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342: Adenocarcinoma of the Appendix Adenocarcinoma of the Appendix K atrina craig, cst Once in a while, what is thought to be a routine appendectomy becomes a more critical issue when cancer is discovered in the appendix. This is a rare occurrence as cancer in this area accounts for a small percentage of all intestinal tumors. Since this is a rare type of malignancy, which is generally not caught until it is in advanced stages, treatment options are limited. Finding probable causes or even genetic predispositions has been challenging as there are not enough cases to obtain the kind of data needed to narrow down such issues.6 Anatomy of the A ppendix LEARNING OBJECTIVES he appendix is a small gland, about four inches long, and extends off the cecum of the large intestine. It is ▲ Review the anatomy of the long and thin, resembling a worm, which prompted it appendix Tto be named vermiform appendix. Just as the other organs of the ▲ List the supplies needed to perform gastrointestinal tract, the appendix has four layers of tissue: the an appendectomy innermost being the mucosal layer, then the submucosal layer, followed by the muscle layer and the external sarosal layer. The ▲ Analyze which procedures may be muscle layer of this structure is thin as it is not involved in peri- necessary for various advancing stalsis. The appendix is composed of lymphatic tissue which is stages of cancer contained in the submucosa layer, but is not considered part of ▲ Study the procedure for the the lymphatic system, even though it does contains a lumen. removal of the appendix The function of the appendix is not fully understood, but some believe it contains fluids to help reboot the intestinal tract after ▲ Determine which operations prove its balance has been upset by diarrhea. There is also the theory to have the best overall success that the appendix has a special function in the immune system, rates although removal of this gland does not have an adverse effect on one’s health.9 JUNE 2012 | the surgical technologist | 255 An appendectomy is observed on a laparoscopic monitor Surgeons watch the laparoscopic monitor while performing an appendectomy Anatomy of C ancer “Tumors that occur in the appendix comprise a large group lining of the appendix, or mucosa, are classified as non- of both benign and malignant diseases. Appendix cancer is carcinoid cancer. Because of the mucus produced by these extremely rare, affecting an estimated 600 to 1,000 Ameri- cells, a noncarcinoid tumor may spread into the abdomi- cans each year. Most patients are diagnosed after undergo- nal cavity and, if not treated, eventually may cause bowel ing surgery for acute appendicitis, or when an abdominal obstruction and cachexia.7 While this condition may be mass is seen during a CT scan for an unrelated condition.”7 life-threatening, it is not malignant. The cellular layer of the appendix that is involved in Goblet cell carcinomas are classified as adenocarcinoid the development of the tumor is the determining factor in tumors which are similar to both the carcinoid and adeno- the type of cancer that is diagnosed. In about two-thirds carcinoma tumors occurring in the appendix.7 Adenocarci- of cases diagnosed, carcinoid tumors are found at the dis- noid tumors occur most frequently in patients in their 50s tal end of the appendix, which does not cause an obstruc- and are found when the symptoms of acute appendicitis tion between the appendix and colon. It is more common present themselves.7 When the appendix develops goblet to find a carcinoid tumor in a female than in a male, and cell carcinoma, it usually infiltrates the entire gland which usually occurs when the patient is in their 40s.7 When a makes it easier to detect during a CT scan.8 This type of patient is examined for other issues, 66 percent of appen- tumor is very rare, occurring in less than one percent diceal tumors that are classified as carcinoid, are found by of appendiceal tumors, and usually is diffused along the accident.11 appendix wall.11 Tumors that originate in the epithelial cells of the inside Cystadenocarcimona occurs in 20 percent of appendi- 256 | the surgical technologist | JUNE 2012 ceal tumors and is found in varying places in the gland.11 risk of metastasis into the abdominal cavity or colon. As This classification of tumor is found in the mucosa cells with some of the other classifications of appendiceal cancer of the appendix which develop into cysts. In 90 percent of it is usually diagnosed after the patient presents symptoms cases this cancer remains localized and presents symptoms of acute appendicitis.4,11 Signet ring is a rare form of adeno- of appendicitis.11 carcinoma, so named for the way the cells appear under Adenocarcinoma develops at the base of the appendix the microscope, and is found in less than one percent of and accounts for about 10 percent of appendiceal tumors. It tumors. This particular type of adenocarcinoma is very involves the cells of the epithelial layer which has a higher aggressive and difficult to successfully treat.11 Anatomy of C ancer Classifications of C ancer the word cancer strikes fear into the heart of almost anyone familiar One of the first parts of diagnosing cancer is to determine the size with the term, but it is not a single disease. cancer is the term given and spread of the malignant tumor or cells. this is called grade and to hundreds of different diseases that have similar characteristics. stage of the disease. how a treatment for cancer is determined, What they have in common is uncontrolled abnormal cell growth depends on the grade and stage of the tumor as the cells will react and the spread of those cells.10 it is the altering of the Dna of a differently at different levels. particular cell that can begin the cascade of events that leads to “grading is a means of affixing a value to a clinical opinion a malignancy. if the mutated cell is not destroyed by the immune of the degree of dedifferentiation (anaplasia) of cancer cells, or system it will begin to replicate which will produce many more cells how much the cells appear different from their original form.”10 a with a mutated genetic code. pathologist will examine the tissue sample and assign a grade from i in normal tissue there is a code that regulates growth, but if to iV. the numbers determine the severity of the cancerous cells, the there is a mutation in that code, the cells may begin to reproduce higher the grade the worse the cancer is thought to have progressed. Surgeons watch the laparoscopic monitor while performing an appendectomy uncontrollably. hyperplasia begins to take place and a tumor begins in healthy tissue there is good differentiation of the cells, but in to form, this is still considered a benign state. if left unchecked, the cancer this is the opposite, and the poor differentiation progresses cells may continue to change which may lead to dysplasia, which as does the disease. follows the classification of hyperplasia, which is rapid over growth the higher the grade assigned to a tissue sample, the more of the tissues. as the cells continue to grow unchecked the purpose advanced the cancer is, or the more dedifferentiated the cells have of those cells may begin to change. When the cells of a tissue lose become. the next step in determining how advanced a malignancy the ability to carry out their original function, and the only purpose is depends on the staging. there are different systems used for this they fulfill is reproduction, a diagnosis of cancer is given. Once purpose, if it is done in a clinical setting it is considered clinical carcinogenesis has begun, the cancer will begin not only destroy- staging. if the value given is assigned by a pathologist it is consid- ing the surrounding tissues but will eventually metastasize to other ered pathologic staging. One example is the TNM staging system. parts of the body. as the cancerous tissue spreads throughout dif- the t will give a value for the size of the tumor, the n is for the ferent systems it takes up residence and begins the destruction of number of lymph nodes that test positive for cancer, and the M rep- the organs, glands and tissues, eventually causing death. 10 resents how far the cancer has metastasized. the values given to t, Malignant neoplasms can originate in any of the different tis- n and M are added together to give the staging number, which will sues and are named accordingly. help to determine the best course of treatment. 10 a malignancy that develops in the epithelial tissue is considered if the cancer has not spread past the original site and has not a carcinoma, connective tissue sarcoma, and lymphatic tissue cancer invaded the organ it is considered to be carcinoma in situ (cis). the is a lymphoma. Malignant tumors in the brain, breast or stomach site of the original tumor is called the primary location and if the that occur outside of lymphatic tissue are considered extranodal cells metastasize to another location this is considered secondary lymphomas. locations. an example of this would be when adenocarcinoma of the appendix has metastasized to the liver, the malignant cells in the liver will be composed of the same type of tissue as the original cancer in the appendix.10 JUNE 2012 | the surgical technologist | 257 Diagnosis of C ancer Treatment A diagnosis of cancer in the appendix usually does not Once it is determined that cancer is present in the appendix occur until the tumor has reached stage IV and the gland a course of action is chosen.
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