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OJHAS Vol. 10, Issue 4:
(Oct-Dec 2011) |
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| Primary
Transitional Cell Carcinoma of the Fallopian Tube |
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Kavita Mardi,
Associate Professor,
Vijay Kaushal, Professor & Head,
Dept. of Pathology, Indira Gandhi Medical College, Shimla. |
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Address for Correspondence |
12-A, Type V Quarters,
GAD Colony, Kasumpti,
Shimla, Himachal Pradesh, India.
E-mail:
kavitamardi@yahoo.co.in |
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Mardi K, Kaushal V. Primary
Transitional Cell Carcinoma of the Fallopian Tube. Online J Health Allied Scs.
2011;10(4):8 |
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Submitted: Dec 5, 2011; Accepted: Jan
5, 2012; Published: Jan 15, 2012 |
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| Abstract: |
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Primary carcinoma of the fallopian
tube is a rare entity that accounts for 0.2-0.5% of all gynecologic
malignancies, and most are discovered during or after surgery. Primary
transitional cell carcinoma of the fallopian tube is an extremely rare
tumor that is reported only occasionally in the worldwide literature.
As primary transitional cell carcinoma (TCC) of the fallopian tube is
so rare, the clinicopathologic characteristics are as yet unknown. The
authors recently experienced a case of primary transitional cell carcinoma
arising in the left fallopian tube and thus report the clinical features,
management, and also a review of the past pertinent literature. A 52 years old
woman presenting with lower abdominal pain was found to have a left
adnexal mass. Exploratory laparotomy revealed a mass arising from the
left fallopian tube with the histologic features of transitional cell
carcinoma.
Key Words:
Transitional cell
carcinoma; Fallopian tube.
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Transitional cell carcinoma
arising from the fallopian tube is an exceedingly rare entity that accounts
for 0.2-0.5% of all gynecologic malignancies.1-3 We herein
report one such rare occurrence in a 52 years old female.
A 52 years old
lady presented with intermittent colicky lower abdominal pain of 1-month
duration. She had Attained menopause 5 years back. Her bladder and bowel
habits were normal. On examination, she was of average build with good
performance status. Her vitals were stable, with no pallor, edema or
lymphadenopathy. On vaginal examination, a left adnexal mass of about
3cm diameter was felt. However, per rectal examination did not reveal
any mass in the pouch of Douglas (POD).
Patient was evaluated with
routine blood investigations, tumor markers and imaging, including ultrasound
and a CT scan of the abdomen and pelvis. Thus, with a provisional diagnosis
of ovarian malignancy, the patient underwent a staging laparotomy. Per-operatively
,there was 3x3cm sized, well circumscribed mass arising from the
left fallopian tube. Cut section of the mass was soild, grey white with
necrotic and hemorrhagic areas. Both the ovaries, on gross examination,
appeared apparently normal (Figure1). No obvious deposits were found on
the POD, abdominal or diaphragmatic peritoneal surfaces. Liver and omentum
appeared free of disease. No significantly enlarged pelvic or para-aortic
nodes were present. Histologically, the tumor surrounded the lumen of
the left fallopian tube and was composed of cells with "coffee-bean"-like
nuclei arranged in solid nests without keratinization. Focally the tumor
cells are arranged around papillae with fine fibrovascular cores (Figure2). In
addition, there were areas of necrosis in the center of sheets of tumor
cells. PAS and Mucicarmine stains were negative. No abnormalities were
found in the right tube, ovaries, or uterus. The diagnosis of primary
transitional cell carcinoma of the fallopian tube was rendered.
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Figure 1: Gross photograph
revealing cut section of the growth arising from the left fallopian
tube |
Figure 2: Photomicrograph
revealing papillae with fibrovascular cores lined by malignant transitional
epithelium.(H&E,20x) |
Primary Fallopian tube carcinoma (PFTC), first described by Renaud in
1847, is the least common gynecological malignancy encountered in practice. These
tumors constitute 0.2 – 0.5% of primary female genital malignancies.1-3
In primary tubal malignancy, the uterus and ovaries should appear
normal on gross examination. The foci of malignancies in these organs,
if present should have the appearance of metastasis or as independent
primaries by virtue of their size and distribution.4
Histologically most of these are adenocarcinomas. Primary transitional
cell carcinoma (TCC) accounts for about 10% of primary tubal carcinomas.1
Thus Transitional cell carcinoma of the fallopian tube is a very rare
histological variant, with only around 20 cases having been reported
worldwide so far.2,3
PFTC is more commonly seen in postmenopausal women, but it is not clear
whether the same is true about primary transitional carcinoma.. Patients
with PFTC appear to have a shorter history of symptoms compared to those
with epithelial ovarian cancer (PEOC). About 50% to 60% of patients
present with vaginal bleeding or spotting, abdominal and/or pelvic mass;
and 30% to 40% of patients present with colicky or dull abdominal pain.5 Latzke triad of symptoms, consisting
of intermittent profuse serosanguinous vaginal discharge, abdominal
and/or pelvic pain, is reported in 15% of cases. Grossly, the tubal
lumen is usually filled and dilated by papillary or solid and necrotic
tumor. The morphology of transitional carcinoma is similar to that of
tumors of the urothelium.
There is a newly recognized entity known as parafallopian tube carcinoma,
where the tumor is closely attached to the extraluminal portion of the
tube. It is presumed to arise from Walthard's rest, paratubal cyst or
directly from the tubal serosa. 6 Hence it is important to distinguish
PTCC of fallopian tube from parafallopian tube transitional cell carcinoma
to identify any difference in clinical characteristics.
Between 0% and 23% of cases of PFTC may have abnormal cervical cytology
suggestive of adenocarcinoma.5 Pap smear was negative in the present
case as well. There is an isolated case report of transitional cell
carcinoma of the fallopian tube diagnosed after a total abdominal hysterectomy
with salpingo-oophorectomy done for repeated Pap smear reports suggestive
of squamous cell carcinoma.2
The reported rate of preoperative diagnosis in fallopian tube carcinoma
is low. Baekelandt et al, have reported a preoperative diagnosis rate
of 2%.7 Both the USG and the CT scan could
not suggest a diagnosis of PFTC in this case because the ovary on the
left side was not seen separately from the adnexal mass. However, markedly
elevated CA-125 level was strongly suggestive of malignancy in the present
case. The pretreatment CA-125 level is an independent prognostic factor
of disease-free survival and overall survival in patients with
PFTC. CA-125 is also found to be a good marker for post-treatment follow-up,
similar to ovarian carcinoma.5
Surgery is the treatment of choice, as in cases of ovarian tumors. A
staging laparotomy through a generous midline vertical incision is recommended,
as in cases of ovarian cancer. Studies suggest that patients with PFTC have
higher rates of retroperitoneal and distant nodal metastases than those with
epithelial ovarian cancer.8 Hence a systematic pelvic and para-aortic
lymphadenectomy is preferred to selective lymph node sampling.
Patients with stage I disease without risk factors like involvement
of the muscularis layer were reported to have 100% 5-year survival and
need not be treated with adjuvant chemotherapy. In contrast, stage I
with invasion of the muscularis layer or tumor in the fimbria and higher
stages should receive adjuvant chemotherapy.8,9 Adjuvant chemotherapy with a combination
of carboplatin and paclitaxel, which is the gold standard of chemotherapy
in epithelial ovarian cancer, is now increasingly being used in PFTC.10 Our literature search did not reveal
any report of conservative management in the form of unilateral salpingectomy
or salpingo-oophorectomy for early-stage PTCC of the fallopian tube.
Uehira et a, in a study comparing
transitional cell (TC)- predominant PFTC with non-TC-predominant PFTC
found that TC-predominant tumors tended to relapse later (mean, 31.2
months after diagnosis) than non-TC-predominant tumors (mean, 14.4 months
after diagnosis), resulting in a significant difference in the 2-year
disease-free survival rate. Hence he concluded that TC pattern and non-TC
pattern are considered to be worthy of distinction in PFTC.11
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Kim
JW, Cho EM, Kim YT, Han JH: A case of primary transitional cell carcinoma
of the fallopian tube. J Obstet Gynaecol Res 1999;25:321-326.
- Gupta N, Srinivasan
R, Nijhawan R, Dhaliwal LK. Primary fallopian tube carcinoma with exfoliation
of malignant cells in cervical pap smear. Cytojournal 2005;2:20.
- Park JS, Chang KH, Byun
JG, Lee JP, Ryu HS, Han JH. A case of primary transitional cell carcinoma
of the fallopian tube . Korean
J Obstet Gynecol 2005;48:1351-1357.
- Rose PG, Piver MS, TsukadaY. Fallopian
tube cancer: The Rosewall park experience. Cancer 1990 ;66:2661-2667.
- Pectasides D, Pectasides
E, Economopoulos T. Fallopian tube carcinoma: A review. Oncologist 2006;11:902-912.
- Paner GP, Gonzalez
M, Al-Masri H, Smith DM, Husain AN. Parafallopian tube transitional cell
carcinoma. Gynecol Oncol 2002;86:379-383.
- Baekelandt M, Kockx
M, Wesling F, Gerris J. Primary adenocarcinoma of the fallopian tube.
Review of literature. Int J Gynecol Cancer1993;3:65-371.
- Maxson WZ, Stehman
FB, Ulbright TM, Sutton GP, Ehrlich CE. Primary carcinoma of the fallopian
tube: Evidence for activity of cisplatin combination therapy. Gynecol
Oncol 1987;26:305-313.
- Alvarado-Cabrero
I, Young RH, Vamvakas EC, Scully RE. Carcinoma of the fallopian tube:
A clinicopathological study of 105 cases with observations on staging
and prognostic factors. Gynecol Oncol 1999;72:367-379.
- Gemignani ML, Hensley
ML, Cohen R, Venkatraman E, Saigo PE, Barakat RR. Paclitaxel-based chemotherapy
in carcinoma of the fallopian tube. Gynecol Oncol 2001;80:16-20.
- Uehira K, Hashimoto
H, Tsuneyoshi M, Enjoji M. Transitional cell carcinoma pattern in primary
carcinoma of the fallopian tube. Cancer 1993;72:2447-2456.
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