Primary fallopian tube carcinoma.SP Pardeshi, MM Kulkarni, VA Hishikar
Dept of Obst & Gynaecology, Grant Medical College & Sir J J Group of Hospitals, Mumbai.
Although Fallopian tubes are frequently involved in benign gynaecological conditions, primary malignant involvement is rare, and because of its rarity, lack of diagnostic accuracy, nonpresenting symptoms and physical findings, primary fallopian tube carcinoma is seldom diagnosed before laparotomy. We are reporting one such rare case.
Keywords: Abdominal Pain, etiology,Adenocarcinoma, Papillary, complications,pathology,surgery,Antineoplastic Combined Chemotherapy Protocols, therapeutic use,Carboplatin, administration &dosage,Case Report, Chemotherapy, Adjuvant, Cyclophosphamide, administration &dosage,Fallopian Tube Neoplasms, complications,pathology,surgery,Female, Human, Hysterectomy, Middle Age,
Although the initial case was reported nearly a century ago, the natural history and treatment of this disease process remain less well understood, when compared with the neoplasms of adjacent Mullerian structures. Also primary Fallopian tube More Details carcinoma represents less than 1% of all gynaecological malignancies. The incidence ranges from 0.142 to 1.8%, with reported incidence being 0.3%.
A 52-year-old nulliparous patient, married since 25 years, menopausal since 3 years, approached the gynaecological out patient department with complaints of dull aching lower abdominal pain since last two years. The pain was not related to meals. She was also complaining of foul smelling white discharge associated with pruritus since 6 months. Patient had no history of postmenopausal or postcoital bleeding. Medical or surgical history was not contributory.
On examination, patient was obese and her vital parameters were stable. Systemic examination was within normal limits. Per abdominal examination revealed a firm and non-tender mass arising from pelvis on the right side extending for about 2 cm. above the level of symphysis pubis. Per speculum examination showed cervix to be congested with foul smelling vaginal discharge. Per vaginal examination revealed uterus to be atrophic and mobile. Bilateral, solid, mobile, non-tender, forniceal masses were felt. The mass on right side measured 8-10 cm in diameter and that on left side measured 6-8 cm. Per rectal examination confirmed the vaginal examination findings.
Patient was admitted and investigated. All routine investigations including liver and renal function tests were within normal limits. Cytology detected inflammatory smear. Ultrasonography showed bilateral solid cystic tubo-ovarian masses, right side measuring 12 x 3 cm. and left side measuring 8 x 6 cm. Ovaries could not be visualised separately. Intravenous pyelography, barium meal and barium enema were within normal limits. Examination under anaesthesia confirmed the findings. Fractional curettage showed normal endometrium and chronic cervicitis. Tumour marker revealed raised CA 125 levels.
Hence, with a presumptive diagnosis of carcinoma of the ovary, the patient was explored. However, on exploratory laparotomy, uterus and both ovaries appeared to be normal, both fallopian tubes were dilated with solid and cystic components. Right side tube measured 12 x 6 cm. and left side tube measured 10 x 5 cm. [Figure - 1].
This gave us a suspicion of fallopian tube carcinoma and frozen section was performed. Frozen section confirmed our suspicion. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Liver and spleen palpated, peritoneum and intestines were visualised, to look for suspicious areas. No suspicious areas were seen and hence peritoneal washing and biopsy from pelvic and aortic lymph nodes taken.
Histopathological examination revealed bilateral papillary adenocarcinoma of the fallopian tube [Figure - 2] extending into the submucosa and muscularis, not penetrating to the serosal surface of the fallopian tube. Peritoneal washing was negative and biopsy from pelvic and aortic lymph nodes showed no malignant involvement. Thus the patient was diagnosed to be a case of primary fallopian tube carcinoma Stage 1.
Patient was given post-operative chemotherapy consisting of:
- Injection carboplatinum 450 ng I.V. infusion
- Injection cyclophosphamide 900 mg I.V. infusion.
With pre-hydration and serial monitoring of complete blood count, renal function test, liver function test. Such courses were given at 3 weeks interval. Patient is following up with us in out patient department. Patient is asymptomatic. CA 125 levels have been repeated, which are within normal levels. Vaginal cytology is normal.
Approximately 80% of the malignancies of fallopian tube are from other sites, most commonly from ovary, endometrium and gastrointestinal tract.
Frequency of primary adenocarcinoma of fallopian tube is 0.3-0.5% according to various series and its aetiology remains unknown. Fallopian tube carcinoma is known to be insidious and asymptomatic for prolonged and variable periods of time. Most common presenting symptoms are perimenopausal or postmenopausal bleeding per vagina seen in about 50% of the patients, followed by amber coloured vaginal discharge and abdominal pain.
The most common finding on physical examination is a palpable pelvic or abdominal mass that occasionally has a characteristic sausage shape. Ascites is rarely present. Preoperative diagnosis of fallopian tube carcinoma is seldom made prior to surgery. It is suspected in fewer than 5% of cases preoperatively. Primary ovarian neoplasm is the most common preoperative diagnosis made in these patients.
Sonography usually demonstrates a cystic and solid mass in the adnexal region. The mass is rarely suggestive of tubal origin, unless the ipsilateral ovary is identified. Computed tomography may be helpful for localising spread to other intra abdominal or retro peritoneal structures. The detection of increased levels of antigenic determinant CA 125 has been described.
There is no official staging system for fallopian tube carcinoma, but the staging system proposed and used by several investigators is essentially based on tumour penetration through the layers of tube similar to "Dukes System" for colon carcinoma.
Surgery, clearly the mainstay of treatment, is also the first approach to diagnosis. The procedure of choice is total abdomen hysterectomy with bilateral salpingo-oophorectomy. The need or benefit of postoperative radiation therapy has not been well substantiated by any study. The role of chemotherapy is limited to advanced stage disease or recurrent tumour,. Its benefit as adjuvant therapy for early stage disease has not been defined. Because of the rarity of the condition, no controlled clinical trials are available.
The role of second look surgery is controversial. The prognostic factor that directly correlates with survival is stage of the disease at the time of surgery.
Thus pre-operative diagnosis of fallopian tube carcinoma is seldom made and most of the time the diagnosis is made on the operating table.
[Figure - 1], [Figure - 2]