A Carollo, T Rosenkranz, D.j. Smith. Northside Medical Center
Cancer of unknown primary (CUP) is a well-known entity that can present in a multitude of clinical presentations. We present a case of a 72 year old female that presented with an abdominal wall mass; on laparoscopy she was found to have a spigelian hernia due to an omental metastatic lesion from a CUP. Patient presented with complaints of pain in the left side of her abdomen and feeling a lump in that location for the past 7-10 days. On physical exam she was found to have a bulge on the left side of the abdomen just lateral to the rectus muscle, firm and immobile, it appeared to be outside of the abdominal wall. A CT scan of the abdomen and pelvis was obtained and showed a hernia as well as signs of carcinomatosis. She was scheduled for a diagnostic laparoscopy and an esophagogastroduodenoscopy (EGD). Her EGD was completely normal, but on her diagnostic laparoscopy she was noted to have diffuse tumor implants along the liver, diaphragm, peritoneum and omentum. The largest omental implant, measuring about 3x4cm was herniated through the semilunar line of the abdominal fascia causing a spigelian hernia. Biopsies of the peritoneal and omental implants were obtained. The pathology report returned as metastatic adenocarcinoma of unknown origin. The cancer stained diffusely positive for CK7 and CK 20; suggestive of gastrointestinal, pancreatic, biliary or ovarian origin, less likely pulmonary origin. Her pathology report from her prior SOO showed both ovaries were benign serous cystadenoma and histologically no similarity to current pathology. She underwent CT chest/brain, colonoscopy, mammogram, and CA 19-9 level; all returned normal. She underwent a PET scan as well and only the known abdominal masses were suggestive of cancer. Decision was made to treat the patient as primary peritoneal malignancy with a platinum-taxane based chemotherapy regimen.
Cancer of unknown primary is a clinical entity that is not as uncommon as previously thought. As our patients CUP presented as a spigelian hernia this is quite a rare occurrence. Spigelian hernias are anterior abdominal wall hernias that occur at a defect adjacent to the semilunar line and they comprise only 0.12% of all abdominal wall hernias and are difficult to diagnose clinically depending on its location. Though rare concomitant disease processes, CUP as a spigelian hernia should be included in the differential diagnosis of anterior abdominal wall masses, even in the absence of symptoms suggestive of cancer.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80672
Program Number: P127
Presentation Session: Poster (Non CME)
Presentation Type: Poster
