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LETTER TO EDITOR  
Year : 2013  |  Volume : 56  |  Issue : 3  |  Page : 324-325
Primary peritoneal serous psammocarcinoma: A rare case


1 Department of Pathology, AFMC, Pune, India
2 Department of Obs and Gynae, AFMC, Pune, India

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Date of Web Publication24-Oct-2013
 

How to cite this article:
Singh V, Srinivas V, Dutta V, Kapoor K. Primary peritoneal serous psammocarcinoma: A rare case . Indian J Pathol Microbiol 2013;56:324-5

How to cite this URL:
Singh V, Srinivas V, Dutta V, Kapoor K. Primary peritoneal serous psammocarcinoma: A rare case . Indian J Pathol Microbiol [serial online] 2013 [cited 2020 Jun 4];56:324-5. Available from: http://www.ijpmonline.org/text.asp?2013/56/3/324/120417


Sir,

Psammocarcinoma is a rare variant of serous carcinoma arising from the peritoneum or ovary. [1] To the best of our knowledge there have been about 35 cases of PPP reported so far, including few case reports from India. [2] PPP mimics ovarian serous adenocarcinoma and peritoneal mesotheliomas but it appears to behave in an indolent fashion. [3]

In this case, a 55-year-old woman, postmenopausal, gravida 2, para 2, presented with pain in lower abdomen and with one month history of abdominal discomfort and distension. Her last gestational event was a child birth 35 years back. She gave no significant past, personal and family history.

Physical examination revealed ascites and positive shifting dullness. Gynecological examination showed hard cervical texture with high tension of uterine fornix. Pelvic ultrasound demonstrated extensive ascites. Tumor markers were investigated. CA 125 level was elevated (262.60 U/mL), while CA19.9 levels, carcino-embryonic antigen (CEA) and anti-α fetoprotein antibody (AFP) were within normal limits. Antinuclear antibody (ANA) test was negative. Hematological parameters and chest roentgenogram were normal. Abdominal ultrasonography showed gross ascites and thickened broad ligaments on both the sides. Both the ovaries, fallopian tubes, uterus appeared normal [Figure 1]a.

A computerized tomography (CT) abdomen confirmed ascites and showed omental nodules of varying size. Ascites was present with omental thickening involving the supracolic and infracolic omentum [Figure 1]b. Cytology of the ascitic fluid showed atypical cells arranged in papillaroid fragments and three-dimensional clusters with focal signet ring cell morphology suggestive of adenocarcinoma.

With a clinical diagnosis of primary peritoneal carcinoma, she was given three cycles of neo adjuvant chemotherapy, followed by interval cytoreduction with hysterectomy and bilateral ­salpingo-oophorectomy' and omentectomy. Intraoperatively, uterus and bilateral ovaries were normal. Gross examination revealed normal cervix, endometrium, myometrium and fallopian tubes. Both the ovaries were normal in size but the surface of right ovary revealed a small nodular prominence. Omental tissue showed multiple thickened nodules, largest measuring 2 × 1 cm in size [Figure 2]a. Microscopic examination of the omentum showed numerous (>80%) psammoma bodies along with atypical cells arranged as papillary architecture surrounded by desmoplastic reaction and chronic lymphomononuclear cells. These atypical cells were of moderate size with scant cytoplasm, enlarged round to oval nuclei showing mild nuclear atypia. Occasional mitoses were seen [Figure 2]b.
Figure 1: Imaging findings: (1A) Ultrasonogram of pelvic region showing ascites and bilateral broad ligament thickening; (1B) Computerized tomography abdomen showing omental thickening and ascites

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Figure 2: Gross and histopathological examination findings: (2a) Omental nodules; (2b) Photomicrograph (Hematoxylin and Eosin stain: 400×) omental nodule showing numerous psammoma bodies with glandular spaces lined by atypical cells of moderate size with scant to moderate cytoplasm, enlarged round to oval nuclei showing mild nuclear atypia; (2c) Photomicrograph (Hematoxylin and Eosin stain: 400×) showing presence of psammoma bodies and similar tumor cells on the ovarian surface and (2d) IHC photomicrograph: 400×) showing strong positi vity of CK 7 in the atypical glands

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Sections from the right ovary showed presence of similar tumor cells, as seen in the omental nodules along with few psammoma bodies on the surface. However, no cortical involvement was seen [Figure 2]c. The cervix, endometrium and myometrium, both fallopian tubes and left ovary were microscopically unremarkable. Immunohistochemistry with cytokeratin (CK) 7 [Figure 2]d and epithelial membrane antigen (EMA) showed strong positivity in atypical cells and showed negativity for CK 20, calretinin, desmin. Her postoperative course was uneventful. Her serum CA 125 level were also normalized.

According to Gilks et al., [1] the diagnostic criteria of PPP include: (1) destructive invasion of the ovarian stroma, vascular, intraperitoneal viscera or peritoneum; (2) no more than moderate nuclear atypicality; (3) presence of nests of solid epithelial proliferations no greater than 15 cells in diameter and (4) psammoma bodies that replace at least 75% of the papillae or epithelial nests. The main differentiating feature from the ovarian carcinoma is gross peritoneal involvement without gross involvement of ovaries.

While PPP mimics ovarian serous adenocarcinoma, it however appears to behave in an indolent fashion. [3] However Akbulut et al. [4] concluded that psammocarcinoma may have recurrences and metastasis with elevated CA125 levels, suggesting the potential for an aggressive behavior. CA 125 was also elevated in our case but due to absence of ovarian pathology, the tumor was considered as a PPP.

The establishment of standard therapeutic protocols is hindered by the rarity of the condition. Poggi et al. [5] also emphasized that the indolent character of PPP should not be postulated and adjuvant treatment must always be seriously considered. A close follow-up is recommended in order to study the recurrence rates and determine the optimal treatment.

 
   References Top

1.Gilks CB, Bell DA, Scully RE. Serous psammocarcinoma of the ovary and peritoneum. Int J Gynecol Pathol 1990;9:110-21.  Back to cited text no. 1
    
2.Asotra S, Gupta S, Gupta N. Primary psammocarcinoma of peritoneum.Indian J Pathol Microbiol 2009;52:280-81.  Back to cited text no. 2
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3.Weir MM, Bell DA, Young RH. Grade 1 peritoneal serous carcinomas: A report of 14 cases and comparison with 7 peritoneal serous psammocarcinomas and 19 peritoneal serous borderline tumours. Am J Surg Pathol 1998;22:849-62.  Back to cited text no. 3
    
4.Akbulut M, Kelten C, Bir F, Soysal ME, Duzcan SE. Primary peritoneal serous psammocarcinoma with recurrent disease and metastasis: A case report and review of the literature. Gynecol Oncol 2007;105:248-51.  Back to cited text no. 4
    
5.Poggi SH, Bristow RE, Nieberg RK, Berek JS. Psammocarcinoma with an aggressive course. Obstet Gynecol 1998;92:659-61.  Back to cited text no. 5
    

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Correspondence Address:
Vikram Singh
Department of Pathology, Armed Forces Medical Collage, Pune
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.120417

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