Teaching Case

63 year old diagnosed to have gall stones came in for laparoscopic cholecystectomy. On inserting the laparoscope extensive calcification of the peritoneum was noted and the procedure was abandoned. Four years earlier the patient had presented with symptoms of abdominal discomfort and chronic constipation.

CT scan was performed to investigate this further which showed multiple calcified deposits on the serosal surfaces of the bowel, stomach, peritoneal surfaces of both para colic gutters (Figure 1) and the pelvis. Subcapsular calcification deposits were also seen around the liver and at the porta. A calcified cyst measuring 3.5 cm was noted within the right part of the pelvis (Figure 2) along with extensive calcification within the pelvis (Figure 3).
CT scan performed four years earlier in 2008 had shown calcification on the peritoneal surface anteriorly (Figure 4).
Abdomino-pelvic calcification was noted on abdominal radiographs (Figures 5 and 6) which were performed due to non specific symptoms reported by the patient after starting chemotherapy but these resolved spontaneously. The abdomino-pelvic calcification has not been described in other case reports of psammocarcinoma.

A.Background
Serous psammocarcinoma is a rare neoplasm which presents in women between the ages of 36 to 76 years [1]. This has a relatively favourable prognosis and very slow progression compared to other tumours although a more aggressive course of this type of neoplasm is also known to occur . Serous psammocarcinoma may arise primarily from the ovary or from the peritoneum. Primary ovarian cancer can be excluded if the size of the ovaries is found to be normal and equal bilaterally [2].
B.Clinical Perspective
Patients can present with a prolonged history of abdominal pain and distension. Imaging is requested to investigate the cause of these prolonged symptoms. Radiologically, calcification deposits are seen in the abdomen and pelvis. Serous psammocarcinoma is known to present with calcification in the omentum as well as in the paracolic and the perihepatic peritoneum [3].
C.Imaging Perspective
Diagnosis is confirmed by histology of biopsy specimens which characteristically shows psammoma bodies which are microscopic, laminated, calcified extracellular bodies[4].
Radiologically, calcification deposits are seen in the peritoneum and distant metastasis may be seen along with calcification of the ovaries. Serous psammocarcinoma is known to present with calcification in the omentum as well as in the paracolic and the perihepatic peritoneum [3]. In this patient we observed calcification around the liver and the porta, along with multiple deposits of calcification identified in the serosal surface of the small bowel, stomach and on the peritoneal surface of the paracolic gutters which had increased gradually over a period of four years. Hiromura et al (2007) described the MRI appreance of a psammocarcinoma arising from the ovary as a large, solid tumor with cystic spaces. Heterogenous areas were noted on T1 and T2 weighted images. Moderate enhancement of the tumor was seen with meglumine gadopentetate along with a sandy or coarse granular appearance on enhanced T1 weighted images
D.Outcome
Serous psammocarcinoma of the ovary is a rare neoplasm arising from the ovary or the peritoneum. It can present with vague symptoms and normal tumour markers [5]. Thus calcification in the peritoneum and abdominal viscera can give an important clue to their diagnosis and must be investigated further. Although in general, peritoneal calcification is usually indicative of benign conditions such as calcified leiomyomas, possibility of psammomacarcinoma has to be excluded as these neoplasms have a better prognosis than serous carcinomas of the ovary[6].