A rare case of Non-Hodgkin’s lymphoma of the appendix and small intestine

A rare case of Non-Hodgkin’s lymphoma of the appendix and small intestine

Acute appendicitis is a very common surgical problem that affects people in all age-groups. It commonly presents with pain in the right lower abdomen and may be accompanied with fever, vomiting, loss of appetite and diarrhoea or constipation. However, rarely appendix could be the site of a cancerous growth. Mr. Rajan (name changed) a 33 years old gentleman, had presented to us with history of pain in right lower abdomen for more than a week. On ultrasound examination he was found to have an inflamed appendix with a mucocele (a condition in which appendix get filled up with mucoid material). On high degree of suspicion, a CT scan of the abdomen was performed just before the scheduled laparoscopic surgery for appendicectomy. Unfortunately, the CT scan revealed a tumour in the appendix as well as the small intestine. On further investigations and evaluation, the patient was found to have Non-Hodgkin’s type of lymphoma of the appendix and the small intestine (Ileum). A laparoscopic right hemicolectomy (removal of the distal part of small intestine, appendix and right side of the large intestine/colon) was done and patient undertook chemotherapy after that for completion of treatment.

Lymphoma is a cancer that develops in the infection fighting cells of the immune system called lymphocytes. In a lymphoma these cells can grow out of control. Lymphomas are commonly seen in lymph nodes, spleen, thymus, bone marrow and some other parts of the body. Primary lymphomas affecting the gastro-intestinal (GI) tract (food pipe, stomach, small intestine and large intestine) are very rare and constitute 1 to 4% of all cancers afflicting the GI tract. The others being adenocarcinomas, carcinoid tumours and GI sarcomas. Lymphomas affecting the appendix are even more rare and are usually found on testing of appendix specimens post appendicectomy surgery.  They are seen in 0.015% of appendicectomy specimens. Most of the times they are Non-Hodgkin’s lymphoma and are more common in men.

Unfortunately, most of the times diagnosis is delayed as patients do not have any specific signs or symptoms. They may present with pain in abdomen, blood in stools, symptoms of obstruction and perforation. Especially when it comes to appendix, most patients will present with an appendicitis like picture and most of the times the diagnosis is confirmed after surgery.

Lymphomas can be treated with surgery or chemotherapy and the outcomes depend on the stage of the disease. Surgical resection is warranted if the tumour is causing symptoms like bleeding, perforation or obstruction. In that case the affected part needs to be resected and removed. Nowadays, most intestinal surgeries can be performed through key-hole or laparoscopic surgery. This leads to lesser pain and helps the patient to recover faster. Additionally, chemotherapy may be instituted as an adjuvant as per the advice of the oncologist.

In conclusion, cancers of the small intestine and appendix are rare. Lymphomas are seen even more rarely. However, patients must be aware of their symptoms. Pain in abdomen, change in bowel habits, blood in stools etc. are some of the symptoms that must be evaluated further.  One must not ignore any new symptoms and must consult a doctor immediately. During Covid-19 pandemic many patients have been hesitant to come to visit their doctors or come to the hospital. In many instances this has led to a delay in diagnosis which can affect the treatment outcomes adversely. At the end of the day our health is most precious and we must take utmost care of it.

Dr. Aparna Govil Bhasker