Carcinoma of the Fallopian tube detected by cervical smear

CARCINOMA H. K. (From

the

OF THE FIDLER,

KU.,*

Department

of

FALLOPIAN TUBE SMEAR AND

D.

Pathology,

R.

LOCK,

ranoozlser British

DETECTED M.T.,*”

General

BY CERVICAL

VANCOUVER,

Hospital

B.

and the

c.

University

of

Colnmhia)

ARCINOMA of the Fallopian tube is one of the rarest neoplasms of the female genital tract. Tip to 1952 the total number of cases reported was FiO3.l In the surgical pathology material at the Vancouver General Hospital during the five-year period 194s t,o 1953, 5 primary carcinomas of the Fallopian tube were encountered. In the same period there were 791 primary malignant lesions of the female genital tract. Thus, the incidence in our material is 0.61 per cent of all female genital tract neoplasms. This figure is higher t,han most others reported, being double that of Hu, Taymor, and Hcrtig? and four times that. of Lofgren and Dockert,p.3 The cases here descrihrd all presented problems in exact, diagnoses. In only one was the correct diagnosis suspected. The preoperative diagnosis in 3 was ovarian carcinoma and in one it was carcinoma of the body of the uterus. The diagnosis is rarely made preoperativelp, and. indeed, the presence of a malignant lesion of anp kind is often not suspected. It appears significant to us that of 4 cases in this series in which preoperative cervical smears were examined, 3 were positive for cancer cells, the morphological features of which suggested adcnocarcinoma. The purpose of this paper is to stress the value of the cervical smear as an aid to diagnosis of carcinoma of t,he Fallopian tube.

C

Case Reports A. L. F. (V. G. H. No. G16281), a 57.year-old white woman, thirteen years postmenopausal, was well until Nov. 25, 1948, when she had a profuse vaginal disrhargl,. This was brownish in color and contained some red blood. It lasted three and one-half hours. During the following two weeks she had two similar episodes. Physical examination revealed tenderness and resistance to deep pressure in the right lower quadrant of the abdomen. Th(are was a little serous vaginal discharge and pelvic csamination showed adnesal thickening and marked tendrxrness in the right fornix. No definite mass was palpable. A cervical smear had been sent to Dr. J. Ernest Ayrc in Montreal, and he reported the smears to contain cells of malignant morphology scattered throughout a large amount of blood and leukocytes. From the history and the type of crll seen, he suggested the possibility of tubal carcinoma. At operation on Dec. 30, 1948, the uterus and left tube and ovary appeared normal. The right Fallopian tube was distended, and curled on itself to the size of a large tangerine This was adherent to the right broad ligament which on palpation was found to be orange. infiltrated, making the whole right pelvic wall and broad ligament a rontinuous indurated mass. CASE

I.-Mrs.

*Director.

Pathology, **Chief

Department

University Technician,

of

of Pathology. British Columbia Cytology Laboratory,

Vancouver C:eneral School of Medicine. British Columbia

1103

Hospital, Cancer

Assistant Institute.

Professor

of

1104

FIDLER

AND

\m

LOCK

Lymph nodes presumed involved in metastatic tumor \vcre palpable along the iliuc. chaiiis, presacral region, and aorta up to the right, kidney. The right Fallopian tube VI as rcmovc< I and the condition was considered too far atl~-an~~~~~l for any further surgery. dilated. scopic

Pathological The wall examination

examination revealed a rotori:shaped was thickcncd to 8 mm. ant1 limtl showed a fairly well-differentiated

Fallopian tube which was cunsi~l~~rnhl~ by soft polypoidal tumor t,is;suts. &lilir:ro papillary adcnoc~arcinorna (Fig. I ).

About two years aftt!r the olleration she dcvulope~l a bowel obstruction from intr:rBilateral urcteral obstrmperitoneal metastases, for which a transvcrs~~ colostomy ~1as ~lonc. tion developed and her comlition deteriorat(~(l x~piclly :tnll she died July 22, 19.51. tlrrec years am1 seven months after operation.

Fig.

2

(Case

2).-Cervical

smear

showing

clumps

of

malignant

rlGttwli;tl

cells.

CASE 2.-Mrs. L. H. (B. C. C. T. 3%198 [II] ), a 5%year-old white wonmu, twelve years postmenopausal, was seen on Oct. ID, 1950. She had been in good health until two months previously vvhen she noticed an odd sensation in the right lower side of her abdomen and a For one month she had noticed a little spotting of vaginal sensation of weakness in the legs. blood which on one occasion was a moderate flooding.

Physical examination revealed some tenderness to the right of the umbilicus and an Pelvic c~xamination indefinite intra-abdominal mass about 4 cm. in diameter in this region. was not remarkable. Cytological examination of rervical smears revealed the following result: Oct. Oct. Dw.

19, 1950-Suspicious for cancer cells. 31, 1950-Cells of definite cancer morphology (Fig. 2). 5, 1950-Suspicious for cancer cells.

present,

suggesting

adenocarcinomx

Bepeatrd p~~lvic examination under anesthesia failed to reveal any abnormality. T.Ttc:rinr She coutinucd to spot irregucurettage fxilcd to obtain any tissue for microscopic study. larly during the subsequent five months. Although a cervical smear at the: (n11 of this time was negative it was felt that the history of recurrent spotting and the previous tinrling UP cells consistent with adcnocarcinoma lsarranted laparotomy.

Fig.

3

(Case

2).-Fallopian

Fig.

4

(Case

2).-Papillary

tube

opened

adenocarcinoma, clumps

longitudinally distal third.

Grade of tumor

and

showing

II, a dilaterl tissue.

papillary

lymphatic

carcinoma

clam1

in

containing

At operation on March 28, 1951, the uterus was found to be small. There was a mild hydrosalpinx of both Fallopian tubes and these were bound down by dense fibrous adhesions. Total hysterectomy and bilateral salpingo-oophorectomy were performed. Pathological examination showed the significant lesion confined to the left Fallopian tube (Fig. 3) which measured 8 cm. in length. The proximal portion xw of uniform diameter of about 8 mm. In the distal 2.5 cm. it was dilated to 1.5 cm. in diameter and the fimbriated end was closed off. Upon opening the tube thr dilated fimbriatcd end was found to bo filled

1106

FIDLER

with a papillary tumor which examination showed a fairly mall only a short distance. was found in the submucosal

ANT)

Am. J. Ob>t. & Gynec. May, 1954

LOCK

did not appear to have invaded the muscle wall. Microscopic well-differentiated papillary carcinoma which infiltrated thrs A widely dilat,rtl l,~~phxtic containing tumor tisPut> t, Fig. -C; connective tissutt.

Postoperatively the patient received dip x-ray therapy. X tumor dose of 1,980 r was given over a period of twenty days but hail to 1,~ abandoned bt~aus~ of symptoms associated with diverticulitis of the colon. She was last seen on Marc.11 18. 1953, t,wo years after operation and there was no evidence of rc,current distqlsr. CASE 3.--I\IrS. &I. &I. (v. ($. 11. No. :iH~tlS), LI W?c!:woitl whit? \vo~an, t\v~~lv~ years postmenopausal, complained of a vaginal hemorrhage of about one cupful of blood two months previously, followed by intermittent spotting since that time. For the same period she had :I constant heavy feeling in the lower abdomen with occasional sharp pains. No

cervical

cytological

i*samination

was

performed.

Upon physical examination she was found to have arteriosclerotic heart disease wit11 paroxysmal auricular fibrillation. Abdominal examination revealed no abnormality. Pelvic examination under anesthesia showed the uterus to bc slightly enlarged and there were bilteral masses interpreted as enlarged ovaries, that on the right being the size of an orange and the left the size of an egg. Curettage failelI to producae cBndometria1 tissue.

Vi!&

5 (Case

3 ).-Section

of

Fallopian

tube

showing

On March !%, 1951, hysterectomy and bilateral At operation several small nodules interpreted as pelvic wall. These were not removed.

papillary

adenocarcinmna,

salpingo-oophorectomy tumor implants were

Gra~le

III.

were performed. seen on the right

Pathological examination showed the right Fallopian tube dilated to 3 cm. in diameter at the fimbriated end, and the lumen was filled with papillary yellowish-red neoplastic tissue. There was a leiomyoma 4 cm. in diameter in the left broad ligament and several leiomyomas Wcroscopic examination of the turn01 measuring up to 1 cm. in diameter in the uterus. in the right Fallopian tube showed a rather poorly differentiated papillary carcinoma (Fig. 5). This had infiltrated into the muscle layers but not to the serosal surface. This patient Operation was followed by a course of deep x-ray therapy to the pelvis. has since had postoperatively.

several

CASE 4.-Mrs. to hospital March

episodes

of

congestive

heart

I(. P. (B. C. C. I. No. 52-404), 31, 1952, complaining of difficulty

failurej

but

a 6%year-old in urination

is otherwise white woman, for one week

well

two

years

was admitted and inability

F;;=r”;

FALLOPIAN

TUBE

CARCINOMA

DETECTED

BY

CERVICAL

SMEAR

1107

to void for three days. For two years previous to this there had been some inconstant nocturia and dysuria. During the past one year she had lost 15 pounds in weight. There was no history of vaginal discharge. Physical examination revealed moderately severe suprapubic: tenderness. ln the right lower quadrant of the abdomen was a mass which was difficult to clelincato because of the tenderness. Pelvic examination was not successful because the patient was too tense. Cystoscopie examination showed marked distortion of the bladder and indicated a nmss filling nearly the whole pelvis, but particularly the right side. It was considered to be a tumor of the ovary. A ~~crvical smear was reported negative for ranter cells. Laparotomy was performed April 9, 1952. A large mass, bluish-gray in color, was found in the pelvis. The uterus was pushed forward. Both tubes and ovaries were found and reported as atrophic. It was impossible to find a line of cleavage in the tumor and as much as possible was scooped out and the abdomen was closed. Pathological examination showed a mass of very soft, friable, reddish-gray tissue -4ttached to this was a structure resembling a Fallopian tube 4 cm. weighing 234 grams. This merged at one end with the tumor tissue. Microscopic in length and 6 mm. in diameter. sections confirmed the identity of the Fallopian tube. One section, through the distal end, showed origin of a very poorly differentiated papillary carcinoma from the mucosal lining (Fig. 6). Elsewhere the tube was surrounded by poorly differentiat,ed carcinoma and sections through tho large soft mass all showed a similar appearance.

Fig.

6 (Case

4).-Section

of Fallopian

tube

showing

an undifferentiated

carcinoma,

Grade

IV.

Postoperatively this patient received two radium insertions and deep x-ray to the pelvis, latter constituting a tumor dose of 3,068 r given over twenty-three days. By November, 1952, the pelvic mass had recurred. This enlarged rapidly and the patient Postmortem examination revealed a large died Dece. 24, 1953, eight months postoperatively. The uterus, tubes, and ovaries were not mass of recurrent carcinoma in the pelvis. identifiable in this tissue. Death was due to a massive pulmonary embolus, presumably from the pelvic veins. There was also complete thrombotic occlusion of the right renal artery causing infarction of the kidney. There was a left hydrourctcr and pyclonephritis.

the

CASE 5.-Mrs. A. B. (V. G. II. Ko. 1171’7L’), a 64.year-old white woman, nine years postmenopausal, was admitted to hospital March 18, 1953, complaining of sharp, shooting, crampy pains in the right lower quadrant of the abdomen for three weeks. These pains occurred two to three times a day and in the interval there was a dull constant pain. There was no associated nausea or vomiting. Apart from some bloody vaginal spotting on two occasions three months previously, she had been quite well.

Am. J. Ohzt. & Gym. May, 1954

Pig. Fig. Fig.

7 (Case 8 (Case

Fig.

i.

5) .--Cervical S).--Section

slnear showing rlun>ps of malignant of Fallopian tube showing papillary

8. epitJs?lial cells. adenocarcinoma,

<>rade

III.

Comment The signs and symptoms of primary rarcinoma of the Fallopian tube arc obscure and indefinite in the early and even in the advanced stages of the disease. Nevertheless, a common triad frequently encountered is the association of (1) bloody or serosanguineous vaginal discharge, sometimes with episodes of massive hemorrhage, (2) lower abdominal pain, and (3) presence of a pelvic mass. If one can Most authors state these three findings in this order of frequency.

c;;m,“ji

FALLOPIAN

TUBE

CARCINOMA

DETECTED

BY

CERVICAL

SMEAR

1109

esclude significant disease in the uterus by cervical biopsy and endometrial curettage, then as MartzlolP has pointed out, an extrauterine origin, logically tubal, and possibly malignant, may be inferred. In view of the fact that a serosanguineous vaginal discharge, originating in the diseased tube, is the commonest complaint it is apparent that the cytological examination of this discharge should assist in arriving at a specific diagnosis. In fact, MacLean urges the use of a cervical cap to facilitate collection of discharges from the upper uterine tract and refers to one case of early carcinoma of the Fallopian tube diagnosed correctly by this means. Ayre6 suggests that screening programs in which cervical cytological examinations are done should result in earlier diagnosis of tubal carcinoma. In the cases reported above, 4 patients complained of vaginal discharge. (!ervical smears were done on 3 of these, and in each instance a positive report for cells consistent with adenocarcinoma was given. In Case 1 the diagnosis Case 4 is a false negative, of tubal carcinoma was suggested by the cytologist. but understandably so in view of the fact that there was no vaginal discharge associated with the lesion. Except for Case 2, these are all examples of advanced carcinoma of the tube, in each instance extending beyond the confines of the tube into adjacent pelvic structures. Case 2 corresponds closely to one described by Isbell and associates,7 which likewise was characterized by periodic vaginal bleeding over a period of six months, with no contributory findings in uterine curettage and absence of pain and pelvic mass. In our case, operation revealed a relatively small carcinoma, showing a minimum of infiltration of the tubal stroma ancl apparently confined to the tube. Although the prognosis would appear to be good in this ease, it is significant that despite the apparently early stage and relat.ivcly good differentiation, some lymph channels, containing small clumps of tumor cells, were found in the muscle. This feature of early lymphatic involvement is probably a factor in the over-all poor prognosis in this condition. This patient has, however, survived for two years postoperatively with no evidence of recurrent disease. The finding of malignant cells in the cervical smear under conditions described above, while pointing to a tubal origin, may, however, be significant of ovarian carcinoma or metastatic carcinoma in the pelvis from some distant primary origin. We have examined cervical smears from 20 patients in whom the diagnosis of ovarian carcinoma was eventually established. In these, 4 showed cells interpreted as suspicious and ‘i showed cells of a definite malignant morWhereas the cells are usually found in clumps and have the other pllologJ~. cytological criteria8 usually ascribed to adenocarcinoma in contradistinction to squamous-cell carcinoma as seen in cervical lesions, we have been unable to distinguish any significant cytological features that would distinguish ovarian from Fallopian tube carcinomas, or indeed from endometrial carcinoma.

C,onclusions Five cases of primary carcinoma of the Fallopian tube are described. were seen in a five-year period and represent 0.61 per cent of 791 primary nant lesions of the female genital tract during this period.

These malig-

62

68

3

4

AGE

57

/

1

CASE

i

iii

Married Para i Grxvida

Jlarried Para iii Gravida

3 n1onths

SO

i lnonths

Married Pam iii Grayida

iii

2 weeks

I , BLOODY ~ VaGINAL 1 DISCHARGE

Married

PARITY AND 1 GRAVIDITY

:i werks

1 wrek

so

No

LOWER ABDOMINAI ~ PAIS

PCS

x-es

SO

No, but adnexal thickening and resistance present

PALPSBT,E PFT>VTC 3IRSS CRRVICAI CYTOI,OG\

I

done

Segatirc

Sot

Positive

l’ositivc

~

TABLE

uterus;r

1. Hydrosalpinx 2. Carcinoma of body

l’REOPI’,MTKE DTAGh’OSTS

( ‘nwinomn of ovnrj

I

Papillary ndenocarc1noma, GEulP III.

t’apilla~y adenocarcmoma, Grade IV

Grade II. with lvllphxtic iLvolve*nent I’apilla~y adenocarcmoma, Grade III

nwamnoma,

xde-

Papillary adenocarcmoma, Grade II

I’ATIIOLOGICAL DTA(;SOSIS

of Papillaqg

of

c’arcinoma of right ovarv

Hilateral ovarian carcinoma

UtPlWS

Fallopian tuhe Carcinoma

I

1

S-ray

12:irlinm x-ray

X-ray

X-ray

-

1

1

FOLT.O\\--1.1’

Died of recurrence ‘7 wars. 7 monthr pw+ operatirelv

tirelC :rn~l I?icd &th TPcurrencc S months postoperatively Aliw and well 1 months posts operatively

POSTOPERATIVE ~ RADIUhL OR ~ X-RAY

;;;;;,;;lcy

J?ALLOYlAN

TUBE

CARCINOMA

DETECTED

BY

CERVICAL

SMEAR

1111

Examination of the cervical smear has been found of value in diagnosis. the preoperative smear being positive in 3 of the 4 cases csamined, anal iu all 3 in which thwe was an associated bloody vaginal discharge. abdominal pain, and The triad of vaginal spottin g or hemorrha.ge, lowr pcJvic massF when accompanied by positive cytology and negative cervical and cndometrial biopsy, is practically diagnostic of tubal carcinoma. (larcinom;L of the ovary with, or sometimes even without, tubal involvement ma.y, howexxr, also yield malignant, cells in the cervical smear. Grateful arknowledgment is made to Drs. G. E. Gillies, J. E. Ayre and A. E. Trites for permission to publish Case 1; Dr. A. M. Evans for Case 2; Dr. J. E. Harrison for (‘ases 3 and 5; and Drs. A. M. Agnew and D. B. Collison for Case 4.

References 1. 2. 3. 4. 5.

Carpenter, R. J., and Jameson, Hu, C. Y., Taymor, M. L., and Lofgren, K. A., and Dockerty, Martzloff, K.: AM. J. OBST. Science 114: MacLean, K. S.: 6. Ayre, J. E.: Cancer Cytology 7. Isbell, P., Jewett, J. F., Allen,

1947. 8. Papanicolaou,

G. N.,

and

Traut,

W. J.: Am. J. Surg. 83: 595, 1952. Hertig, A. T.: AW J. OBST. & GYNEC. 59: 58, M. B. : Surg., Gynec. $ Obst. 82: 199, 1946.

1950.

S; GYNEC. 40: 804, 1940. 181, 1951. of the Uterus, New York, 1951, Grune & Stratton, p. 361. M. S., and Hertig, A. T.: Aal. J. OBST. & GYNEC. 54: 576, 1~. F.:

AM. J. OBST. & GYNEC. 42: 193, 1941.