Appendiceal Adenocarcinoma Masquerading as an Ovarian Mass: A Case Report

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Introduction: Primary appendiceal carcinomas are rare neoplasms of the gastrointestinal tract that have seen an increase in diagnosis over the past 10 years. The most common presentation is acute appendicitis or abdominal distension, although occasionally they may present as an adnexal mass due to their anatomical location. We present a case report of the diagnosis of an appendiceal adenocarcinoma found on colonoscopy that presented as a gynecological neoplasm. Case: A 77 year old female was referred to the office from gynecological oncology for evaluation an 8cm x 7cm right pelvic mass seen on CT scan. The CT was ordered due to complaints of several months of weakness, 30lb weight loss, and intermittent localized right lower quadrant abdominal pain. The mass was extensive and was causing deviation of her bladder and severe right-sided hydroureter. A colonoscopy done about 10 years ago was normal. History was significant for right-sided breast cancer status post right radical mastectomy, total abdominal hysterectomy, and 25 pack year history of smoking. Her family history was positive for esophageal cancer in her mother, but denied breast, ovarian, gastric, and colon cancers. Her vitals were within normal limits. Her abdominal exam was significant for tenderness to palpation in the right lower quadrant with fullness. On pelvic exam, there was a large, non-tender, fixed right-sided adnexal mass. Lab studies revealed CEA = 416.2; CA-125 = 11; and CA 19-9 = 1. A colonoscopy was performed prior to her planned surgical resection. Initial observation was unremarkable, including examination of the distal terminal ileum. The markedly elevated CEA level and location of the lesion warranted more aggressive investigation, and the appendiceal orifice was gently probed with a closed cold forceps. This revealed a large friable, appendiceal mass which was biopsied. The biospies revealed adenocarcinoma, with markers suggesting colon over ovarian etiology. An attempt was made to resect the tumor, but due to the extent of the disease and co-morbidities, this was not done and a palliative bypass was performed. Discussion: In this case, based on the right lower quadrant/pelvic mass, ovarian and colonic tumors were considered. On colonoscopy, care was given to search for tumors, particularly inside the appendiceal orifice. With a known elevated CEA in a patient with a right lower quadrant mass, a diagnosis of appendiceal adenocarcinoma was able to be made preoperatively on colonoscopy. Diagnosis of appendiceal adenocarcinoma is rarely made on colonoscopy and is often found incidentally on appendectomy.