An unexpected tumour

A 47-year-old Caucasian woman from Dublin presented to the gynaecology clinic in Beaumont Hospital with a six-month history of progressively worsening, irregular, heavy intermenstrual bleeding and abdominal discomfort. She also had severe pelvic pressure symptoms. On palpation, she had a firm, tender pelvic mass. A transabdominal pelvic ultrasound scan showed a 10x6cm mass that was determined to be a uterine fibroid. The patient was scheduled for total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). At laparotomy, a large, irregular, nodular left ovarian mass and smaller right ovarian mass were discovered. Incidentally, the appendix was found to be grossly abnormal in appearance and distorted due to an irregular mass. Histology revealed a primary mixed adenocarcinoma and goblet cell neuroendocrine carcinoma of the appendix with ovarian metastases. Mixed adenocarcinoma and neuroendocrine tumours of the appendix are extremely rare, aggressive, and difficult to diagnose due to their nonspecific presentation. Few of these tumours have been reported in the literature and thus the standard of management and prognosis have not yet been established. The management of the few cases that have been published generally includes right hemicolectomy due to the invasiveness of the tumour. In this case, diagnosis was not made until a laparotomy intended to remove a uterine fibroid revealed an unexpected tumour.