In April 2020, a 58-year-old man presented with abdominal distension and complained of weight loss of approximately 10 kg in the last two months, with abdominal distension, positive mobile dullness, and no other discomfort, such as jaundice and fever. The hematological examinations revealed that the tumor indicators, such as CEA, significantly increased. Hepatitis B was small and positive, albumin and prealbumin were close to normal, and diet and sleep were acceptable. The patient denied a history of surgery upon admission to the hospital. However, the patient had a history of smoking and drinking for more than 30 years. The external hospital performed relevant examinations to rule out the possibility of tuberculosis. The diagnosis initially considered gastrointestinal tumors with cancerous ascites, and the prognosis was poor. However, after admission, there was no obvious abnormality after gastroscopy and enteroscopy. The MRI revealed multiple metastatic cancers of the liver and peritoneum, but the primary focus was not clear. Then, family members requested for a PET-CT examination. However, the primary focus was still uncertain. Next, abdomen puncture was performed to introduce a small amount of atypical cells from the ascites, but it was not clear whether it was a tumor. The patients and their families are very anxious, eager to get a confirmed diagnosis, and put a lot of pressure on the medical staff. After the multidisciplinary discussions, it was considered that the liver lesions are more likely to metastasize, the diameter was small, and the location was difficult to perform the puncture examination. Although a peritoneal puncture is feasible, the success rate is low.
The surgeon came to consult and asked again for a detailed medical history, the patient’s abdominal wall was found to have insignificant surgical incision marks. The patient remembered undergoing an appendectomy at the primary hospital due to appendicitis in 2013.However, the physician did not ask the medical history carefully and the patient did not offer to provide it. The pathological report suggesting that the patient had abnormal cells in the appendix. However, the pathologist did not take further measures to rule out the tumor, such as a consultation in an authoritative hospital.
The patient was recommended to directly undergo laparoscopic exploration, during the laparoscopic exploration, the patient’s abdominal pelvis was covered with grape-like, jelly-like tumors, which violated the entire abdominal wall, omentum, liver surface and mesentery. Several pieces of tumor tissue were sent for postoperative pathology, which suggested pseudomyxoma peritonei (PMP). The local hospital was contacted again, and the patient’s appendix specimens were re-sectioned to confirm that a small amount of mucinous cystic tumor was observed at that time. At this point, the patient’s diagnosis is clear. That is, the patient had appendix mucinous adenocarcinoma with multiple intra-abdominal metastases after seven years.