Mahanti S*, Chaudhari HK**.
(* Senior Resident, ** Associate Professor, Department of Obstetrics and Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
The incidence of primary fallopian tube carcinoma is 0.1-1.8% of all malignancies of the female genital tract. This entity in gynecological oncology presents a diagnostic dilemma because in most cases it is extremely hard to have a provisional diagnosis of fallopian tube carcinoma preoperatively in view of non specific history and clinical findings. We are here presenting a case of a 52 year old postsurgical menopausal woman with primary endometrioid adenocarcinoma of the fallopian tube.
Primary fallopian tube cancer is a very uncommon entity in the gynecological oncology spectrum. However, with high clinical suspicion especially in the elderly population the condition can be diagnosed early and managed appropriately. Despite high clinical suspicion, the preoperative diagnosis of fallopian tube cancer is only as common as 0-10% and is most often an incidental intraoperative finding or histopathological diagnosis as was in this case.
52 year old presented to the gynecology outdoor patient department (OPD) with complaints of lower abdominal pain. She underwent vaginal hysterectomy five years back in view of abnormal uterine bleeding. However, she did not have any medical records or operative notes to elaborate on the indication and procedure performed. She had now come to the hospital in view of lower abdominal pain that was dull aching and localized to the lower abdomen. General and systemic examination was unremarkable. On abdominal examination, all quadrants were soft and non-tender. Vault appeared healthy on speculum examination. On bimanual examination, a soft boggy mass of 3 cm diameter was felt in the anterior fornix which was tender on palpation. Ultrasonography (USG) showed a retort shaped convoluted cystic lesion of 13.5 cm diameter in the pelvis in close proximity of the right ovary with a diameter of 8 mm at the ovarian end and 20 mm on the other end. Right ovary was 2x1cm in diameter whereas left ovary could not be visualized. There was no evidence of abdominal lymphadenopathy, ascites or collection in the right iliac fossa. USG reported it as right sided hematosalpinx. On re-evaluation of the USG findings by a senior radiologist, the mass was noted to have similar dimensions however, the contents of the mass were hyperechoic and the folds of the right fallopian tube were of increased vascularity. This led to a provisional diagnosis of right sided pyosalpinx and less likely to be hematosalpinx. Patient was managed conservatively with oral antibiotics (doxycycline and metronidazole) for 2 weeks. Repeat USG showed similar findings but features were suggestive of torsion of the right adnexal lesion. She continued to have complaints of lower abdominal pain. Hence, she was admitted and posted for exploratory laparotomy with bilateral salpingo-oophorectomy. Intraoperatively, right-sided, brown irregular cystic mass involving the right fallopian tube was seen with four turns of torsion around the right infundibulopelvic ligament. Right ovary appeared normal. Left ovary and fallopian tube grossly looked normal. Left mesosalpinx showed two tubercles of 0.5 cm diameter which were isolated and sent for histopathological examination. Uterus was absent (post-vaginal hysterectomy) and there was no free fluid in the abdomen. Curved clamp was applied across the right infundibulopelvic ligament, cut and pedicle was transfixed using polyglactin 910. Similar procedure was repeated on the left side. Specimen including bilateral ovaries, left fallopian tube and the right irregular cystic mass (pyosalpinx) was sent for histopathological examination. She tolerated the procedure and anesthesia well and was discharged on the eighth day after suture removal. On follow-up, histopathology report was suggestive of foci of endometrioid adenocarcinoma from a section of dilated right fallopian tube. There was evidence of proliferating glands, papilloid projections, tubules with complex architecture cytoplasmic vacuoles in the tubular lumen with focal invasion in the sub-epithelium.[Fig.1] There was no evidence of pre-existing endometriosis. Section from right ovary showed normal ovarian parenchyma. Left ovary and fallopian tube were unremarkable. Tubercle like tissue isolated from left mesosalpinx showed single hyalinised nodule with fibro-collagenous tissue but with no accompanying evidence of granuloma or malignancy. She was subsequently referred to a gynecological oncologist with the above report. A contrast enhanced computerised tomography of the abdomen and pelvis was done which did not reveal any lymphadenopathy or organomegaly. There was no ascites. She was started on cycles of paclitaxel and carboplatin based chemotherapy after confirming glomerular filtration rate above 83. Till date, she has received two cycles of chemotherapy and is planned to undergo exploratory staging laparotomy (re-look surgery) after the third cycle.
Figure1. Histopathological appearance of endometrioid adenocarcinoma of fallopian tube.
Though clinically and pathologically fallopian tube cancer resembles epithelial ovarian cancer, the exact etiology has still not been isolated. It is difficult to distinguish from serous epithelial ovarian cancer or primary peritoneal serous carcinoma. Unlike ovarian cancers that often present at a later stage, primary fallopian tube cancer presents earlier by virtue of the symptoms of pain abdomen in view of distension and torsion of the distended tube. All components of Latzko’s triad of symptoms of primary fallopian tube cancer including colicky abdominal pain, ‘hydrops tubae profluens’ or profuse sero-sanguineous vaginal discharge and abdominal or pelvic mass were rarely present. Since our patient had already undergone vaginal hysterectomy previously, the symptom of vaginal discharge was absent and the vault smear did not describe any atypical cells. Tumor markers such as CA 125 can also lead to the clinical suspicion of epithelial tumors of the fallopian tube. Tumor markers were however not done preoperatively for our patient and neither was it advised post operatively, when histopathology report suggestive of endometrioid carcinoma was noted. The role of tumor markers such as CA 125 have been evaluated in primary fallopian tube cancer and has been found to be elevated in advanced or recurrent conditions. Its role in primary endometrioid cancer of fallopian tube has still not been studied in detail. CA 125 maybe of significance in patients where initial levels are high to predetermine prognosis of the tumor and detect recurrence. Imaging modalities such as USG may show adnexal mass with solid mural nodules or complex sausage shaped lesions with cog wheel appearance. They however have poor specificity for detection of fallopian tube cancers. Magnetic resonance imaging is considered superior to computed tomography to evaluate the spread of disease in the soft tissues beyond the fallopian tube. According to the diagnostic criteria for primary fallopian tube cancer established by Hu and colleagues; grossly, the main tumor is in the tube and arises from the endosalpinx, the histological pattern reproduces the epithelium of tubal mucosa and transition from benign to malignant tubal epithelium should be demonstrated and ovaries and endometrium are either normal or have a much smaller tumor volume than that of the tube. Like ovarian carcinoma, fallopian tube carcinoma also has a surgical staging and the stage of the disease at initial exploration is a major determinant of the prognosis. The classification system for ovarian and fallopian tube carcinoma however is the same FIGO classification. Other determinants include volume of residual disease after initial cytoreductive surgery, presence of ascites and the histological grade of tumor. The most common histological subtype of fallopian tube cancer is adenocarcinoma. Endometrioid adenocarcinoma of the fallopian tube was the subtype seen in this case. Endometrioid adenocarcinoma is often associated with a previous history of endometriosis, which was not present in our case neither in her history nor on pathology to suggest of a pre-existing endometriosis. Definitive stage of the disease was not ascertained during the exploratory laparotomy since we did not have clinical suspicion regarding the condition. The re-look surgery planned after three cycles of chemotherapy could further enhance information regarding the same, even though postoperative computed tomography did not reveal any residual disease. Primary mode of management of fallopian tube cancer involves cytoreductive surgery to remove as much of the tumor as physically possible which usually includes total abdominal hysterectomy, bilateral salpingo-ovariectomy, omentectomy, selective pelvic and para-aortic lymphadenectomy for any stage of fallopian tube carcinoma. Postoperatively these patients usually receive adjuvant platinum based chemotherapy. Endometrioid carcinomas of the fallopian tube are typically noninvasive or only superficially invasive. This type usually has a favorable prognosis and hence this subtype of tubal carcinoma should be differentiated from the more common neoplasms of fallopian tube i.e. serous type. Rosen et al studied the 5-year survival rate for stage I and stage II cases and was 59% and for stage III and IV cases was 19% but this as not evaluated specific for the different histopathological types of carcinoma. The prognosis after adequate treatment also depends on the age and the medical co-morbidities of the patient.
Primary fallopian tube cancer though rare should be a differential diagnosis while evaluating postmenopausal patients with adnexal mass and pain abdomen. This will help provide adequate surgical management in the primary setting. The learning points in this case was to perform tumor markers which could have possibly heightened our clinical suspicion and to perform an intra-operative frozen section histopathology of the tumor could have facilitated a more complete surgical management in the form of a surgical staging. That said, fallopian tube cancers continue to remain a primary histopathological diagnosis in a majority of early stage cases at least.
We thank Dr. Ameya from department of surgical histopathology for providing us with the histology picture.
- Kalampokas E, Kalampokas T, Tourountous I. Primary fallopian tube carcinoma. Eur J Obstet Gynecol Reprod Biol. 2013 Jul;169(2):155–61.
- Jeung IC, Lee YS, Lee HN, Park EK. Primary carcinoma of the fallopian tube: report of two cases with literature review. Cancer Res Treat. 2009 Jun;41(2):113–6.
- Tahiri EL, Erragad FZ, Jayi S, Hammas S, Harmouch T, Chbani L, et al. Primary adenocarcinoma of the fallopian tube: report of two cases. J Clin Case Rep. 2016 May; 6: 792.
- Lau HY, Chen YJ, Yen MS, Chen RF, Yeh SO, Twu NF. Primary fallopian tube carcinoma: a clinicopathologic analysis and literature review. J Chin Med Assoc. 2013 Oct;76(10):583–7.
- Ajithkumar TV, Minimole AL, John MM, Ashokkumar OS. Primary fallopian tube carcinoma. Obstet Gynecol Surv 2005 Apr;60:247–252.
- Ludovisi M, De Blasis I, Virgilio B, Fischerova D, Franchi D, Pascual MA, et al. Imaging in gynecological disease (9): clinical and ultrasound characteristics of tubal cancer. Ultrasound Obstet Gynecol. 2014 Mar;43(3):328–35.
- Hu CY, Taymor ML, Hertig AT. Primary carcinoma of the fallopian tube. Am J Obstet Gynecol. 1950 Jan;59(1):58–67.
- Hariprasad PSH, Srinivas T, Shetty KJJ. Primary bilateral fallopian tube carcinoma the report of a single case with review of the literature. Clin Diagn Res. 2013;7(5):930–2.
- Navani SS, Alvarado-Cabrero I, Young RH, Scully RE. Endometrioid carcinoma of the fallopian tube: a clinicopathologic analysis of 26 cases. Gynecol Oncol. 1996 Dec;63(3):371-8.
- Berek JS, Crum C, Friedlander M. Cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet. 2015 Oct;131 Suppl 2:S111-22.
- Rosen AC, Ausch C, Hafner E, Klein M, Lahousen M, Graf AH. A-15 Year Overview of Management and prognosis in primary fallopian tube carcinoma. Austrian Cooperative Study Group for fallopian tube carcinoma. Eur J Cancer. 1998;34:1725–1729.
Mahanti S, Chaudhari HK. Fallopian Tube Cancer: A Rare Presentation. JPGO 2019. Vol.6 No. 7. Available from: https://www.jpgo.org/2019/07/fallopian-tube-cancer-rare-presentation.html