PMC7298331_01
Initial (Pre- IP therapy) radiological, laparoscopic and pathological picture.. a. MRI image with mucus filled appendix compressing the sigmoid lumen (arrow).. b. Omental caking.. c. Composite intra-operative picture showing omental mass and mucinous deposits all over abdomen.. d. Gross specimen picture of perforated appendix.
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On evaluation by primary physician alarge appendicular mass compressing the sigmoid and the upper third of the rectum was found(Fig. 1.a). There was omental caking and multiple areas of loculated mucinous ascites suggesting Pseudomyxoma Peritonei (PMP) probably arising from appendicular pathology (Fig. 1.b). Exploratory Laparoscopy was performed and following findings (Fig. 1.c) were noted - a. 2000 mL of ascites b. 15 x 20 cm Omental cake compressing on small bowel c. large perforated appendicular mass occupying the right iliac fossa and pelvis c. Involvement of the cecum by tumor and tumor perforation precluded the performance of simple appendectomy (Fig. 1d). Gross pathological examination revealed perforation of tip of appendix (Fig. 1.d) and microscopic examination showed clusters of tumor cells in background of mucin with increased cellularity and high atypia.
Post IP chemotherapy.. a. MRI imaging showing resolution of omental mass.. b. No tumor deposits in peritoneum and small bowel.. c. Normal small bowel mesentery.
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There was complete clinical resolution of ascites and imaging resolution of omental mass (Fig. 2a). In March 2020, she underwent a laparotomy and the following operative findings were noted (Fig. 2b& c) - a.
Gross pathological pictures.. a. Omentum devoid of tumor and mucinous deposits, b. Pelvic Peritonectomy with en-bloc hysterectomy showing mucinous deposits, c. Completion right colectomy devoid of tumor and mucinous deposits.
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Intense staining with Alcian blue indicating mucin deposition is shown in the picture (Fig. 3, Fig. 4).
Histological picture.. a. Appendix with high grade tumor cells after initial appendectomy. b. Microscopic examination (10x) of Omentum - without tumor cells (after CCRS) c. Acellular mucin in deposits (10x) with intense Alcian blue staining (after CCRS).
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MIB-1 index was 22 % and a diagnosis of high grade mucinous appendicular neoplasm was made (Fig. 4.a).