Locally advanced carcinoma of the cecum presenting as a right inguinal hernia: a case report and review of the literature
© Meniconi et al.; licensee BioMed Central Ltd. 2013
Received: 3 April 2013
Accepted: 11 July 2013
Published: 14 August 2013
An inguinal hernia is a common surgical disease in elderly patients, but an association with intra-abdominal malignancies is rare.
We report a case of a 78-year-old Caucasian woman presenting with a right inguinal mass suspected to be an irreducible hernia. A computed tomography scan showed the presence of the cecum in her inguinal canal, with an irregular thickening of the cecal wall suggesting a neoplasm within the inguinal hernia. A colonoscopy was not completed owing to the huge involvement of the cecum into the hernia sac. A laparotomy was performed, at which time the cecum was herniated through her right inguinal canal and the cecal tumor had infiltrated her abdominal wall and femoral artery. A right inguinal incision was necessary for good vascular control and to carry out an en bloc resection of the tumor with the inguinal wall. A right colectomy was performed and the inguinal wall repaired. The postoperative course was uneventful and our patient received adjuvant radiochemotherapy.
We describe a rare case of a locally advanced cecal tumor presenting as a right inguinal hernia. Both diagnosis and surgical treatment in elderly patients represent a challenge for the surgeon in cases of aggressive tumors as reported in this paper.
KeywordsCecum carcinoma Inguinal hernia Intrasaccular tumors Right colectomy
Intra-abdominal malignancies presenting as inguinal hernias are rare and have been classified as saccular or intrasaccular tumors based on their relationship with the inguinal sac . Saccular tumors are tumors of the peritoneal surface of the sac that can be primary (such as mesothelioma) or secondary (for example, peritoneal carcinomatosis). Intrasaccular tumors are primary tumors of abdominal organs (for example, colonic cancer) contained within the inguinal sac. Intrasaccular tumors are rarer and the most commonly reported site is the left inguinal hernia containing a sigmoid cancer [2, 3]. The treatment of this rare condition is not standardized and the correct surgical strategy may represent a challenge for the surgeon, especially in cases of advanced tumors. We report a rare case of an intrasaccular tumor due to an aggressive cecal cancer presenting within a right inguinal hernia in an elderly woman.
Inguinal hernias and colonic malignancies are frequent diseases in the elderly population, but their association is relatively rare. Two previous literature reviews [3, 4] revealed that the sigmoid colon was involved in most cases and all patients were male. Out of 28 patients reported, only four had a cecal tumor, presenting in all cases as a right long-standing inguinal hernia that become painful or incarcerated. In our case, a female patient recently noticed a mass in her right groin, without any symptoms or signs of obstruction; she had no history of inguinal hernia or primary malignancy, only a general asthenia. A correct diagnosis in these cases may be difficult, especially in elderly patients, and computed tomography should always be performed to confirm the suspicion of an underlying malignancy. A colonoscopy may present with negative results as in our case owing to the involvement of the colon into the hernia.
The best surgical treatment is not clear and depends on the patient’s characteristics (age, general condition), local findings (infiltration of organs or vessels) and the surgeon’s experience . In the majority of the reported cases, a laparotomic resection of the colon followed a traditional inguinal repair through two separate incisions [2, 4]. In cases of perforation or occlusion, most authors performed a colonic resection through the inguinal incision to prevent the peritoneal cavity from contamination and completed the operation via a midline laparotomy [3, 5]. Other authors described a transverse left iliac fossa incision for a sigmoid cancer incarcerated into a left inguinal hernia . More recently, a laparoscopic approach has been described in one case : the tumor was reduced and resected by laparoscopy, while the inguinal defect was repaired by a traditional approach. Despite our experience with laparoscopic colorectal surgery, and considering the advanced local status of the tumor, we decided to perform a midline laparotomy and found an irreducible cecal tumor within the inguinal canal. A secondary inguinal incision was necessary to take control of vascular structures, performing an en bloc resection of the tumor with the inguinal wall. Marking the operative field with metallic clips for postoperative radiotherapy could be a good solution in cases of aggressive tumors suitable for adjuvant radiotherapy after microscopically incomplete resections. As to neoadjuvant treatment, we decided to address the patient directly to surgery due to the risk of obstruction and tumor progression during preoperative radiochemotherapy, but it might otherwise be considered, especially when positive margins are expected after resection.
Inguinal hernias containing a colonic malignancy are not frequent, but should be evaluated in elderly patients presenting with an irreducible mass in the inguinal region associated with gastrointestinal symptoms or non-specific features such as asthenia or anemia. The surgical treatment can be achieved either by an open or laparoscopic approach but should always respect the oncological standards of a radical resection, especially when adjacent structures are involved.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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