Appendix cancer differential diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]
Overview
Appendix cancer must be differentiated from benign appendix lesions (mucocele, acute appendicitis), colorectal cancers, adenexal masses (ovarian tumors), and carcinoid tumors of the other organs.
Differentiating appendix cancer from other Diseases
- Appendix cancer must be differentiated from benign appendix lesions (mucocele, acute appendicitis), colorectal cancers, adenexal masses (ovarian tumors), and carcinoid tumors of the other organs.
- As appendix cancer manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype.
- Carcinoid tumors must be differentiated from other diseases that causecarcinoid syndrome, such as palpitation, facial flushing, diarrhea, .
- In contrast, adenocarcinomas and cystadenocarcinomas must be differentiated from other diseases that cause acute appendicitis or present with pseudomyxoma peritonei, such as colorectal cancers, appendix mucoceles.
Diseases | Clinical manifestations | Para-clinical findings | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Symptoms | Physical examination | ||||||||||||||
Lab Findings | Imaging | Histo-
pathology | |||||||||||||
Abdo- minal pain |
Change in girdle size | Bowel
freq- uency |
Other
symptoms |
Abdo- minal mass |
Abdo- minal tender- ness |
Other
physical exami- nation findings |
5-HIAA and/or CgA |
Other lab findings | CT scan | MRI | Utra-
sounography |
Other
diagnostic studies and imaging modalities | |||
Appendix cancer | Adeno-
carcinoma1 |
+/- | -/+ | <math>\downarrow</math> |
|
- | - |
|
- |
|
|
|
|
Positron emission tomography (PET) |
Gross pathology:
Microscopic
IHC might
|
Carcinoid
tumor2 |
+/- | - | <math>\uparrow</math> |
|
- | - |
|
+ |
Ki67: |
|
Gross pathology:
Microscopic
IHC
| ||||
Goblet
cell carcinoid |
+ | +/- | <math>\uparrow</math> |
|
+/- | + |
|
+/- |
|
Unfortunately, compared to the other carcinoid tumors of appendix, GCC is more aggressive and patients with GCC generally present at higher stages. Hence, in addition to the above mentioned general findings for appendix cancers, imaging studies should look for evidences of peritoneal involvement, bone metastasis, lymphadenopathy, and metastatic lesions in ovaries and/or prostate. |
Gross
Microscopic
| ||||
Diseases | Abdo- minal pain |
Change in girdle size | Bowel
freq- uency |
Other
symptoms |
Abdo- minal mass |
Abdo- minal tender- ness |
Other
physical exami- nation findings |
5-HIAA and/or CgA |
Other lab findings | CT scan | MRI | Utra-
sounography |
Other
diagnostic studies and imaging modalities |
Histo-
pathology | |
Appendix Mucocele | Mucosal
hyperlasia |
- | - | - |
|
- | +/- | N/A | - | N/A |
|
Rounded right iliac fossa mass
|
|
N/A | Similar to hyperplastic colon polyp |
Simple
or retention cyst |
- | - | - | - | +/- | - | - | N/A | Degenerative epithelial changes because of obstruction | ||||||
Mucinous cystadenomas | +/- | +/- | <math>\uparrow</math><math>\downarrow</math> |
|
+/- | +/- | If develop
pseudo-
|
- |
|
| |||||
Mucinous cystadeno-
carcinomas |
+/- | +/- | <math>\uparrow</math><math>\downarrow</math> | +/- | +/- | - | - |
|
| ||||||
Diseases | Abdo- minal pain |
Change in girdle size | Bowel freq- uency |
Other
symptoms |
Abdo- minal mass |
Abdo- minal tender- ness |
Other
physical |
5-HIAA and/or CgA |
Other lab findings | CT scan | MRI | Utra- sounography |
Other diagnostic studies and imaging modalities |
Histo-
pathology | |
Ovarian cancer | +/- | +/- | +/-<math>\downarrow</math> |
|
+ | +/- |
|
- |
|
|
|
|
N/A | Depends on the tumor type. You may find the details here. | |
Colorectal cancer | +/- | +/- | <math>\uparrow</math><math>\downarrow</math> |
|
+ | +/- | Colonoscopy
Adeno- carcinoma
Carcinoids
|
-/+(Carcinoid tumors) |
|
Generally not recommended: may evaluate liver metastasis or presence of fluid in abdominal cavity, but it is neither sensitive nor specific. |
PET scan, Endoscopy, Colonoscopy, Barium enema |
| |||
Pseudomyxoma | + | + | <math>\uparrow</math><math>\downarrow</math> | Bloating | - | + | Ascites
Shifting dullness |
- |
|
|
Charact- |
|
18F-FDG PET scan |
||
Carcinoid syndrome | -/+ | - | <math>\uparrow</math> | Flushing
Palpitation Dyspnea |
- | - |
|
+ | Depends on the tumor type:
|
Depends on the primary tumor location and type |
|
| |||
Appendicitis 3 | PU, RLQ |
- | <math>\uparrow</math><math>\downarrow</math> | Nausea & vomiting, decreased appetite |
+/- | + |
|
- |
|
|
Increased fluid signal on T2 weighted sequence |
Evidences of inflammation
|
Tc-99m labeled anti- CD15 antibodies |
Evidences of inflammation | |
Diseases | Abdo- minal pain |
Change in girdle size | Bowel
frequ- f ency |
Other
symptoms |
Abdo- minal mass |
Abdo- minal tender- ness |
Other
physical exami- nation findings |
5-HIAA and/or CgA |
Other lab findings | CT scan | MRI | Utra-
sounography |
Other
diagnostic studies and imaging modalities |
Histo-
pathology |
1 Adenocarcinomas usually present with appendicitis, barely they might present with Pseudomyxoma peritonei; meanwhile Pseudomyxoma peritonei is more prevalent in perforated mucocele, goblet cell tumor or high stages of adenocarcinoma.
2 Generally appendix carcinoids are asymptomatic, they were only become symptomatic if they metastasize to the liver, or in rare cases make an obstruction and present with appendicitis which is quit uncommon in appendiceal carcinoids compared to appendiceal adenocarcinoma. Any patient with carcinoid syndrome should be evaluated for appendix carcinoids.
3 Every patient with appendicitis should be evaluated for appendix cancer, 0.5 in 100 appendicitis cases are because of appendix cancer.
4 Imaging is not a reliable method to distinguish between neoplastic and nonneoplastic lesions, hence every patient should undergo surgery, appendectomy and histopathologic evaluation of the lesion
*Abbreviations: RLQ: Right Lower Quadrant, AFP: Alpha Fetoprotein, HCG: Human chorionic gonadotropin, LDH: Lactate Dehydrogenase, CEA: Carcinoembryonic antigen, CA 125: Cancer antigen 125, 5-HIAA: Urinary 5-hydroxyindoleacetic acid , CgA: Serum Chromogranin A ,PU: Periumbelical, TR: Tricuspid regurgitation