Aust. N.Z.J . Surg. 1991, 61. 707-708
707
UNUSUAL PRESENTATION OF CANCER H. Y.AL-IDRISSI,A. L. AL-ARFAJ,S . A. SOWAYAN, H.0. QUTUBAND M. K. K
m
College of Medicine and Medical Sciences, King Faisal University, Dammam, Saudi Arabia
The large bowel is the most frequent primary site for metastases in inguinal hernial sacs. We report four cases, two due to carcinoid of unknown primary, and one each due to adenocarcinoma of colon, stomach and pancreas. We recommend that all hernial sacs, particularly in the elderly, be examined microscopically. Key words: carcinoma, hernial sacs, microscopic examination, unusual presentation.
Introduction Patients presenting with groin masses are most likely to have hernias although, in the elderly, metastatic abdominal malignancies should be borne in mind. We describe four such patients proven by histopathological examination of the hernial sacs.
1 I .7g/dL after a month, and an albumin level of 3.3g/dL. On endoscopy, there was a mass at the cardia. Its biopsy showed differentiated adenocarcinoma, as did histology of the hernial sac. At the herniorrhaphy, the peritoneum of the deep inguinal ring was unremarkable.
case 3 case 1
D. A., a 45 year old man, was admitted with a left groin swelling of 2 years’ duration. It had increased in size gradually and had recently become painful. He had no cough, his bowel habits were regular and his weight was constant. He had a reducible left inguinal hernia, hepatomegaly and shotty bilateral submandibular lymphadenopathy. Routine laboratory investigations - complete blood picture, electrolytes, stool examination and occult blood tests -were all within normal limits. Ultrasound showed a thickened gall-bladder and barium enema a narrowing in the sigmoid colon that biopsy confirmed as a mucin-secreting adenocarcinoma. The patient had herniorrhaphy. The peritoneum at the deep inguinal was clear. Histopathological examination of the hernial sac showed metastatic colloid carcinoma. Case 2
S. N.,a 60 year old man, was admitted with a left inguinal hernia of 3 years’ duration. It was initially reducible but had recently become irreducible. He smoked cigarettes and gave a history of chronic cough and constipation. Routine laboratory investigations were all within normal limits, except for a Hb level which fell from 13g/dL on admission to Correspondence: Hassan Y. Al-ldrissi, Associate Professor of Medicine and Oncology, King Faisal University, Po Box 2114. Dammam 31451. Saudi Arabia. Accepted for publication 24 July 1990.
B. M.,a 29 year old woman, presented with an 8 month history of an irreducible right groin swelling. She had regular bowel habits. At herniorrhaphy, the hernial sac contained a lymph node, and histopathology showed that both contained metastatic carcinoid.
case 4 0. R., a 55 year old man, presented with low back pain, weight loss, and anorexia of 5 months’ duration, as well as a painless right inguinal lump of 6 weeks’ duration. Given a clinical diagnosis of incarcerated right inguinal hernia, herniorrhaphy was performed in another hospital. Histopathological examination of the sac showed a differentiated adenocarcinoma of undetermined origin. He was then referred to the King Fahd Teaching Hospital. He had ascites but a negative cytology. All routine laboratory tests were within normal limits, except for a raised CEA (9.1 pg/mL) and KUB showing calcification across LI. At lapamtomy, he was found to have carcinoma of the pancreas.
Discussion Occult cancer and external herniae often co-exist in the elderly,’ but rarely does the hernial sac give the first clue of metastases. Tumours within hernial sacs are rare and occur in fewer than 0.5% of surgically excised sacs.* Grossly, the hernial sacs in our cases looked normal; if not for the histopathological examination, the diagnosis of malignancy
AL-IDRISSI E T A L .
708
would have been missed. We agree with the suggestion that all hernial sacs from elderly patients, irrespective of their gross appearance, must be microscopically ~ t u d i e dAs . ~ this has been the practice in our hospital, these four cases were detected. A wide spectrum of malignant and benign tumours can present as hernias. ' - I 2 Carcinoma of the colon is the commonest tumour associated with hernial sac metastases; others are cancer of prostate, pancreas, ovary, bile duct," as well as tonsils, stomach, pericardium and skim3 Inguinal hernial sacs are the most frequent site, but rarely, umbilical hernia' and, more rarely still, femoral hernia have been reported." In our series, there was one each of metastatic carcinoid, and adenocarcinoma of stomach, colon, and pancreas. This, to our knowledge, is the first reported case of metastatic carcinoid in an inguinal hernia.
References I . TEREZIAS N . L., DAVIS W . C. &JACKSON F. C. (1963) Carcinoma of the colon associated with inguinal hernia. N . Engl. J. Med. 268, 744-76. 2. TANG C. K., GRAY G. F. & KENHUELIAN J. G. (1976) Malignant peritoneal mesothelioma in an inguinal hernia sac. Cunrer 37. 1887-90. 3. YOELLJ . H. (1959) Surprises in hernia sacs. Calif. Med. 91. 146-7.
4. BAILEYH. (1960) 1936 Demonstrations of Physical Signs in Clinical Surgery. Williams & Wilkins Com-
pany, Baltimore. V. P., HIELEY R. W. & TARASIDIA G. D. 5. DROSS ( 1973) Irreducible inguinal hernia due to carcinoma of the cecum. W. Va. Med. J . 69, 86-7. S. S. & WOLSTENHOLME J. T. (1955) Primary 6. FIEBER tumors in inguinal hernia sacs. Arch. Surg. 71, 254. G. W., MILLAR R. C. & KETCHAM A. S. 7. GEELHOED (1974) Hernia presentation of cancer in the groin. Surgery 75,436-41. J. C. & TOOMEY W. F. (1964) Large bowel 8. GRIFFITHS obstruction due to a herniated carcinoma of sigmoid colon. Brit. J. Surg. 51, 715-8. A. (1951) Inguinal endometriosis diag9. VON HELLENS nosed preoperatively as irreducible inguinal hernias: Case report. Ann. Chir. Gynaec. Fenn. 40.256. 10. INNKENTI M. (1948) Angioma cavernosos del ligament0 rotondo simulante unernia inguinale strozzata. Boll. e Mem. SOC. Tosco-umbra Chir. 9.43. II. LOWENFELS A. B . , ROHMAN M . , AHMEDN. & LEFKOWITZ M. (1969) Hernia sac cancer. Lancet i , 651. 12. PHILLIPSN. B. & HOLMES T. W . (1972) Torsion infarction in ectopic cryptorchidism: A rare entity occurring most commonly with spastic neuromuscular disease. Surgery 71, 335-8. D. & SHAPIRO A. L. (1943) Multilocular 13. KERSHNER serous cysts of the round ligament simulating incarcerated herniae. Ann. Surg. 117, 216. L. M. (1963) External and internal abdomi14. ZIMMERMAN nal hernias. Amer. J. Gastroenterol. 40,405-8.
Aust. N . Z . J . Surg. 1991.61. 708-710
MULTIPLE HEPATIC ABSCESSES DUE TO YERSINIA ENTEROCOLITICA T. B. ELLIOTT'AND B. W. 0. PARTRIDGE' Department of Surgery, Public Hospital, Tauranga. New Zealand A case of multiple hepatic abscesses due to Yersiniu enterocolitica is presented.
Key words: hepatic abscess, Yersinia enterocolilica.
Introduction Several authors have recently commented on the increasing incidence of Yersinia enterocolitica infection. The most common presentation is with acute gastroenteritis. However, a spectrum of
' BSc. MB. ChB: Surgical Regislrar. ' FRCS. FRACS. General and Vascular Surgeon. Correspondence: Dr T. B . Elliott, 42 Kensington Avenue, Mt Eden. Auckland. New Zealand. Accepted for publication 25 July 1990.
systemic and post-infectious manifestations is recognized, often in susceptible hosts. A case of multiple hepatic abscesses due to Yersinia enterocolitica is presented.
Case report A 71 year old male European retired farmer was first admitted to a medical ward with a febrile illness of 4 days' duration. A diagnosis of pneumonia was made and the patient was commenced on intravenous amoxycillin with clavulanic acid, to which he had a good response. He was discharged after a 4 day course.
707
UNUSUAL PRESENTATION OF CANCER H. Y.AL-IDRISSI,A. L. AL-ARFAJ,S . A. SOWAYAN, H.0. QUTUBAND M. K. K
m
College of Medicine and Medical Sciences, King Faisal University, Dammam, Saudi Arabia
The large bowel is the most frequent primary site for metastases in inguinal hernial sacs. We report four cases, two due to carcinoid of unknown primary, and one each due to adenocarcinoma of colon, stomach and pancreas. We recommend that all hernial sacs, particularly in the elderly, be examined microscopically. Key words: carcinoma, hernial sacs, microscopic examination, unusual presentation.
Introduction Patients presenting with groin masses are most likely to have hernias although, in the elderly, metastatic abdominal malignancies should be borne in mind. We describe four such patients proven by histopathological examination of the hernial sacs.
1 I .7g/dL after a month, and an albumin level of 3.3g/dL. On endoscopy, there was a mass at the cardia. Its biopsy showed differentiated adenocarcinoma, as did histology of the hernial sac. At the herniorrhaphy, the peritoneum of the deep inguinal ring was unremarkable.
case 3 case 1
D. A., a 45 year old man, was admitted with a left groin swelling of 2 years’ duration. It had increased in size gradually and had recently become painful. He had no cough, his bowel habits were regular and his weight was constant. He had a reducible left inguinal hernia, hepatomegaly and shotty bilateral submandibular lymphadenopathy. Routine laboratory investigations - complete blood picture, electrolytes, stool examination and occult blood tests -were all within normal limits. Ultrasound showed a thickened gall-bladder and barium enema a narrowing in the sigmoid colon that biopsy confirmed as a mucin-secreting adenocarcinoma. The patient had herniorrhaphy. The peritoneum at the deep inguinal was clear. Histopathological examination of the hernial sac showed metastatic colloid carcinoma. Case 2
S. N.,a 60 year old man, was admitted with a left inguinal hernia of 3 years’ duration. It was initially reducible but had recently become irreducible. He smoked cigarettes and gave a history of chronic cough and constipation. Routine laboratory investigations were all within normal limits, except for a Hb level which fell from 13g/dL on admission to Correspondence: Hassan Y. Al-ldrissi, Associate Professor of Medicine and Oncology, King Faisal University, Po Box 2114. Dammam 31451. Saudi Arabia. Accepted for publication 24 July 1990.
B. M.,a 29 year old woman, presented with an 8 month history of an irreducible right groin swelling. She had regular bowel habits. At herniorrhaphy, the hernial sac contained a lymph node, and histopathology showed that both contained metastatic carcinoid.
case 4 0. R., a 55 year old man, presented with low back pain, weight loss, and anorexia of 5 months’ duration, as well as a painless right inguinal lump of 6 weeks’ duration. Given a clinical diagnosis of incarcerated right inguinal hernia, herniorrhaphy was performed in another hospital. Histopathological examination of the sac showed a differentiated adenocarcinoma of undetermined origin. He was then referred to the King Fahd Teaching Hospital. He had ascites but a negative cytology. All routine laboratory tests were within normal limits, except for a raised CEA (9.1 pg/mL) and KUB showing calcification across LI. At lapamtomy, he was found to have carcinoma of the pancreas.
Discussion Occult cancer and external herniae often co-exist in the elderly,’ but rarely does the hernial sac give the first clue of metastases. Tumours within hernial sacs are rare and occur in fewer than 0.5% of surgically excised sacs.* Grossly, the hernial sacs in our cases looked normal; if not for the histopathological examination, the diagnosis of malignancy
AL-IDRISSI E T A L .
708
would have been missed. We agree with the suggestion that all hernial sacs from elderly patients, irrespective of their gross appearance, must be microscopically ~ t u d i e dAs . ~ this has been the practice in our hospital, these four cases were detected. A wide spectrum of malignant and benign tumours can present as hernias. ' - I 2 Carcinoma of the colon is the commonest tumour associated with hernial sac metastases; others are cancer of prostate, pancreas, ovary, bile duct," as well as tonsils, stomach, pericardium and skim3 Inguinal hernial sacs are the most frequent site, but rarely, umbilical hernia' and, more rarely still, femoral hernia have been reported." In our series, there was one each of metastatic carcinoid, and adenocarcinoma of stomach, colon, and pancreas. This, to our knowledge, is the first reported case of metastatic carcinoid in an inguinal hernia.
References I . TEREZIAS N . L., DAVIS W . C. &JACKSON F. C. (1963) Carcinoma of the colon associated with inguinal hernia. N . Engl. J. Med. 268, 744-76. 2. TANG C. K., GRAY G. F. & KENHUELIAN J. G. (1976) Malignant peritoneal mesothelioma in an inguinal hernia sac. Cunrer 37. 1887-90. 3. YOELLJ . H. (1959) Surprises in hernia sacs. Calif. Med. 91. 146-7.
4. BAILEYH. (1960) 1936 Demonstrations of Physical Signs in Clinical Surgery. Williams & Wilkins Com-
pany, Baltimore. V. P., HIELEY R. W. & TARASIDIA G. D. 5. DROSS ( 1973) Irreducible inguinal hernia due to carcinoma of the cecum. W. Va. Med. J . 69, 86-7. S. S. & WOLSTENHOLME J. T. (1955) Primary 6. FIEBER tumors in inguinal hernia sacs. Arch. Surg. 71, 254. G. W., MILLAR R. C. & KETCHAM A. S. 7. GEELHOED (1974) Hernia presentation of cancer in the groin. Surgery 75,436-41. J. C. & TOOMEY W. F. (1964) Large bowel 8. GRIFFITHS obstruction due to a herniated carcinoma of sigmoid colon. Brit. J. Surg. 51, 715-8. A. (1951) Inguinal endometriosis diag9. VON HELLENS nosed preoperatively as irreducible inguinal hernias: Case report. Ann. Chir. Gynaec. Fenn. 40.256. 10. INNKENTI M. (1948) Angioma cavernosos del ligament0 rotondo simulante unernia inguinale strozzata. Boll. e Mem. SOC. Tosco-umbra Chir. 9.43. II. LOWENFELS A. B . , ROHMAN M . , AHMEDN. & LEFKOWITZ M. (1969) Hernia sac cancer. Lancet i , 651. 12. PHILLIPSN. B. & HOLMES T. W . (1972) Torsion infarction in ectopic cryptorchidism: A rare entity occurring most commonly with spastic neuromuscular disease. Surgery 71, 335-8. D. & SHAPIRO A. L. (1943) Multilocular 13. KERSHNER serous cysts of the round ligament simulating incarcerated herniae. Ann. Surg. 117, 216. L. M. (1963) External and internal abdomi14. ZIMMERMAN nal hernias. Amer. J. Gastroenterol. 40,405-8.
Aust. N . Z . J . Surg. 1991.61. 708-710
MULTIPLE HEPATIC ABSCESSES DUE TO YERSINIA ENTEROCOLITICA T. B. ELLIOTT'AND B. W. 0. PARTRIDGE' Department of Surgery, Public Hospital, Tauranga. New Zealand A case of multiple hepatic abscesses due to Yersiniu enterocolitica is presented.
Key words: hepatic abscess, Yersinia enterocolilica.
Introduction Several authors have recently commented on the increasing incidence of Yersinia enterocolitica infection. The most common presentation is with acute gastroenteritis. However, a spectrum of
' BSc. MB. ChB: Surgical Regislrar. ' FRCS. FRACS. General and Vascular Surgeon. Correspondence: Dr T. B . Elliott, 42 Kensington Avenue, Mt Eden. Auckland. New Zealand. Accepted for publication 25 July 1990.
systemic and post-infectious manifestations is recognized, often in susceptible hosts. A case of multiple hepatic abscesses due to Yersinia enterocolitica is presented.
Case report A 71 year old male European retired farmer was first admitted to a medical ward with a febrile illness of 4 days' duration. A diagnosis of pneumonia was made and the patient was commenced on intravenous amoxycillin with clavulanic acid, to which he had a good response. He was discharged after a 4 day course.
