[Medical Human Story]-Time Hidden Beneath the Skin(Episode 51) Red Blooms on the Peritoneum(1)

 A Record of Adenocarcinoma of the Appendix and Krukenberg Tumour


 

Prologue

An Afternoon in the Consultation Room

"Doctor... wasn't it just appendicitis?"

The middle-aged woman sitting across from me was nervously rubbing her hands. Her name was So-yeon Park (pseudonym), forty-five years old, and a mother of two. The CT scan was displayed on the monitor. I pressed the Zoom button.

At the tip of the cecum—the appendix—there was a subtle thickening. And a small, mucinous shadow. It looked like simple acute appendicitis, yet something felt off.

"We need a biopsy," I said. At my words, her husband asked, "Is it cancer?"

That word always makes the air in the room feel heavy. I took a moment to catch my breath before speaking. "We cannot rule out the possibility. Adenocarcinoma of the appendix, in particular, can look like appendicitis in its early stages".

🩺 Medical Insight: What is Adenocarcinoma of the Appendix?

A rare malignant tumor occurring in the appendix.

Accounts for less than 1% of all gastrointestinal cancers.

Early symptoms are similar to acute appendicitis.

Mucinous adenocarcinoma is the most common type.

Often discovered only after peritoneal metastasis due to difficulty in early detection.

The Surgery

The lights in the operating room are always serene. Before picking up the scalpel, I pause. A surgeon always stands in silence before facing the truth hidden within the body.

The appendix was more swollen than expected, and its surface was uneven. I carefully resected it. But the problem didn't end there. Inside the abdominal cavity, jelly-like mucus was slowly pooling. In that moment, a term flashed through my mind: Pseudomyxoma Peritonei.

 

🩺 Medical Insight: Pseudomyxoma Peritonei

Mainly arises from mucinous adenocarcinoma of the appendix.

Cancer cells produce mucus that spreads throughout the abdominal cavity.

Causes abdominal distension and digestive issues.

Requires complete cytoreduction and HIPEC treatment.

In the guardian briefing room after surgery: "It is cancer". Her husband couldn't speak for a while. "Has it spread?" "At this point, we suspect mucinous spread within the peritoneum". Silence. Then, a very small voice asked: "Will she live?" Instead of answering, I closed the chart. "I will do my very best". A doctor’s language is sometimes cowardly. But one cannot abandon hope.

An Unexpected Second Discovery

The pathology results were clear: suspected Stage IIIC mucinous adenocarcinoma of the appendix. However, a few days later, the patient complained of abdominal bloating again. I performed an ultrasound. And there, I saw another shadow.

Both ovaries were enlarged. These were no simple cysts. I requested a consultation with Gynecology.

"Could another cancer have traveled to the ovaries?" her husband asked. The Gynecology professor spoke cautiously. I nodded. "It’s possible. Especially if it’s a Krukenberg Tumour". The guardian didn't understand. "What... what kind of disease is that?" I drew a diagram on a piece of paper. "There are cases where the primary cancer is in the stomach, colon, or appendix, and those cells metastasize to the ovaries. We call that a Krukenberg Tumour".

 

🩺 Medical Insight: Krukenberg Tumour

A metastatic tumor of the ovary.

Primarily originates from stomach, colorectal, or appendiceal cancer.

Characterized by signet ring cells.

Frequently bilateral (affecting both ovaries).

Poor prognosis.

That night, I went up to the hospital rooftop. The winter air in Cheongju was cold. A doctor knows the statistics—the five-year survival rate, median survival time, and recurrence rates. But patients don't know statistics. For her, the remaining time isn't a number; it’s her child's graduation, a family trip, and birthday cakes.

Her Question

The next day, she asked, "Doctor, is my illness rare?" "Yes, it is very rare". "Why me?" Science cannot answer that question. Instead, I said, "What we can do is understand this disease accurately and choose the best treatment". She thought for a moment and smiled. "Then please, leave my case in the textbooks". It sounded like a joke, but in that moment, I knew I had to record this story.

The Second Shadow in the Ovaries

Three days after the pathology results came out, I headed to the Gynecology conference room. CT, MRI, and PET scans were laid out on the table. Her abdominal cavity on the screen looked like an unfolded map.

"It's bilateral," the Gynecology professor’s voice was low but firm. "The likelihood of metastasis is high. It’s a classic Krukenberg Tumour pattern". I stared at the ovaries on the screen. Round, solid shadows with mucinous components inside. The primary was appendix cancer, and now it was in the ovaries. This wasn't just appendiceal cancer anymore; this was a story traversing the entire abdominal cavity.

In the Briefing Room

"Has it spread to the ovaries?" Her husband stared intensely at my face, hands clasped. I slowly flipped through the chart. "Current imaging suggests metastatic ovarian tumors, known as Krukenberg Tumours". She lowered her head for a moment. "Then the uterus, too...?" "The uterus shows no signs of involvement currently, but the scope of surgery may need to be widened". A long silence followed. She finally spoke: "Doctor, I’m only forty-five". In those words were her fears of losing her femininity, her youth, and her life.

 

🩺 Medical Insight: Why does appendix cancer spread to the ovaries?

Cancer cells in the abdominal cavity move along the flow of peritoneal fluid and gravity.

Ovaries have rich blood and lymph circulation, making them a "fertile soil" for cancer cells.

Mucinous adenocarcinoma cells have high cell-adhesion properties.

Krukenberg tumours are mostly bilateral.

Deciding on Surgery

The treatment options were clear: bilateral oophorectomy, cytoreductive surgery for the peritoneal tumors, and HIPEC. "What is HIPEC?" her husband asked. I drew another diagram. "It's a treatment where we circulate heated chemotherapy drugs directly into the abdominal cavity after surgery to eliminate microscopic cancer cells". She nodded. "Is it painful?" "It is a grueling surgery, but it is currently the most aggressive treatment available".

 

🩺 Medical Insight: HIPEC (Hyperthermic Intraperitoneal Chemotherapy)

Circulating heated chemo drugs within the abdominal cavity.

Maintained at 41–43°C.

Reported to improve survival rates in peritoneal metastasis.

Standard treatment for appendiceal cancer and pseudomyxoma peritonei.

"Doctor," she called out to me. "If I have this surgery... how long can I live?" I took a breath and said, "Statistically, the five-year survival rate is reported between 40% and 60%. But it varies for every individual". She smiled. "Then I'll stand on the 60% side". In that moment, I bowed my head—not as a doctor, but as a human being.

Telling the Children

The day before surgery, she called her children to her hospital room. A sixteen-year-old son and a twelve-year-old daughter. "Mom has some bad cells in her belly". The son was silent; the daughter burst into tears. "Are you going to die?" That question is always so direct. She hugged her daughter and said, "Mom will be back after the surgery. The doctor is going to help me". I stood outside the door, listening. A doctor holds the scalpel, but the family endures the time.

Six Hours in the Operating Room

The surgery was long. Tiny mucinous nodules were scattered across the peritoneal surface, and I resected them one by one. The ovaries were hard. After resection, I sent them to pathology. Then, we prepared for HIPEC. We inserted tubes into the abdominal cavity and circulated the heated chemotherapy. The temperature in the OR rose, and sweat beaded on my forehead. This wasn't just a surgical procedure; it was a battle to claw back even a few percentage points of survival probability.

 

🩺 Medical Insight: Prognosis of Krukenberg Tumour

Depends on the type of primary cancer.

Early surgical resection can extend survival.

Prognosis worsens with the presence of peritoneal metastasis.

Multidisciplinary treatment is essential.

The ICU

After surgery, she was in the Intensive Care Unit. Her consciousness was hazy, but her hands were warm. Her husband asked, "Doctor, was it a success?" In medicine, "success" is rarely clear-cut. I said, "We did our best. Now we must wait for her recovery". He lowered his head. "I wish I could be the one hurting instead". Those words are not written in any medical textbook.

10. When She Opened Her Eyes

Two days later, she woke up. "Is it over?" "Yes. You endured it well". She smiled. "So, can I live now?" Instead of answering, I handed her some water. "We are still fighting".

11. An Unexpected Question

One day during her recovery, she asked, "Doctor, what if it comes back?" I was silent for a moment. "We will treat it then, too. However..." "However?" "We must also consider your quality of life". She looked out the window. "More than living a long time, I want to remain a healthy mother in my children's memories". That statement hit me deep in my chest.

 A Doctor's Night

That night, I re-read her chart in the hospital records room.

  • Adenocarcinoma of the appendix.
  • Pseudomyxoma peritonei.
  • Krukenberg tumour.
  • HIPEC performed.

Medically, it was a complex case. But the essence was simple: a woman who wanted to live.

The End of the Prologue, and a New Beginning

She was discharged. Chemotherapy lay ahead, as did the risk of recurrence. Yet, she walked out of the hospital on her own. I watched her back and thought: cancer is a rebellion of cells, but life is a history of will.

And so, I decided to record this story. This isn't just a case of appendiceal cancer; it is a record of a family’s time and the humility a doctor learned.

 

 Part I: The Season of Chemotherapy

 

On her first outpatient visit after discharge, she appeared wearing a hat. Her surgical scars were healing, but the look in her eyes had changed. If before it was a resolve mixed with fear, now it held a quiet calculation.

"Doctor, this is the real start, isn't it?" I nodded. "Yes. We begin systemic chemotherapy now". Her diagnosis was still written in bold at the top of the chart: Adenocarcinoma of the appendix with peritoneal metastasis; Status post cytoreductive surgery + HIPEC; Suspicious Krukenberg Tumour. To a doctor, it’s a long, complex sentence; to her, it meant just one thing: "I am a cancer patient".

 Explaining the Chemo

"What kind of drugs will be used?" "We are considering a FOLFOX-based regimen, which includes 5-FU and Oxaliplatin". She quietly took notes. "Will all my hair... fall out?" "It’s a possibility". She smiled briefly. "The kids will be surprised". I told her seriously, "Hair loss is just a part of the treatment. It doesn't mean the cancer is winning".

🩺 Medical Insight: Chemotherapy for Appendix Cancer

Large-scale standardized clinical studies are limited.

Colon cancer protocols (FOLFOX, FOLFIRI) are often applied.

Mucinous adenocarcinoma tends to have lower response rates to chemo.

Adjuvant chemotherapy is recommended after HIPEC.

The First Infusion

The chemo room is always quiet. The liquid dripping from the IV feels like units of time. She looked out the window and asked, "You've seen many patients like me, haven't you?" "Yes, but every time is different". "Will I be different, too?" "You will". She laughed. "Then I'll be 'different' by being the one who survives". That resolve was quiet but powerful.

Hair Loss

After the third cycle, she took off her hat. Her remaining short hair came away at her fingertips. "Now I really look like a patient, don't I?" I shook my head. "No. You look like someone undergoing treatment". She looked in the mirror. "It’s a bit sad, as a woman". I thought for a moment and said, "Losing your ovaries, losing your hair... those are parts of your body. But your life is still yours".

 

🩺 Medical Insight: Krukenberg Tumours and Hormonal Changes

Bilateral oophorectomy causes early menopause.

Increased risk of hot flashes, mood swings, and osteoporosis.

Hormone replacement therapy must be decided cautiously based on the primary cancer type.

She nodded. "Doctor, I am still a mother". That statement was stronger than any medicine.

Tumor Markers

CEA levels dropped slightly. CA 19-9 also decreased. "This is a good sign," I said. Her husband exhaled. "Does that mean she’s getting better?" "For now, there is a response". She looked at me. " 'Response.' I like that word". I closed the chart, thinking how in cancer treatment, we use the word "response" far more often than "cure".

Fatigue

Week five of chemo. She was more soft-spoken. "I'm so tired". "Are you eating?" "I'm forcing myself to". Her daughter asked, "Mom, are you okay?" She smiled and said, "Mom is just fighting a battle inside her body right now". I repeated those words in my heart: Yes, she is fighting.

 

🩺 Medical Insight: Managing Chemotherapy Side Effects

Peripheral neuropathy (from Oxaliplatin).

Nausea and vomiting.

Myelosuppression → decreased white blood cell count.

Infection prevention is essential.

A Question in the Clinic

"Doctor, is a full recovery possible?" The question always repeats. I told her honestly: "The condition is close to Stage IV. The probability of a complete cure is low; however, there are cases of long-term survival". She thought for a moment. "Then I will become a case of long-term survival". I smiled. "You might even end up in a medical journal". "That sounds good. Use my children’s names instead of mine".

The Husband's Confession

After the appointment, the husband sought me out separately. "Doctor, honestly, how much time does she have left?" I was silent for a moment. "The median survival time is reported as 3 to 5 years, but it varies greatly by individual". He closed his eyes. "Then during that time, I will be an even better husband". I looked at him and said, "That, too, is part of the treatment".

 A Small Miracle

Six months later, the CT scan showed the peritoneal nodules had decreased in size. There were no new lesions. I zoomed in on the monitor to double-check. "It is a stable disease". She clasped her hands together. "Thank you". I shook my head. "This is the result of your endurance".

However...

Medicine always leaves a clue. There was a tiny shadow on the surface of the liver. It wasn't certain yet. I closed the chart. "We’ll re-examine in three months". She read my eyes. "You saw something, didn't you?" I nodded. "It’s not confirmed yet". She sighed. "Cancer is truly relentless".

 

🩺 Medical Insight: Recurrence Patterns of Appendix Cancer

Peritoneal recurrence is common.

Metastasis to the liver surface is possible.

Long-term follow-up is mandatory.

Rising CEA levels are an early warning sign.

Her Choice

"Doctor, if it comes back, will I have surgery again?" "We will consider it if it's possible". "Then I will keep fighting". I said softly, "Sometimes, just living is more important than fighting". She looked out the window. "Then I will do both". The answer was simple, yet profound.

Chemotherapy continued. Her hair began to grow back slowly. Her children found their laughter again. But I knew this story hadn't even reached its midpoint. The cells remaining on the peritoneum were silent. And silence is never forever.


To be continued! 

#AppendixAdenocarcinoma #KrukenbergTumour #PeritonealMetastasis #HIPEC #MedicalHumanStory #CancerAndLife #PalliativeMedicine


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