Introduction

Hernia sac tumors are classified as intrasaccular, saccular and extrasaccular, based on the anatomical relationship of the tumor to the hernia sac (1, 2). Intrasaccular tumors, one of the most frequent type, consist of primary tumors of organs in the hernia sac, such as cancers of colon, bladder, and metastatic neoplasm involving the omentum. Saccular tumors include primary or secondary malignant lessions involving the peritoneum, such as primary mesothelioma and peritoneal metastasis from intrabdominal organs. Extra saccular tumors are  those that protrude through the hernia defect but are outside the hernia sac, examples include metastatic inguinal lymph nodes(1-3). We report a case of metastatic adenocarcinoma in the inguinal hernial sac, confirmed by histopathology. Post-operative work up revealed an adenocarcinoma of the of the distal ileum and ileocecal junction.

Case report

A 57 year old man, with no known comorbid, was admitted with the complain of bilateral inguinal swelling since one year. Physical examination showed bilateral non reducible inguinal hernia. His base line laboratory tests were all within normal limits and chest radiographs was unremarkable. Patient was given cardiac fitness and he was prepared for laparoscopic hernioplasty. During surgery, white nodules were seen on parietal peritoneum and omentum and only right sided inguinal hernia was observed. So biopsy was taken and mesh repair was done on the right side. Histopathology of the biopsy showed metastatic adenocarcinoma. The patient was evaluated for any intrabdominal neoplasms. We aslo conducted the patients CEA levels and CA19-19 levels, which came out to be 14.04ng/ml (<3.5ng/ml) and 125.2u/ml( <27u/ml), respectively. Abdominal and pelvic ultrasound only revelaed hypoechoic lessions on the liver.  Esophagogastroduodenoscopy (O.G.D) showed antral gastritis and biopsies were taken which showed no evidence of malignancy. Colonoscopy showed rounded well demarcated lessions measuring 1.5cm seen in the cecum, multiple biopsies were taken. However, Biospsy showed no evidence of malignancy. Computed topography (C.T)  of abdomen and chest showed a neoplastic mass involving the distal ileum and the ileocecal junction, with lymphadenopathy, peritoneal carcinomatosis, as well as hepatic and lung deposits metastasis. The patient was considered inoperable and hence, no surgery was considered. The patient left against medical advice for unknown reasons and was not followed. Discussion Malignant tumors presenting within inguinal hernias are very rare. Literature reveals less than 0.4% of the excised hernia tissue shows microscopic evidence of neoplasia (4). Furthermore, amongst the neoplasms, carcinoma of the colon is the most common primary tumor associated with hernia sac metastasis (1, 4). In our case, the neoplasm involved small bowel ( distal ileum) as well as the ilececal junction. To our knowledge, there is no literature available which mentions a case of metastatic  ileal/illeocecal junction neoplasm presenting as an inguinal hernia. One possible explanation for the occurrence of inguinal hernia could be due to the increased intra-abdominal pressure secondary to the intra- abdominal neoplasm, occurring especially in the elderly (1, 5). For instance, obstructive colon cancer, massive tumors or tumors associated with ascites can lead  to increased intra-abdominal pressures and resulting in inguinal hernia. However, in our patient, there were no additional symptoms, indicating that other factors were involved. Patients presenting complain can be an important factor, which could  raise suspicion of an underlying malignancy(2).  Some Authors believe that long standing hernia, becoming acutely incarcinated has a greater chance of containing a tumor while others believe that any non reducuible mass in inguinal canal, lacking an impulse, should raise concern for malignancy (2). Furthermore, constitutional symptoms can also suggest the possibility of an underlying malignancy. According to (2), abdominal pain was the most frequent symptom present pre-operatively. Our patient had bilaterally non reducible inguinal hernia, however, he showed no constitutional symptoms. Since peritoneum is a common site of intra-abdominal metastasis, a hernia repair gives a good opportunity to the surgeon for a peritoneal biopsy, thereby providing an earlier diagnosis. Furthermore, due to reports of occult malignancies in histopathological examination of hernia sac, several authors have recommended routine microscopic examination of hernia sac(1, 6). However, other authors have reported histopathological examination in only selected cases(1). Several authors also suggest a routine fiber optic sigmoidscopy in patients presenting with hernia, because of the coexistence of inginal hernia and colonic cancer (1, 7). Conclusion  In conclusion, our study showed that inguinal hernia and ileum/illeocecal junction neoplasm can coexist togather, especially in the elderly. In addition, it also reported that any irreducible hernia can raise suspicion of metastasis and, the patient  can be asymptomatic as well at the time of presentation. Despite the rare co-existence between hernia and malignancy, we still recommend the routine microscopic histopathologic examination, as this can lead to an earlier diagnosis and if the patient is asymptomatic, this can be the only means to determine an occult malignancy.

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