Keywords
Adenocarcinoma, inguinal hernia, hernioplasty, metastases, incidental finding
Adenocarcinoma, inguinal hernia, hernioplasty, metastases, incidental finding
Inguinal hernia sac tumors are a rare occurrence, with one study reporting only 0.07% of repairs being positive for metastatic tumors1. Traditionally, hernia sac tumors are classified as intrasaccular, saccular and extrasaccular, based on the anatomical relationship of the tumor to the hernia sac2,3. Intrasaccular tumors are one the most frequent type. They generally consist of primary tumors of organs lying within the hernia sac, such as cancers of colon, bladder, and metastatic neoplasms involving the omentum. Tumors that extend into the hernia sac by way of peritoneal involvement are classified as saccular and include, among others, primary mesothelioma and peritoneal metastasis from the intra-abdominal organs. When the tumor is within the hernia defect but lies outside the hernia sac, it is classified as extrasaccular. Examples include metastatic involvement of inguinal lymph nodes2–4. In this case report we present a case of metastatic growth that was found inside the inguinal hernial sac, later confirmed by histopathology to be metastatic adenocarcinoma. Post-operative workup revealed the primary tumor to be an adenocarcinoma involving the distal ileum as well as the ileocecal junction.
A 57-year-old man, with no known comorbid, from Karachi, Pakistan, was admitted to the Civil Hospital, Karchi, Pakistan, in November 2017, with a history of bilateral inguinal swelling that had begun a year prior to presentation, that had been small and inconsequential initially, but had recently grown larger and would become painful during prolonged standing and walking. In last three weeks prior to admittance, the swelling would not reduce with lying down. On physical examination, he was found to have a bilateral, incomplete, non-reducible inguinal hernia. His baseline laboratory investigations were all within normal limits, and chest radiograph was unremarkable. The patient underwent a cardiac review and was declared fit for general anesthesia. He was scheduled for laparoscopic hernioplasty. Intra operative findings revealed white nodules on parietal peritoneum and the omentum, while only the right-sided inguinal hernia was observed. A biopsy was taken, and mesh repair was done on the right side. Histopathology of the biopsy showed metastatic adenocarcinoma. The patient was evaluated for an intra-abdominal neoplasm. Carcinoembryonic antigen (CEA) levels and carbohydrate/cancer antigen (CA 19-9) levels were sent and patient scheduled for an ultrasound scan (US) of the abdomen and pelvis, esophagogastroduodenoscopy (OGD), colonoscopy and computed tomography (CT) scan of the chest, abdomen and pelvis with contrast enhancement. The patient’s CEA levels were 14.04 ng/ml (normal level <3.5 ng/ml) and CA 19-9 levels were 125.2 U/ml (normal level <27 U/ml). The only findings of the abdominal and pelvic ultrasound were hypo-echoic lesions in the liver. OGD showed antral gastritis and biopsies were taken which showed no evidence of malignancy. Colonoscopy showed rounded well-demarcated lesions measuring 1.5 cm seen in the cecum, multiple biopsies were taken. However, biopsy showed no evidence of malignancy. Computed tomography (CT) of abdomen and chest showed a mass involving the distal ileum and the ileocecal junction, with lymphadenopathy, peritoneal carcinomatosis, as well as hepatic and lung metastasis (Figure 1). The patient was considered inoperable and hence, no surgery was considered. The patient left against medical advice and no follow up was obtained.
Malignant tumors presenting within inguinal hernias are a rare occurrence. Literature reveals less than 0.4 % of the excised hernia tissue shows microscopic evidence of neoplasia5. Among these the most common primary tumor associated with hernia sac metastasis is carcinoma of the colon2,5. This case was unique as in our patient the neoplasm involved the small bowel (distal ileum) as well as the ileocecal junction. To our knowledge, there is no literature available which mentions a case of metastatic ileal/ileocecal junction neoplasm presenting as an inguinal hernia. In most cases of colon cancer presenting as an inguinal hernia one possible explanation for the occurrence of an inguinal hernia could be the increased intra-abdominal pressure, perhaps secondary to the intra-abdominal neoplasm, occurring especially in the elderly2,6. For instance, obstructive colon cancer, massive tumors or tumors associated with ascites can lead to increased intra-abdominal pressures and result in an inguinal hernia. However, in our patient, there were no additional symptoms, indicating that other factors were involved.
Here we turn to the history the patient gave us on presentation. A patient’s presenting complainant is an important factor and can raise suspicion of an underlying malignancy3. It has been suggested that a long-standing hernia, becoming acutely incarcerated has a greater chance of containing a tumor. Some authors have even gone so far as to say that any non-reducible mass in the inguinal canal, lacking an impulse, should raise concern for malignancy3. Furthermore, constitutional symptoms can also suggest the possibility of an underlying malignancy. In many such cases, abdominal pain was the most frequent symptom present pre-operatively3. Of note in our patient is the history of acute incarceration, as the patient said that up till recently the swelling would reduce on lying down. Since the peritoneum is a common site of intra-abdominal metastasis, a hernia repair gives a good opportunity for the surgeon to perform a peritoneal biopsy, thereby providing an earlier diagnosis. Furthermore, due to reports of occult malignancies from histopathological examination of hernia sac, several authors have recommended routine microscopic examination of the hernia sac2,7. However, other authors have reported histopathological examination in only selected cases2. Several authors also suggest a routine fiberoptic sigmoidoscopy in patients presenting with a hernia, because of the coexistence of an inguinal hernia and colonic cancer2,8.
In conclusion, our study showed that an inguinal hernia and ileum/ileocecal junction neoplasm can coexist together, especially in the elderly. In addition, we also reported that an irreducible hernia can raise suspicion of metastasis and, the patient can be asymptomatic at the time of presentation. Despite the rare co-existence of hernia and malignancy, we still recommend routine microscopic histopathological examination in all suspicious cases, as this can lead to an earlier diagnosis, and if the patient is asymptomatic this can be the only means to determine an occult malignancy.
Written informed consent for publication of their clinical details and clinical images was obtained from the patient.
All data underlying the results are available as part of the article and no additional source data are required.
Views | Downloads | |
---|---|---|
F1000Research | - | - |
PubMed Central
Data from PMC are received and updated monthly.
|
- | - |
Is the background of the case’s history and progression described in sufficient detail?
Yes
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Partly
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
No
Is the case presented with sufficient detail to be useful for other practitioners?
Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Histopathologist.
Is the background of the case’s history and progression described in sufficient detail?
Yes
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Partly
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Yes
Is the case presented with sufficient detail to be useful for other practitioners?
Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Gastroenterology.
Is the background of the case’s history and progression described in sufficient detail?
Partly
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Partly
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Partly
Is the case presented with sufficient detail to be useful for other practitioners?
Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: General and minimally invasive surgery. Gastrointestinal and colorectal surgery.
Alongside their report, reviewers assign a status to the article:
Invited Reviewers | |||
---|---|---|---|
1 | 2 | 3 | |
Version 1 29 Jan 19 |
read | read | read |
Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list:
Sign up for content alerts and receive a weekly or monthly email with all newly published articles
Already registered? Sign in
The email address should be the one you originally registered with F1000.
You registered with F1000 via Google, so we cannot reset your password.
To sign in, please click here.
If you still need help with your Google account password, please click here.
You registered with F1000 via Facebook, so we cannot reset your password.
To sign in, please click here.
If you still need help with your Facebook account password, please click here.
If your email address is registered with us, we will email you instructions to reset your password.
If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance.
Comments on this article Comments (0)