Primary peritoneal serous carcinoma – a case report and literature review

Primary peritoneal serous carcinoma represents a rare epithelial tumor originating at the level of the peritoneum which might exhibit common features with ovarian carcinoma; therefore, establishing the correct diagnostic might represent a real cornerstone and, in certain cases, the final diagnostic is established only at the time of surgery. Fortunately, in most cases the therapeutic strategies of primary peritoneal serous carcinoma and ovarian carcinoma are similar in terms of surgical procedure and oncological treatment. The aim of the current paper is to report the case of a 71 year old patient with preoperative diagnostic of ovarian carcinoma and in whom the final diagnostic was of a primary peritoneal serous carcinoma.


INTRODUCTION
Primary peritoneal serous carcinoma represents a rare epithelial malignancy originating at the level of the peritoneal lining, initially described in 1959 by Swerdlow [1]. One of the most important features of this tumor is the fact that it has common clinical and histopathological characteristics with ovarian carci noma, especially with the serous epithelial subtype [2]. Due to these reasons, and due to the rarity of cas es, therapeutic strategies for primary peritoneal se rous carcinomas have been extrapolated from those for epithelial ovarian cancer [3]. However, we should not omit the fact that even radical surgery with cura tive intent followed by adjuvant chemotherapy is performed, primary serous peritoneal carcinoma ex hibits a poorer prognosis when compared to epitheli al ovarian cancer [4]. The aim of the current paper is to present the case of a 71 year old patient investigat ed for asthenia and distension of the abdomen who was initially suspected to have an ovarian malignant tumor but in whom a primary peritoneal serous car cinoma was found.

CASE REPORT
The 71 year old patient with no significant medi cal history was investigated for diffuse abdominal pain, abdominal distension and fatigability; the ab dominal ultrasound demonstrated the presence of a ABSTRACT Primary peritoneal serous carcinoma represents a rare epithelial tumor originating at the level of the peritoneum which might exhibit common features with ovarian carcinoma; therefore, establishing the correct diagnostic might represent a real cornerstone and, in certain cases, the final diagnostic is established only at the time of surgery. Fortunately, in most cases the therapeutic strategies of primary peritoneal serous carcinoma and ovarian carcinoma are similar in terms of surgical procedure and oncological treatment. The aim of the current paper is to report the case of a 71 year old patient with preoperative diagnostic of ovarian carcinoma and in whom the final diagnostic was of a primary peritoneal serous carcinoma.
Keywords: primary peritoneal serous carcinoma, ovarian carcinoma, surgery, chemotherapy high volume of ascites while the paraclinical tests revealed increased levels of serum CA 125 (measur ing 2100U/ml). The patient was further submitted to a computed tomography which demonstrated the presence of a tumoral mass at the level of the left adnexa measuring 4/5/4 cm and a high amount of ascites. Therefore, the presumptive diagnostic was of an advanced stage ovarian carcinoma so the pa tient was further submitted to surgery. Intra ope ra tively 4000 ml of ascites were evacuated; however, although the presence of peritoneal carcinomatosis was expected, no macroscopic nodule was found. At the level of the pelvis the tumoral mass at the level of the left adnexa was found, so the patient was fur ther submitted to the standard surgical procedure consisting of total hysterectomy with bilateral ad nexectomy, pelvic lymph node dissection and omen tectomy (Figures 1, 2). When transecting the speci men, we observed that the tumor was in fact developed at the level of the peritoneum of the left broad ligament and came in close contact with the    left ovary without invading the parenchyma. The fi nal histopathological result confirmed the presence of a primary peritoneal serous carcinoma with no metastases at the level of the omentum and at the level of the retrieved lymph nodes. The postopera tive outcome was uneventful, the patient being dis charged in the fourth postoperative day and re ferred to the oncology service in order to be submitted to the standard adjuvant treatment.

DISCUSSIONS
Primitive peritoneal serous carcinoma usually spreads via peritoneal route, leading to the develop ment of omental metastases and rarely involves the ovaries [5]. However, these tumors usually exhibit common characteristics with ovarian carcinoma in terms of histopathological features and therefore, the therapeutic strategies are similar, the first intent option being represented by optimal cytoreduction followed by platinum based chemotherapy [6]. In order to maximize the effects of debulking surgery, the NCCN guidelines recommend association of in traperitoneal chemotherapy followed by adjuvant intravenous chemotherapy [7].
Another interesting aspect which should be dis cussed when it comes to primitive peritoneal serous carcinoma is related to the correlation with the se rum levels of CA 125 and with the presence of as cites; although traditionally it has been thought that these two elements are associated with the presence of ovarian cancer, it seems that these two parame ters are also found at elevated values in cases diag nosed with primitive peritoneal serous carcinoma. Meanwhile, CA 125 levels are also useful in order to provide an effective follow up after surgery and to allow a rapid identification of recurrent disease [8].
Besides CA 125 levels, other prognostic factors in these cases are represented by age at the initial diag nostic, performance status and completeness of cy toreduction [9].
Unfortunately, patients diagnosed with primary peritoneal serous carcinoma exhibit a poorer prog nosis when compared to epithelial ovarian cancer, the median overall survival ranging between 11 and 17 months [9].

CONCLUSIONS
Primitive peritoneal serous carcinomas are rare epithelial malignancies with similar features in terms of clinical, histopathological and therapeutic options to epithelial ovarian cancer; therefore, al though in certain cases the patient is submitted to surgery with the preoperative diagnostic of ovarian cancer, the final diagnostic will be established at the time of surgery. However, due to the fact that the type of the procedure is similar, this fact does not influence the overall outcome.