1. The “Hand” of Appendix Cancer Presented to American Association of Primary Care Endoscopy Brian W. Meeker, D.O. Vinton, Ia. 53 y/o male presents for “screening” colonoscopy No GI symptoms No family history

2. American Association of Primary Care Endoscopy Colonoscopy was completed to the terminal ileum Hypertrophic mucosa was noted at the appendiceal orifice in finger-like projections resembling a small hand Biopsies revealed adenomatous polyp with low grade dysplasia Lesion was felt to be endoscopically unresectable so a surgical referral was made

3. “hand” emerging from appendix

4. Biopsy of “finger” of The “hand”

5. Primary malignant neoplasms of the appendix A population-based study from the surveillance, epidemiology and end-results program, 1973-1998 Cancer 2002;94:3307 Appendix Cancer An estimated 1% (0.9%–1.4%) of all appendectomy specimens contain a neoplasm. The majority of appendiceal tumors are carcinoids, while the remaining 10% to 20% are mucinous cyst adenocarcinoma, adenocarcinoma, lymphosarcoma, paraganglioma, and granular-cell tumors. As expected, most present as acute appendicitis, and in some 40% of cases, the diagnosis is made after appendectomy

6. Surgical Findings Original plan was to do a laparoscopic “generous” appendectomy. Adhesions in the RLQ required open laparotomy Appendix was 9 inches long and obviously involved with tumor

7. Pathological Findings Moderately differentiated adenocarcinoma arising from a tubulovillous adenoma filling the appendix Right hemicolectomy performed The tumor invaded through the muscularis propria into the periappendiceal soft tissues It was directly invasive into the wall of the adherent terminal ileum 9 regional nodes and all surgical margins negative

8. Post-surgical follow-up 10 cycles of adjuvant chemotherapy with Folfox. 1 year follow-up colonoscopy negative