Patients under 40 years old have increased the most.
•Particularly, carcinoid tumours are increasing (from 24% to 45% in the group under 40 years old).
Protocol
●Management of Adenocarcinoma in the Appendix
1. Medical & Surgical Management
The final course of treatment is a right hemicolectomy with en bloc resection, which was carried out in this instance.
Stage, depth of invasion, and lymph node status all affect extent.
2. Adjuvant Therapy:
Chemotherapy: For stage II high-risk, stage III/IV disease. (For instance, FOLFOX, CAPOX).
For peritoneal dissemination or high-risk residual illness, hyperthermic intraperitoneal chemotherapy, or HIPEC, is used.
3. Systemic chemotherapy: For illness that has spread, especially to the liver, lungs, nodules, or peritoneum.
4. Follow-up care includes imaging, tumour markers (CEA, CA19-9), and routine clinical evaluation.
To exclude out synchronous lesions, a colonoscopy is performed.
multidisciplinary approach that includes a nurse, radiologist, surgeon, and oncologist.
● Nursing Management
➣Pain (referred thigh and abdominal pain as a result of psoas/femoral nerve tumour invasion)
•Evaluation: Track pain levels and look for radiation to the thigh and inguinal area.
•Interventions: Give prescription NSAIDs and opioids as analgesics.
Non-pharmacological pain management methods include posture and relaxation strategies.
Teach them how to change their activities to lessen the burden on the surgical site.
A lower pain score and the patient's ability to move freely are the objectives.
➣ Nutritional Deficit (10 kg of weight loss in 5 months, poor appetite)
•Assessment: Track lab results (albumin), BMI, and calorie and protein consumption.
•Interventions: Serve modest, frequent meals that are heavy in calories and protein.
Work together to create a nutritious plan with a dietician.
Promote the use of nutritional supplements taken orally.
When recovering from surgery, make sure you get the recommended parenteral or enteral nourishment if you are unable to take it orally.
Improved nutritional indicators and weight stabilisation are the objectives.
➣Risk of Modified Bowel Function (as a result of anastomosis and hemicolectomy)
• Evaluation: Keep an eye on stool frequency, consistency, and bowel noises.
• Interventions include a gradual shift in diet from liquids to soft foods to normal.
Inform people of potential changes in bowel habits, such as constipation or diarrhoea.
Promote the consumption of fibre and water.
As directed, provide stool softeners or antidiarrheals.
• Goal: The patient adjusts to dietary modifications and maintains normal bowel function.
➣ Reduced Mobility (caused by post-surgery weariness, psoas invasion, or discomfort)
• Examine muscular strength, mobility, and gait.
• Interventions: Start by offering support with walking.
To avoid problems (DVT, pneumonia), promote early mobilisation after surgery.
For strength and mobility workouts, see a physiotherapist.
The objective is to gradually restore mobility and independence in ADLs.
● Common Problems in Case Management:
•Patients frequently struggle to navigate complex healthcare systems, which can result in underutilisation, overutilization, or disorganised treatment and services.
•Because of fragmented treatment, managing chronic conditions can lead to high rates of ER visits, recurrent hospital stays, and higher healthcare expenses.
•Anxiety, despair, and other psychological problems are common, particularly following major surgery like bariatric treatments.
•Persistent problems include patients' poor self-management abilities and low adherence to recommended therapy programs.
•Holistic health results may be hampered by obstacles to communication between care providers and access to multidisciplinary support.
●Management Strategies:
•Identification and Evaluation: of In order to ascertain a patient's eligibility for case management, they are methodically identified and thoroughly evaluated, taking into account their social support networks, healthcare requirements, and available resources. Building rapport is essential throughout this stage to guarantee information accuracy and confidence.
• Care Planning and Coordination: A thorough care plan that outlines treatment objectives, necessary services and supports, and desired results is developed. In addition to scheduling appointments and facilitating interdisciplinary communication for comprehensive plans, case managers assist patients in overcoming obstacles to receiving care.
• Implementation: The care plan is followed out by helping patients connect with the right professionals (such as social workers, psychologists, and doctors), assisting them through each stage, and making sure everything goes according to plan.
● Interventions in Nursing
➣ Multidisciplinary Teamwork: Nurses facilitate communication between members of the healthcare team, guaranteeing the exchange of information and the planning of coordinated treatment.
➣ Support for Patient Self-Management: Nurses monitor adherence to care plans, provide self-management education, and employ motivational interviews or reminders as necessary.
➣ Psychological and Behavioural Support: Nursing interventions for post-surgery management (e.g., bariatric patients) include counselling, anxiety/depression evaluation, and coordination with psychologists.
➣ Health Education: Using written materials and individualised advice, nurses instruct patients about illness processes, lifestyle changes, and recovery procedures.
➣ Measurement of Outcomes: In order to modify the treatment plan, nurses routinely gather information on functional status, quality of life, contentment, and self-reported health. They then communicate this information to the case manager.
Notes
For more information visit 10.1016/j.ijscr.2023.108001
