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Diverticulosis of the fallopian tubes—Salpingitis isthmica nodosa
Clin. Radiol. (1968) 19, 233-235
DIVERTICULOSIS OF THE FALLOPIAN TUBES-SALPINGITIS ISTHMICA NODOSA J O H N MILLS, P. P. U P A D H A Y A Y and L. S. CARSTAIRSt
From the Departments of Radiology, the Royal Northern Hospital, London, N.7 and the Middlesex Hospital, London, W.1. Hysterosalpingograms performed on 364 patients complaining of infertility have been reviewed. Ten cases (2.8~) showed diverticulosis of the fallopian tubes and the characteristic radiological features of this condition have been described.
SALPINGI'FIS Isthmica Nodosa is a condition in which there is nodular thickening of the medial third of one or both fallopian tubes, giving them a beaded appearance. The nodules measure up to 2.5 cms. in diameter and may be multiple. Microscopically the lesions begin as herniation of the tubal mucosa into the myosalpinx, and these develop into gland-like spaces lined with tubal epithelium which are surrounded by hypertrophied muscle. The condition and its causes have been under discussion at various times since von Recklinghausen (1896) advanced the theory that it occurred at the angle of the tube at a point where the Mullerian and Wolffian ducts cross during development. The aetiology of the condition remains controversial and various theories have been put forward to support claims that it may be a
congenital, inflammatory, or acquired but not necessarily due to inflammation: Benjamin and Beaver (1951) described a series of these lesions which they believed were neither congenital nor inflammatory in origin. Their evidence suggested that: the lesion began as a proliferation of normal epithelium of the tubal isthmus, followed by penetration of the muscle of the tube by the epithelium in a mamler similar to endometriosis. The continued division and penetration of the epithelium into the wall formed a labyrinth in communication with the lumen. There was a secondary hypertrophy and hyperplastic response by the muscle. These authors concluded that the condition appeared to be an acquired one. There was pathological evidence of a previous infection in 24 of the 51 cases they reviewed. "~ Requests for reprints to this author, at the Royal Northern Hospital, London, N.I.
FIG. 1 From Schenken and Burns: American Journal of Obstetrics and Gynecology 45: 624, 1943. 233
234
CLINICAL
FIG. 2 Photomicrograph of nodule excised from Fallopian tube at laparotomy to show salpingitis isthmica nodosa. There are numerous epithelial clefts and spaces in the muscle and the tubal lumen cannot be defined. The clefts are lined with tubal epithelium showing stereo-cilia. A distinguishing feature from endometriosis is the absence of endometrial stroma around the spaces.
RADIOLOGY
Fallopian Tubes' for these types of lesions. The remaining 18.3 ~ of nodules showed no evidence of diverticulosis and were due to a variety of lesions. During their investigations, these workers radio. graphed some of their surgical specimens after Thorotrast had been introduced and one of their radiographs is reproduced (see Fig. 1). It is on the basis of the work done by Schenken and Burns that certain radiological appearances seen occasionally during hysterosalpingography wilt be discussed. Hysterosalpingograms performed with oily contrast medium on 364 patients for infertility were reviewed and 10 cases (2.8 ~), 5 of whom were non-Caucasian; showed abnormalities of a type which could be due to diverticulosis of the tubes. These closely resembled the appearances illustrated by Schenken and Burns. We were fortunate in having histological confirmation of 'Salpingitis Isthmica Nodosa' in 2 of these patients who were subsequently operated upon, 1 for acute appendicitis, and the other
FIG. 3 Filling Phase. Diverticula are demonstrated in the proximal part of the tube bilaterally. Note the well-defined position of the lesions.
In their comprehensive and exhaustive study and classification of nodular lesions of the fallopian tubes, Schenken and Burns (1943) studied 329 nodules removed from 208 patients. In a histological classification of these nodules, they concluded that 81.7~ of them were due to diverticula of the tubal mucous membrane with associated muscle hypertrophy. Most specimens showed evidence of present or past inflammatory change. These authors suggested the term 'Diverticulosis of the
for tubal re-implantation. In general, however, surgical specimens were not available for histology as the nature of the original complaint usually precluded operation. RADIOLOGY The lesions were bilateral in 6 patients and unilateral in 4 patients. In the 4 in which only one tube showed the abnormality, 2 tubes failed to fill at all.
DIVERTICULOSIS OF THE FALLOPIAN T U B E S ~ S A L P I N G I T I S ISTHMICS NODOSA
235
Fro. 4 Bilateral tubal diverticula. The involvement on the left side appears to be more extensive. O n the affected side o r sides, m i n u t e globules o f contrast m e d i u m were seen on f l u o r o s c o p y to collect on all sides o f the periluminal tissues d u r i n g introduction. R a d i o g r a p h s confirmed t h a t the globules were in c o n t i n u i t y w i t h the l u m e n o f the fallopian tubes. T h e a b n o r m a l i t y was usually confined t o a well circumscribed area in the p r o x i m a l ½ o f the tube, b u t was also seen to involve the p r o x i m a l § occasionally. There was no radiological evidence o f involvement o f the uterine c o r n u or the tissues i m m e d i a t e l y a d j a c e n t to it. The a p p e a r a n c e o f the uterus a n d parts o f the tube n o t involved in this process were n o r m a l . The a p p e a r a n c e f r o m w h i c h this c o n d i t i o n m u s t be differentiated is i n t r a v a s a t i o n o f the c o n t r a s t medium. The latter usually occurs into the uterine b o d y a n d cornu a n d p r o d u c e s a ' h a z e ' a r o u n d the opacified lumen. I f i n t r a v a s a t i o n is seen a r o u n d the tube, the 'haze' has a linear distribution parallel to and n o t in continuity with the tube lumen.
Aeknowledgements.--We thank the staff of the Philip Hill Parenthood Clinic, Royal Northern Hospital, London, N.7, and the North Kensington Marriage Welfare Clinic, Telford Road, London, W.t0. We are indebted to Dr. P. M. Peters for the photomicrograph, and grateful to Mr. J. Turney of the Middlesex Hospital for the photographic reproductions.
REFERENCES ANDERSON,W. A. D. (1961). Pathology, 4th Ed. BENSAMaN, C. L. & BEAVER,D. C. (1951). Am. J. clin. Path., 21,212. J~FFCOAT~, T. N. A. (1962). Principles of Gynaecology, 2rid Ed. London: Butterworths. NOVAK, E. R. & WOODRUFF, J. D. (1962). Gynecologic and Obstetric Pathology, 5th Ed. Philadelphia: Saunders. RAmNOVITZ, M. (1913). Am. J. Obstet. Dis. Worm., 68,711. YON REeKLINGHAUSEN (1896). Die Adenomyoma and Cystadenoma der Uterus und Tubenwandund. Berlin. (Cited by Rabinovitz, M., 1913). SCHENKEN, J. R. & BURNS, E. L. (1943). Am. J. Obstet. Gynec., 45, 624.
DIVERTICULOSIS OF THE FALLOPIAN TUBES-SALPINGITIS ISTHMICA NODOSA J O H N MILLS, P. P. U P A D H A Y A Y and L. S. CARSTAIRSt
From the Departments of Radiology, the Royal Northern Hospital, London, N.7 and the Middlesex Hospital, London, W.1. Hysterosalpingograms performed on 364 patients complaining of infertility have been reviewed. Ten cases (2.8~) showed diverticulosis of the fallopian tubes and the characteristic radiological features of this condition have been described.
SALPINGI'FIS Isthmica Nodosa is a condition in which there is nodular thickening of the medial third of one or both fallopian tubes, giving them a beaded appearance. The nodules measure up to 2.5 cms. in diameter and may be multiple. Microscopically the lesions begin as herniation of the tubal mucosa into the myosalpinx, and these develop into gland-like spaces lined with tubal epithelium which are surrounded by hypertrophied muscle. The condition and its causes have been under discussion at various times since von Recklinghausen (1896) advanced the theory that it occurred at the angle of the tube at a point where the Mullerian and Wolffian ducts cross during development. The aetiology of the condition remains controversial and various theories have been put forward to support claims that it may be a
congenital, inflammatory, or acquired but not necessarily due to inflammation: Benjamin and Beaver (1951) described a series of these lesions which they believed were neither congenital nor inflammatory in origin. Their evidence suggested that: the lesion began as a proliferation of normal epithelium of the tubal isthmus, followed by penetration of the muscle of the tube by the epithelium in a mamler similar to endometriosis. The continued division and penetration of the epithelium into the wall formed a labyrinth in communication with the lumen. There was a secondary hypertrophy and hyperplastic response by the muscle. These authors concluded that the condition appeared to be an acquired one. There was pathological evidence of a previous infection in 24 of the 51 cases they reviewed. "~ Requests for reprints to this author, at the Royal Northern Hospital, London, N.I.
FIG. 1 From Schenken and Burns: American Journal of Obstetrics and Gynecology 45: 624, 1943. 233
234
CLINICAL
FIG. 2 Photomicrograph of nodule excised from Fallopian tube at laparotomy to show salpingitis isthmica nodosa. There are numerous epithelial clefts and spaces in the muscle and the tubal lumen cannot be defined. The clefts are lined with tubal epithelium showing stereo-cilia. A distinguishing feature from endometriosis is the absence of endometrial stroma around the spaces.
RADIOLOGY
Fallopian Tubes' for these types of lesions. The remaining 18.3 ~ of nodules showed no evidence of diverticulosis and were due to a variety of lesions. During their investigations, these workers radio. graphed some of their surgical specimens after Thorotrast had been introduced and one of their radiographs is reproduced (see Fig. 1). It is on the basis of the work done by Schenken and Burns that certain radiological appearances seen occasionally during hysterosalpingography wilt be discussed. Hysterosalpingograms performed with oily contrast medium on 364 patients for infertility were reviewed and 10 cases (2.8 ~), 5 of whom were non-Caucasian; showed abnormalities of a type which could be due to diverticulosis of the tubes. These closely resembled the appearances illustrated by Schenken and Burns. We were fortunate in having histological confirmation of 'Salpingitis Isthmica Nodosa' in 2 of these patients who were subsequently operated upon, 1 for acute appendicitis, and the other
FIG. 3 Filling Phase. Diverticula are demonstrated in the proximal part of the tube bilaterally. Note the well-defined position of the lesions.
In their comprehensive and exhaustive study and classification of nodular lesions of the fallopian tubes, Schenken and Burns (1943) studied 329 nodules removed from 208 patients. In a histological classification of these nodules, they concluded that 81.7~ of them were due to diverticula of the tubal mucous membrane with associated muscle hypertrophy. Most specimens showed evidence of present or past inflammatory change. These authors suggested the term 'Diverticulosis of the
for tubal re-implantation. In general, however, surgical specimens were not available for histology as the nature of the original complaint usually precluded operation. RADIOLOGY The lesions were bilateral in 6 patients and unilateral in 4 patients. In the 4 in which only one tube showed the abnormality, 2 tubes failed to fill at all.
DIVERTICULOSIS OF THE FALLOPIAN T U B E S ~ S A L P I N G I T I S ISTHMICS NODOSA
235
Fro. 4 Bilateral tubal diverticula. The involvement on the left side appears to be more extensive. O n the affected side o r sides, m i n u t e globules o f contrast m e d i u m were seen on f l u o r o s c o p y to collect on all sides o f the periluminal tissues d u r i n g introduction. R a d i o g r a p h s confirmed t h a t the globules were in c o n t i n u i t y w i t h the l u m e n o f the fallopian tubes. T h e a b n o r m a l i t y was usually confined t o a well circumscribed area in the p r o x i m a l ½ o f the tube, b u t was also seen to involve the p r o x i m a l § occasionally. There was no radiological evidence o f involvement o f the uterine c o r n u or the tissues i m m e d i a t e l y a d j a c e n t to it. The a p p e a r a n c e o f the uterus a n d parts o f the tube n o t involved in this process were n o r m a l . The a p p e a r a n c e f r o m w h i c h this c o n d i t i o n m u s t be differentiated is i n t r a v a s a t i o n o f the c o n t r a s t medium. The latter usually occurs into the uterine b o d y a n d cornu a n d p r o d u c e s a ' h a z e ' a r o u n d the opacified lumen. I f i n t r a v a s a t i o n is seen a r o u n d the tube, the 'haze' has a linear distribution parallel to and n o t in continuity with the tube lumen.
Aeknowledgements.--We thank the staff of the Philip Hill Parenthood Clinic, Royal Northern Hospital, London, N.7, and the North Kensington Marriage Welfare Clinic, Telford Road, London, W.t0. We are indebted to Dr. P. M. Peters for the photomicrograph, and grateful to Mr. J. Turney of the Middlesex Hospital for the photographic reproductions.
REFERENCES ANDERSON,W. A. D. (1961). Pathology, 4th Ed. BENSAMaN, C. L. & BEAVER,D. C. (1951). Am. J. clin. Path., 21,212. J~FFCOAT~, T. N. A. (1962). Principles of Gynaecology, 2rid Ed. London: Butterworths. NOVAK, E. R. & WOODRUFF, J. D. (1962). Gynecologic and Obstetric Pathology, 5th Ed. Philadelphia: Saunders. RAmNOVITZ, M. (1913). Am. J. Obstet. Dis. Worm., 68,711. YON REeKLINGHAUSEN (1896). Die Adenomyoma and Cystadenoma der Uterus und Tubenwandund. Berlin. (Cited by Rabinovitz, M., 1913). SCHENKEN, J. R. & BURNS, E. L. (1943). Am. J. Obstet. Gynec., 45, 624.