Journal of Cytology
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Is cytology of purulent aspirates imperative?: An instance of a periappendicular abscess


1 Department of Radiodiagnosis, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Department of Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of General Surgery, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India

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Date of Submission27-Jun-2019
Date of Decision02-Oct-2019
Date of Acceptance05-Feb-2020
Date of Web Publication02-Apr-2020
 


How to cite this URL:
Santosh Rai P V, Sreeram S, Goel AM, Bhat A. Is cytology of purulent aspirates imperative?: An instance of a periappendicular abscess. J Cytol [Epub ahead of print] [cited 2020 Aug 8]. Available from: http://www.jcytol.org/preprintarticle.asp?id=281793




Dear Sir,

A 47-year-old man presented with complaints of right lower abdominal pain for a month. The pain was of moderate-to-severe intensity, nonradiating, and partially relieved on medication. Examination revealed a palpable mass of 6 × 4 cm size with well-defined margins, in a soft, nondistended abdomen with mild tenderness. Contrast-enhanced computed tomography (CECT) suggested appendicular abscess. Image-guided aspiration was done and thick yellow aspirate was sent for microbiological culture, reported sterile. The patient requested discharge and refused to undergo any further evaluation. He was explained about the impact of his decision and strictly advised to admit himself immediately in case of worsening complaints. Antibiotics and analgesics were advised.

However, he was readmitted within a fortnight with persisting complaints. Repeat CT showed an ill-defined irregular heterogeneously enhancing hypodensity with more hypodense central areas in the ileocaecal region measuring about 6.9 × 4.2 × 5.5 cm; appendix was not visualized separately [Figure 1]. Few enhancing ovoid lymph nodes were noted in the pericaecal region, largest about 11 mm. Aspiration was repeated and the sample sent for culture; reported sterile again. The aspirate had also been sent for cytological examination. It showed abundant mucin along with neutrophils and necrosis in the background [Figure 2]a and [Figure 2]b. In addition, clusters of pleomorphic tumor cells [Figure 2]c were discerned amidst the necrosis. The aspirate was satisfactory for evaluation and cytological diagnosis was given as mucin secreting adenocarcinoma. Colonoscopy done subsequently revealed only cecal erythema. A terminal ileal biopsy was negative for any malignancy [Figure 2]d. The patient underwent right hemicolectomy with ileotransverse anastomosis at a specialized oncology center as part of the standard treatment protocol. The diagnosis on histopathology of the specimen also was mucinous appendiceal adenocarcinoma, in concordance with the cytological diagnosis. The patient received chemotherapy and is well after a 6-months follow-up.
Figure 1: Serial contrast-enhanced computed tomography (CECT) scans. First scan axial images in arterial (a) and venous (b) phases shows a peripherally enhancing hypodense area in the right iliac fossa adjacent to the ileocaecal region (white arrows). Review CT scan axial images, a fortnight later in arterial (c) and venous (d) phases shows persistent peripherally enhancing hypodense area in the right iliac fossa (white arrows). Review CT scan images, 8 weeks later shows persistent peripherally enhancing hypodense area in the right iliac fossa, adjacent to the ileocaecal region in the axial (e) and coronal (f) contrast CT images (white arrows)

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Figure 2: Microscopic examination images: (a) Abundant mucin in the background (Pap stain, 4×) (b) Numerous polymorphs and necrotic debris (Pap stain, 10×) (c) Pleomorphic tumor cells in clusters (May-Grunwald-Giemsa stain, 40×) (d) Terminal ileum biopsy showing nonspecific mild lymphocytic inflammation and Peyer's patches (hematoxylin-eosin stain, 4×)

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Periappendiceal abscess due to underlying malignancy may present as recurrent or persistent collections.[1] Clinical and imaging findings for appendiceal carcinoma are indistinguishable from acute inflammatory processes.[2] Drainage unmasks the underlying lesion. Fusari et al. described acute appendicitis on a preoperative CT scan with a loculated fluid collection and lymphadenopathy adjacent to the appendix. Signet-ring cell carcinoma revealed in histological analysis concluded that preoperative diagnosis of carcinoma is imperative. Localized ascites, intramural air, and focal cecal apical thickening on imaging were considered to be in favor of an inflammatory lesion whereas the presence of lymph nodes favored malignancy.[2] Fiume et al. described a caecal adenocarcinoma that presented as an appendiceal abscess.[3]

Imaging alone is inadequate for the follow-up of complicated appendicitis. Patients older than 40 years should undergo an early colonoscopy to exclude the possibility of coexistent colorectal cancer.[4] This case is an example of an appendiceal malignancy that presented as appendiceal abscess and was diagnosed as adenocarcinoma on cytology.

Preoperative diagnosis of appendiceal carcinoma is crucial for surgical decision-making as a right hemicolectomy is recommended instead of appendicectomy in advanced malignancy. The cytological preoperative diagnosis of adenocarcinoma in the aspirate played a pivotal role in the treatment plan in this case. The presence of pericecal lymph nodes on imaging also corroborated malignancy.

The usual approach to a patient presenting with appendicular abscess with mass formation without any features suggestive of peritonitis and sepsis is oral antibiotics, monitoring of vitals and follow up of the size of the mass for 6-8 weeks. In patients who do not show a decrease in size of the mass, an aspiration biopsy should be the next line of investigation, especially in the elderly. Purulent aspirates are usually sent for microbiological examination and leukocyte count estimation. This case underlines the pivotal role of cytological examination of aspirates obtained from internal organs like appendix. We recommend that all non-resolving/recurrent periappendicular abscesses must undergo a cytological examination to unmask any underlying malignancy

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Leonards LM, Pahwa A, Patel MK, Petersen J, Nguyen MJ, Jude CM. Neoplasms of the appendix: Pictorial review with clinical and pathologic correlation. Radiographics 2017;37:1059-83.  Back to cited text no. 1
    
2.
Fusari M, Sorrentino N, Bottazzi EC, Vecchio WD, Cozzolino I, Maurea S, et al. Primary signet ring cell carcinoma of the appendix mimicking acute appendicitis. Acta Radiol Short Rep 2012;1:1-3.  Back to cited text no. 2
    
3.
Fiume I, Napolitano V, Del Genio G, Allaria A, Del Genio A. Cecum cancer underlying appendicular abscess. Case report and review of literature. World J Emerg Surg 2006;1:11.  Back to cited text no. 3
    
4.
Shankar S, Ledakis P, El Halabi H, Gushchin V, Sardi A. Neoplasms of the appendix: Current treatment guidelines. Hematol Oncol Clin North Am 2012;26:1261-90.  Back to cited text no. 4
    

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Correspondence Address:
Saraswathy Sreeram,
Department of Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka - 575 001
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JOC.JOC_89_19



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