Carcinoma of the Cecum Presenting as a Right Inguinal Hernia
Carcinoma of the Cecum Presenting as a Right Inguinal Hernia
Inguinal hernias and colonic malignancies are frequent diseases in the elderly population, but their association is relatively rare. Two previous literature reviews 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. 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. 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.
Discussion
Inguinal hernias and colonic malignancies are frequent diseases in the elderly population, but their association is relatively rare. Two previous literature reviews 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. 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. 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.
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