Appendiceal adenocarcinoma in a patient with chronic ulcerative colitis: what is the appropriate surgical procedure?

Restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) is the surgical therapy of choice for patients with chronic ulcerative colitis (CUC).1 The association between appendiceal cancer and CUC with long-standing disease and pancolitis was reported.2–5 However, therewere no established surgical intervention strategies for these patients. We report a case of CUC associated with an appendiceal adenocarcinoma undergoing a limited right sided hemicolectomy. A 68 year old male with a 35-year history of ulcerative colitis (UC) in remission on 5-aminosalicylic acid (5-ASA) developed right lower quadrant abdominal pain. An abdominal/pelvic CT scan noted a distended and inflamed appendix consistent with acute appendicitis, and the distal colon wall thickening. Recent colonoscopy showed no colonic dysplasia. He underwent laparoscopic appendectomy with caput cecectomy and preservation of ileocecal valve. Pathology revealed a T2 adenocarcinoma of the appendix that extended to the cecectomy staple line. The patient refused the preferred proctocolectomy with J-pouch reconstruction and underwent a right sided hemicolectomy. At 4-year follow up, he is free of malignancy, and in remission on oral 5-ASA with only one mild flare which was controlled after a course of corticosteroid enemas and 5-ASA. RP/IPAA has become the standard surgical intervention of chronic ulcerative colitis since 1978. However, the incidence of complications remains relatively high in contrast to the low mortality rate.1 In 1994, Odze et al.3 reported the first case of appendix adenocarcinoma in a patient with a 20-year history of CUC with pancolitis but no dysplasia. The patient underwent a total colectomy, appendectomy and ileostomy. Zannoni et al.4 in 1997 described a female patient with a 20-year history of CUC with slightly active pancolitis but no dysplasia and with a cystadenocarcinoma of the appendix who underwent a right hemicolectomy. Appendix adenocarcinoma associated with CUC of a 60-year-old with a 5-year history of left colon CUC without dysplasia who underwent an elective total proctocolectomy with ileostomy after the failure of medical treatment was published by Villanueva