Pseudomyxoma peritonei (PMP) is a rare and uncommon condition, characterized by the presence of mucinous ascites in the abdominal cavity. The most common cause of PMP is mucinous adenocarcinoma of the appendix, followed by neoplasms of the ovary, endocervix, fallopian tube, alimentary organs, urachus, urinary bladder, lung, mucinous cyst of the spleen, and breast.

Herein, we report a case of a 64-year-old postmenopausal woman (gravida 2, para 2) who presented at the department of gynecology with a short history of nausea and abdominal distention. Abdominal and vaginal ultrasonography showed a large amount of free fluid in the pelvis with hyperechoic echogenicity and right pelvic tumor with mixed echogenicity. Computed tomography demonstrated the presence of a heterogeneous, hypodense mass, without contrast enhancement, located on the right side of the pelvis, near the right ovary. Laparotomy was performed. Revision of the abdominal cavity revealed a large amount of yellow gelatinous mucinous ascites – approximately 1.5 l. A tumor (6 x 7 cm in diameter), arising from the appendix and located in the pouch of Douglas near the right ovary, was observed. Histopathology examination revealed poorly differentiated mucinous appendiceal adenocarcinoma, comprising up to 50% signet ring cells.

Gastrointestinal tumors such as appendiceal neoplasms combined with PMP may mimic ovarian carcinomas. Computed tomography, abdominal/vaginal ultrasonography and tumor marker levels (carcino-embryonic antigen, carbohydrate antigen 19.9, carbohydrate antigen Ca-125) may establish the diagnosis.

A differential diagnosis with appendiceal tumors should be considered for patients with right pelvic masses.

• appendectomy
• appendiceal neoplasm
• mucin
• ovarian tumors
• pseudomyxoma peritonei

Appendiceal tumors are rare lesions that may not be easily differentiated from primary ovarian lesions preoperatively, despite the use of advanced diagnostic methods by experienced clinicians.

A 59-year-old G2P2 woman, with chronic pelvic pain, underwent a pelvic ultrasound that revealed an adnexal mass measuring 58 mm × 34 mm × 36 mm, with irregular borders, heterogeneous echogenicity, no color Doppler vascularization and without acoustic shadowing. Normal ovarian tissue was visualized in contact with the lesion, and it was impossible to separate the lesion from the ovary by applying pressure with the ultrasound probe. Ascites, peritoneal metastases or other alterations were not observed. With the international ovarian tumor analysis ADNEX model, the lesion was classified as a malignant tumor (the risk of malignancy was 27.1%, corresponding to Ovarian-Adnexal Reporting Data System category 4). Magnetic resonance imaging confirmed the presence of a right adnexal mass, apparently an ovarian tumor measuring 65 mm × 35 mm, without signs of invasive or metastatic disease. During explorative laparotomy, normal morphology of the internal reproductive organs was noted. A solid mobile lesion involved the entire appendix. Appendectomy was performed. Inspection of the abdominal cavity revealed no signs of malignant dissemination. Histopathologically, the appendiceal lesion corresponded to a completely resected low-grade mucinous appendiceal neoplasm (LAMN).

The appropriate treatment and team of specialists who should provide health care to patients with seemingly adnexal lesions depend on the nature (benign vs malignant) and origin (gynecological vs nongynecological) of the lesion. Radiologists, gynecologists and other pelvic surgeons should be familiar with the imaging signs of LAMN whose clinical presentation is silent or nonspecific. The assistance of a consultant specializing in intestinal tumors is important support that gynecological surgeons can receive during the operation to offer the patient with intestinal pathology an optimal intervention.

• Adnexal mass
• Appendiceal neoplasm
• Diagnostic imaging
• Pelvic neoplasm
• Adnexal diseases
• Pelvic neoplasm
• Case report

• Appendiceal mucinous neoplasm
• Appendiceal mucocele
• High grade
• Low grade
• Pseudomyxoma peritonei

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Appendiceal mucocele defines as an intraluminal dilation of the appendix in response to mucin accumulation.

Appendiceal mucocele (AM) is a very rare neoplasm with an incidence of 0.2–0.3% of all appendectomy specimens. AM usually defined as an intraluminal dilation of the appendix in response to mucin accumulation. The preoperative diagnosis is difficult and can be misdiagnosed to any of the other differential diagnosis especially in female patients. If it is suspected, imaging modalities and colonoscopy can be helpful as a guide for the right surgical approach.

A 41-year-old lady who found to have an appendicular tumor discovered incidentally on magnetic resonance imaging (MRI) of the abdomen during a follow-up in the referral hospital for persistent right lower quadrant abdominal pain with enlarging right ovarian cyst for 2 years. MRI revealed a sizeable cyst measuring 7 × 4 × 3 cm in the right iliac fossa (RIF) region with high suspicion of an AM. The patient was managed with open right limited hemicolectomy. The patient was diagnosed as a well-differentiated low-grade AM neoplasm with stage 0 (pTis, pN0, M0) based on the 8th edition of the American Joint Committee on Cancer (AJCC) Staging System. The patient had an uneventful recovery and advised for regular follow-up of at least 5 years.

AM is a very rare neoplasm. The imaging modalities that can be diagnostic methods are the abdominal ultrasonography (US), transvaginal US, abdominal computed tomography (CT) and abdominal MRI. Fine needle aspiration must be avoided as the risk of perforation is high that will lead to dissemination of the mucinous material causing a serious complication called pseudomyxoma peritonei. Laparotomy is superior on laparoscopy as the risk of perforation is lower in laparotomy.

The presentation of AM is usually not specific, because of its anatomic position. Physicians should consider it in the differential diagnosis of persistent enlarging ovarian cyst or adnexal mass.

• Appendix
• Mucocele
• Ovarian cyst

• appendiceal neoplasm
• classification
• cytoreductive surgery
• hipec
• intraperitoneal hyperthermia
• pseudomyxoma peritonei