Grand Rounds Vol 8 pages 35–37

Speciality: Specialties General Surgery; Colorectal Surgery

Article Type: Case Report

DOI: 10.1102/1470-5206.2008.0011

� 2008 e-MED Ltd

Colonic cancer invading appendicectomy

incision: a case report and literature review

I. Uchendu, A. Hotouras, S. Jonalagadda, K. Osman, A. Mandal and D. Mathur

Department of Surgery, Grantham and District Hospital, United Lincolnshire

Hospitals NHS Trust, UK

Corresponding address: Dr Alex Hotouras, Department of General Surgery,

Grantham and District Hospital, Grantham, Lincs, UK.

E-mail: alex007@doctors.org.uk

Date accepted for publication 18 August 2008

Abstract

We report the case of a 62-year-old man who presented with puckering and tethering of his

appendicectomy scar; he was found to have an underlying caecal carcinoma. We review the

literature regarding this uncommon presentation of caecal cancer.

Keywords

Caecal carcinoma; appendicectomy; cutaneous metastases.

Case report

A 62-year-old gentleman, who underwent an appendicectomy 50 years previously, presented with

puckering and tethering of his appendicectomy scar (Fig. 1). On examination there was a palpable

mass in the right iliac fossa associated with puckering of the appendicectomy scar and the skin

was tethered to the underlying mass. He was otherwise fit and well and not on any medication.

The examination findings were confirmed on computed tomography (CT) imaging which showed

the presence of a large caecal mass invading the intrabdominal wall, subcutaneous fat and

appendicectomy incision (Fig. 2).

At laparotomy, via a standard midline incision, the tumour appeared to be adherent to the

appendicectomy scar so he underwent a right hemicolectomy with en block resection of the

appendicectomy scar and an ellipse of healthy surrounding skin. His post-operative recovery was

uneventful and he was discharged home on the 7th post-operative day. Histology confirmed

adenocarcinoma Dukes C1 with extramural vascular invasion. Resection was complete at all

margins. The tumour had invaded the bowel wall and into the fibrous tissue of the anterior

abdominal wall without any invasion of the striated muscle of the skin. He had post-operative

chemotherapy which he tolerated relatively well and at almost 4 years post-operatively, there is

no evidence of recurrence.

Discussion

Colonic cancer may be completely asymptomatic. The location of the tumour often dictates

the symptoms. Right-sided colon cancers tend to be larger and more likely to bleed, whereas

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Fig. 1. Tethering of appendicectomy scar.

Fig. 2. CT imaging showing caecal mass.

36 I. Uchendu et al.

left-sided tumours tend to be smaller and more likely to be obstructing[1]. Uncommon

presentations of colorectal cancer include acute appendicitis[2], Fournier’s gangrene of the

anterior abdominal wall[3] and vaginal bleeding in a post-menopausal woman[4]. In our case report,

the presenting complaint was tethering of a pre-existing appendicectomy scar which, as far as we

know, has not been reported in the literature previously.

Colonic carcinoma most often metastasizes to the liver and lung with cutaneous metastases

occurring in less than 4% of all cases[5], the most common site being the abdomen, especially

the site of a previous surgical incision[6]. Cutaneous metastases in surgical scars usually occur in

incisions used for tumour resection[7]. However, rarely metastasis can occur in pre-existing scars

such as a cholecystectomy scar[8] or a prostatectomy scar[9].

The mechanism of cutaneous metastasis is not fully understood and remains a matter of

speculation although several theories have been proposed including direct extension, hemato-

genous or lymphatic spread, spread along the ligaments of embryonic origin and implantation

of tumour cells[8]. In our case, the involvement of the scar is presumably due to direct extension

of the tumour based on previous adhesions.

Teaching point

The diagnosis of colorectal carcinoma should be considered whenever a patient presents with

puckering and tethering of an abdominal surgical scar even in the absence of a palpable mass.

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