Metastatic ovarian carcinoid tumor.

Case report The patient was a multiparous, unmarried female, age 66 years. She presented with a history of sudden onset of varicose veins some months previously, followed by oedema of the ankles for 6 weeks. Eight years previously she was investigated extensively for post-menopausal vaginal bleeding, no cause being found at that time. At the same time a duodenal ulcer was discovered, and treated successfully with a medical regimen. Five years later, a severe attack of diarrhoea was diagnosed clinically and radiologically as due to diverticulitis, and controlled with adequate doses of 'Lomotil'. On examination the patient was fit, and abdominal examination was essentially negative. Rectal examination revealed a large, firm mass in the pouch of Douglas. This was confirmed vaginally, but the mass appeared separate from the uterus, right-sided, and fixed to the lateral pelvic wall. Both legs showed marked varicosity of the long saphenous systems, together with minimal oedema of the ankle to midcalf regions. Operation. A laparotomy was performed through a lower, right paramedian incision. The terminal ileum was obstructed due to an extensive tumour. There was a large mass of glands along the right ovarian vein, particularly at the junction of the vein with the vena cava. Both lobes of the liver contained numerous metastatic tumour deposits. The pelvis contained a large, incarcerated, solid tumour of the right ovary, with involvement of the uterus medially, and the pelvic wall laterally. A total hysterectomy, bilateral salpingo-oophorectomy and radical excision of the right ovarian vessels, and lymph nodes as far as the vena cava, were performed. An ileo-transverse colostomy was also necessary to bypass the obstruction in the small bowel. Following operation she made a complete clincal recovery, the ankle oedema subsiding and the varicose veins completely resolving. The diarrhoea temporarily cleared, only to return after 4 months. At the same time, she began to develop more symptoms and signs of the malignant carcinoid syndrome, namely flushing attacks, facial cyanosis and attacks of breathlessness. The diarrhoea became uncontrollable. One year after operation, the liver has enlarged to fill approximately the upper half of the abdomen, and contains palpable secondary deposits of tumour. Despite all these problems she manages to lead a reasonably active life. Post-operatively, the 24-hr urinary excretion of 5-hydroxyindole acetic acid was 45 mg (upper limit