Malignant Lesions of the Fallopian Tube and Broad Ligament Workup

Investigations usually are for postmenopausal bleeding and include the following:

• Papanicolaou smear test, showing malignant glandular cells
• Endometrial biopsy

The cancer antigen 125 (CA-125) tumor marker assay is performed for follow-up study as a marker of response to therapy.

CT scan and MRI help detect location and size of adnexal mass, any metastatic mass, lymph nodes, and other findings for preoperative planning and counseling.

Hysterosalpingography can help detect intraluminal growth; however, spreading the malignancy is a risk.

Color Doppler can help detect arteriovenous shunts, microaneurysms, tumoral lakes, vascular blind ends, dichotomous branching, neovascularization, and low resistance indices.

Three-dimensional ultrasound can help detect papillary protrusions, pseudoseptae, tumoral lakes, microaneurysms, and arteriovenous shunting.

Ultrasound helps detect an adnexal mass, especially a solid mass corresponding with the expected location of the fallopian tubes in association with normal ovaries or as a sausage-shaped cystic mass with papillary projections.

If symptoms warrant, an upper and lower GI series and barium enema can be performed.

Type of carcinomas found include serous carcinoma (50%), endometrioid carcinoma (25%), transitional cell carcinoma (11.7%), undifferentiated carcinoma (7.8%), mixed carcinoma (3.9%), and clear cell carcinoma (1.9%).

Immunohistochemistry

Glucose transporter (GLUT1) immunostaining of fallopian tube adenocarcinoma was stronger and more extensive than staining of benign tubal epithelium. GLUT1 positivity is observed in regions most distal from stromal capillaries, suggesting hypoxia-driven GLUT1 induction. On average, GLUT1 staining in primary fallopian tube cancer was less extensive than in primary ovarian adenocarcinomas.^[2]

Although the fallopian tubes are derived from the same embryonic structure as the uterus, histologically and clinically, malignant lesions of the fallopian tubes behave like ovarian tumors. Unlike ovarian tumors, 50% of fallopian tube tumors are stage I and II, whereas more than 50% of ovarian malignancies are usually in stage III and IV. Fallopian tube carcinomas have a predilection for metastasis to retroperitoneal lymph nodes in contrast to intraperitoneal spread of ovarian carcinomas.

International Federation of Gynecology and Obstetrics (FIGO) fallopian tube cancer staging is as follows:

• Stage 0 - Carcinoma in situ (limited to tubal mucosa)
• Stage I - Growth limited to the fallopian tubes
• Stage Ia - Growth limited to 1 tube, with extension into the submucosa and/or muscularis but not penetrating the serosal surface; no ascites
• Stage Ib - Growth limited to both tubes with extension into the submucosa and/or muscularis but not penetrating the serosal surface; no ascites
• Stage Ic - Tumor stage 1a or 1b but with tumor extension through or onto the tubal serosa, or with ascites present containing malignant cells, or with positive peritoneal washings
• Stage II - Growth involving 1 or both fallopian tubes with pelvic extension
• Stage IIa - Extension and/or metastasis to the uterus and/or ovaries
• Stage IIb - Extension to other pelvic tissues
• Stage IIc - Tumor stage IIa or IIb, with ascites present containing malignant cells, or with positive peritoneal washings
• Stage III - Tumor involving 1 or both fallopian tubes, with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes; superficial liver metastasis equals stage III; tumor appears limited to true pelvis but has histologically proven malignant extension to the small bowel or omentum
• Stage IIIa - Tumor grossly limited to the true pelvis, with negative nodes but with histologically confirmed microscopic seeding or abdominal peritoneal surfaces
• Stage IIIb - Tumor involving 1 or both fallopian tubes, with histologically confirmed implants on abdominal peritoneal surfaces, none exceeding 2 cm in diameter; lymph node findings negative
• Stage IIIc - Abdominal implants larger than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes
• Stage IV - Growth involving 1 or both fallopian tubes, with distant metastases; if pleural effusion is present, positive cytology results necessary to be stage IV; parenchymal liver metastases equal stage IV

Staging for fallopian tube carcinoma is via the surgical pathological system. Operative findings designating stage are determined before tumor debulking.

Modified FIGO staging for fallopian tube carcinoma is as follows:

• Stage 0 - Carcinoma in situ (limited to tubal epithelium)
• Stage I - Growth limited to tube
• Stage IA - Growth limited to 1 fallopian tube, without extension through or onto serosa, ascites containing malignant cells, or positive peritoneal washings
• Stage IA to 0b - Growth limited to 1 fallopian tube, with no extension into lamina propria
• Stage IA to 1b - Growth limited to 1 fallopian tube, with extension into lamina propria but no extension into muscularis
• Stage IA to 2b - Growth limited to 1 fallopian tube, with extension into muscularis
• Stage IB - Growth limited to both fallopian tubes, without extension through or onto serosa, ascites containing malignant cells, or positive peritoneal washings
• Stage IB to 0b - Growth limited to both fallopian tubes, with no extension into lamina propria
• Stage IB to 1b - Growth limited to both fallopian tubes, with extension into lamina propria, but not extension into muscularis
• Stage IB to 2b - Growth limited to both fallopian tubes, with extension into muscularis
• Stage IC - Tumor either stage IA or IB, but with extension through or onto tubal serosa, with ascites containing malignant cells, or with positive peritoneal washings
• Stage I(F) - Tumor limited to fimbriated end of fallopian tube(s), without invasion of tubal wall
• Stage II - Tumor involving 1 or both fallopian tubes, with pelvic extension
• Stage IIA - Extension and/or metastasis to uterus and/or ovaries
• Stage IIB - Extension to other pelvic tissues
• Stage IIC - Tumor either stage IIA or IIB, with ascites containing malignant cells or with positive peritoneal washings
• Stage III - Tumor involving 1 or both fallopian tubes, with peritoneal implants outside pelvis, including superficial liver metastasis, and/or positive retroperitoneal or inguinal nodes; tumor limited to pelvis except for histologically proven extension to small bowel or omentum
• Stage IIIA - Tumor grossly limited to pelvis, with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces
• Stage IIIB - Tumor involves 1 or both fallopian tubes, with grossly visible histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter; lymph node findings negative
• Stage IIIC - Abdominal implants larger than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes
• Stage IV - Growth involving 1 or both fallopian tubes, with distant metastases, including parenchymal liver metastases; if pleural effusion present, fluid must be positive cytologically for malignant cells
• Modification in terminology - Modifications to accommodate subsets of tumor that otherwise cannot be assigned a stage or to distinguish among subsets that may differ in their associated prognosis