a 32-year - old woman presented with abdominal pain and distension for 2 months and vaginal bleeding of 1 month duration . on palpation , a vague mass was felt in the lower abdomen . per vaginal examination revealed a normal anteverted uterus . a 56  cm size mass was felt in the left fornix , which was firm , mobile and non - tender . a markedly elevated serum alpha - fetoprotein ( afp ) level to 11.357 ng / ml suggested the diagnosis of an ovarian yolk sac tumor . all other biochemical and laboratory investigations , including serum urea and creatinine , were also normal . subsequently , contrast - enhanced ct of the abdomen was performed , which revealed a 4.55.26  cm size complex mass lesion in the left adenexa . a well - defined enhancing solid component was seen with cystic areas adjacent to it . the uterine body was displaced to the contralateral side by the ovarian mass . enhancing soft tissue density nodular lesions were seen in the peritoneal reflections along the left paracolic gutter and pelvis ( fig . 1a , b ) . coarsened nodular and curvilinear sheetlike hyperdensities ( attenuation approaching that of bone ) were present , distributed along the undersurface of the hemidiaphragm , the perihepatic region and morrison 's pouch ( fig . these findings were suggestive of yolk sac tumor of the left ovary ( in view of the raised afp level ) with calcified peritoneal carcinomatosis . fine - needle aspiration cytology was obtained , which further confirmed the presumptive diagnosis of endodermal sinus tumor . the smear showed tumor cells arranged in papillary groups ; tight cell clusters were seen forming a glandular patterned acinar structure with a central capillary ( schiller  duval body ) . however , a histological diagnosis could not be ascertained as the patient did not undergo surgery . figure 1contrast - enhanced axial ct section through the pelvis : a complex left ovarian mass with pelvic peritoneal metastasis ( arrows ) . figure 2contrast - enhanced ct of the abdomen showing calcified peritoneal implants in the undersurface of the right dome of the diaphragm , perihepatic and perisplenic region , and morrison 's pouch ( arrows ) . contrast - enhanced axial ct section through the pelvis : a complex left ovarian mass with pelvic peritoneal metastasis ( arrows ) . contrast - enhanced ct of the abdomen showing calcified peritoneal implants in the undersurface of the right dome of the diaphragm , perihepatic and perisplenic region , and morrison 's pouch ( arrows ) . metastatic malignant peritoneal calcification is most frequently seen in serous cystadenocarcinoma , the most common type of ovarian malignancy , which also shows histological calcification in nearly 30% cases.the other malignancies that may cause peritoneal calcification are primary papillary serous peritoneal carcinoma , colon cancer , gastric cancer and also squamous cell lung cancer , renal cell carcinoma , and melanoma , which induce paraneoplastic hyperparathyroidism and hypercalcemia . systemic causes of mineral imbalance , such as uremia or hyperparathyroidism , cause metastatic calcification ; local tissue injury , the aging process or disease including malignancy cause a dystrophic type of calcification . peritoneal calcification is classified based on its morphological features . circumscribed or focal calcification is described as nodular , and flat curvilinear calcification extending along the peritoneal plane as sheetlike . although sheetlike calcification is more commonly associated with benign causes of peritoneal calcification ( peritoneal dialysis , tuberculosis ) it may be seen in its malignant counterpart ( 22% ) . calcified peritoneal metastasis has not been described in yolk sac tumor of the ovary before . endodermal sinus tumor of the ovary , also known as yolk sac tumor , is a rare complex malignant ovarian tumor of germ cell origin that occurs in girls and young women , usually in the second decade of life(mean age 19 years ) . all malignant germ cell tumors constitute about 5% and endodermal sinus tumor constitute < 1% of total malignant ovarian neoplasms . the diameter of this aggressive tumor ranges from 7 to 28  cm , with a median of 15  cm . yolk sac tumors exhibit malignant changes in a cell line committed to extra embryonic differentiation and secrete alpha - fetoprotein . the cut surface of the tumor shows cystic and solid areas along with large areas of hemorrhage and necrosis . cysts of varying sizes are diffusely scattered throughout the tissue , giving the tumor a honeycombed appearance . microscopically , the many endodermal sinus patterns may include reticular , papillary , solid , polyvesicular vitelline , and polyembryonal histology . . the tumor may be predominantly solid with areas of hemorrhage and cysts , displaying a heterogeneous appearance . ultrasonography reveals a pelvic mass depicting both echogenic solid and hypo / anechoic cystic components . ultrasonography may also show concurrent dermoid cyst of the ovary ( occurring in 14% cases ) , ascites , or urinary obstruction . however , the cystic nature of the mass is more easily appreciated on ct , probably because of the hemorrhage or protein content and multiple internal septations . ct is also useful in further characterizing and staging the mass . as extensive areas of hemorrhage and necrosis are common and striking findings in endodermal sinus tumor , identification of hemorrhage on magnetic resonance imaging ( mri ) as high intensity foci on t1-weighted images supports the diagnosis . hypervascularity in the form of prominent enhancement on post - contrast ct images or signal voids on mri may also be seen . metastases to the peritoneum , bowel serosa , omentum , liver or lymph nodes occur in 30% of cases . however , calcified peritoneal implants seen in the index case are not documented in the literature . the differential diagnoses of yolk sac tumor in a young female with a complex solid cystic abdominopelvic mass on imaging are cystic teratoma , tuboovarianabscess , appendiceal abscess , mesenteric cyst , or gastrointestinal duplication cyst . the serum alpha - fetoprotein level clinches the diagnosis . as endodermal sinus tumor exhibits rapid growth due its aggressive nature , a delay in diagnosis and subsequent treatment may harm the patient and sharply reduce the chances of survival , especially in patients with advanced disease . with surgery alone , survival is rare for these radio - resistant tumors . prior to the introduction of effective combination chemotherapy , the prognosis for patients with endodermal sinus tumor was poor ; with a 3-year survival rate of 13% . however , now the survival rates have risen to 82.5% for patients receiving cisplatin , vinblastine , and bleomycin combination chemotherapy . a high percentage of cases of clinically aggressive malignant ovarian germ cell tumors respond well to cisplatin - based chemotherapy and are curable .
abstractcalcified peritoneal implants have been attributed to various malignant and benign causes . 
 we present an interesting case of a 32-year - old woman who presented with abdominal pain , distension and vaginal bleeding . 
 contrast - enhanced computed tomography revealed calcified peritoneal implants with a malignant ovarian mass . 
 histopathology showed an endodermal sinus tumor , a rare cause of calcified peritoneal carcinomatosis .