Gastrointestinal Case Clinical 30 year old female Acute onset - - PowerPoint PPT Presentation

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Jul 27, 2023 129 likes •420 views

Gastrointestinal Case Clinical 30 year old female Acute onset right lower quadrant pain emergency room CT scan - probable appendicitis OR - appendectomy Operative findings: 2 cm appendiceal mass with tumor adherent to

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Gastrointestinal Case

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Clinical

30 year old female
Acute onset right lower quadrant pain – emergency room
CT scan - probable appendicitis
OR - appendectomy
Operative findings:
2 cm appendiceal mass with tumor adherent to the terminal ileum and its

mesentery

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Pathology

“Appendix”
2.9 x 2.2 x 1.8 cm tan-pink to red soft tissue with a 1.9 cm linear staple line
External surface: granular with focal areas of fibrous adhesions
Gross evaluation:
Lumen ranging from 0.2 cm to 0.7 cm
Wall thickness 0.2 to 0.9 cm with a dense white fibrous cut surface
But….“No lesions were identified”
Entirely submitted

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What is your diagnosis?

A. Low-grade appendiceal mucinous neoplasm (LAMN)
B. LAMN with endometriosis
C. Invasive mucinous adenocarcinoma
D. Endometriosis

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PAX-8 CDX2

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CDX2 ER

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ER

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ER

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Diagnosis

MDACC: Endometriosis with intestinal metaplasia

(referring diagnosis: LAMN and endometriosis)

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Discussion

Endometriosis not an uncommon finding in the gastrointestinal tract
Form polypoid or mass lesions or cause perforation occasionally with

hemoperitoneum

Mimic metastatic adenocarcinoma in abdominal lesions in patients with

known malignancy undergoing diagnostic procedures

Appendix – associated with acute appendicitis, perforation, mucoceles

Uwaezuoke Ethiop J Health Sci 23 3013 Clement Adv Anat Pathol 14 2007 Hapke Human Pathol 8 1977 Curbelo-Peña J Surg Case Reports 8 2015

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Unusual Forms of Endometriosis

Stroma only
Decidualized forms
Metaplastic
Colonization of normal mucosa
Dysplasia/neoplasia arising in endometriosis

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6 patients, 39-71 years
All with masses (3 appendiceal, 2 cecal, 1 ”pelvic” (adnexal mass adherent to

appendix with mucin pools)

3 appendectomy +/- cecectomy; 2 right hemicolectomy, 1 appendectomy with

hysterectomy and bilateral salpingo-ophorectomy

5 referring diagnosis was mucinous appendiceal neoplasm (mucinous

cystadenoma, LAMN, or mucinous adenocarcinoma)

All had mucin pools in the mesoappendix or serosa
Appendix completely submitted in all
Follow-up 1-7 years (mean 3.6); no PMP

Misdraji Am J Surg Pathol 38 2014

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Endometriosis Mimicking LAMN

All patients: endometriosis with endometrial-type, “goblet-like”, and intestinal-type glands with some transitions

Misdraji Am J Surg Pathol 38 2014

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“Metaplasia” in Endometriosis

Ciliated
Eosinophilic
Hobnail
Squamous
Mucinous
Endocervical type (usual)
Intestinal type – “goblet-like” mucinous cells, goblet cells, Paneth cells (rare)
Metaplasia
Colonization

Clement Adv Anat Pathol 14 2007 Kim Pathol 45 2013 Vyas Pathol Res Pract 213 2017

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Mai Histopathol 35 1999 Mitchell Diagn Pathol 9 2014 Libbrecht Virchows Arch 461 2012

LAMN COLONIZED BY ENDOMETRIOSIS

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Conclusions

Most mucinous lesions of the appendix need extensive/complete sampling

– distinguish benign lesions and neoplasms

Endometriosis is not uncommon in the gastrointestinal tract, can
ccasionally have intestinal differentiation, can colonize mucosa, and

become neoplastic

Multiple lesions (benign and neoplastic, multiple neoplastic) may co-exist