Localized peritoneal carcinomatosis mimicking an irreducible left inguinal hernia

Abstract

Perforated colonic cancers are not rare and leave patients at risk of developing peritoneal carcinomatosis. We present a 68-year-old male patient with a perforated transverse colonic tumour who underwent emergency extended right hemicolectomy. He made an uneventful postoperative recovery, and received adjuvant chemotherapy. Unfortunately, a routine positron emission tomography-computed tomography scan 16 months later demonstrated an fluorodeoxyglucose-avid nodule in the left scrotum associated with an irreducible left inguinal hernia that contained sigmoid colon. At laparotomy, the discovery of isolated peritoneal recurrence in the hernia sac was unexpected, given the absence of local recurrence in the region of the original transverse colon cancer perforation. The etiology therefore remains uncertain, but one may speculate that cell implantation occurred within the hernia sac at the initial emergency laparotomy. Whilst PC is not rare, its management and its preoperative diagnosis in particular remain challenging. Only 40% of patients can be diagnosed by imaging modalities and, in many of them, PC will be found only at the time of surgery. 1 We present an interesting case of peritoneal recurrence, mimicking an irreducible inguinal hernia. Case presentationA 68-year-old male with a known left inguinal hernia was admitted with acute abdominal pain and peritonitis. Abdominal computed tomography (CT) identified a perforated transverse colonic tumour. He underwent emergency extended right hemicolectomy, abdominal washout, curettage and omental obliteration of a cavity in the left upper quadrant, and received a primary ileocolic anastomosis. He made an uneventful postoperative recovery. Pathological examination showed a Dukes' B (pT4N0Ly1V1R0) adenocarcinoma and the patient received an adjuvant FOLFIRI chemotherapy regimen.Sixteen months later, routine positron emission tomography-computed tomography (PET-CT) scan demonstrated an fluorodeoxyglucose-avid nodule in the left hemiscrotum that was associated with both a left inguinal hernia containing sigmoid colon and a further nodule at the neck of the scrotum (Figures 1 and 2). Clinically, the hernia was irreducible, although there was no sign of obstruction or strangulation. There was no obvious testicular mass. A flexible sigmoidoscopy did not reveal any intraluminal colonic lesion.At laparotomy, and following reduction of the sigmoid colon out of the hernia sac, a nodule was found on the sigmoid serosa, and another at the neck of the sac adjacent to the pubic tubercle. Macroscopic disease was not seen anywhere else in the abdomen. On-table colonoscopy confirmed the absence of mucosal disease, and a limited segmental sigmoid resection, preserving the inferior mesenteric artery (IMA), and a separate resection of the peritoneal sac and second nodule were performed. Metastatic adenocarcinoma was confirmed microscopically in the two nodules. While three mesenteric lymph nodes were also positive for adenocarcinoma, no luminal cancer was detected. All disease was i...