Fallopian Tube Carcinoma With Upper Abdominal Dissemination
Fallopian Tube Carcinoma With Upper Abdominal Dissemination
This case report presents a 66-year-old Caucasian female housekeeper. Her background includes squamous carcinoma of the nose treated with surgery (14 years ago), hypertension and appendectomy (at a young age). She was nulliparous and had no previous known gynecological problems (menarche and menopause at normal ages, no combined hormonal contraceptives or hormonal replacement therapy). Her only symptom was diffuse abdominal pain, more intense on the flanks, progressing for 3 months and with increasing intensity. The family doctor requested a computed tomography scan that suggested peritoneal carcinomatosis, moderate ascites, with no reference to the primary tumor site. When further examined, a complete and thorough examination showed:
(Enlarge Image)
Figure 1.
Abdominopelvic magnetic resonance imaging. Axial T2-weighted image. Heterogeneous soft-tissue thickening of the greater omentum ("omental cake") (arrow). Moderate ascites (arrowhead).
The patient's case was reviewed by the Gynecology team at the Portuguese Institute of Oncology of Oporto and an exploratory laparotomy was decided. The intra-operatory findings showed diffuse parietal peritoneal implants (pelvic and abdominal) with a voluminous mass involving her epiploon, from the hepatic hilum to the splenic hilum, invading the great gastric curvature. An anterior abdominal wall implant was removed and sent for extemporary examination which revealed high-grade adenocarcinoma. Ascitic fluid was collected; atypical gastrectomy, omentectomy and myomectomy were performed. When reviewing the adnexial area, a small dilation and purple color were noticed on her left fallopian tube. The surgery was completed with left adnexectomy. Macroscopic residual disease (>2cm) was present at the end of surgery. During the postoperatory period, a positron emission tomography scan revealed multiple ganglion metastases with several small implants on her pelvic and abdominal cavities (Figure 2). The pathology report showed infiltrative serous adenocarcinoma of epiploon and gastric curvature (papillary pattern Figures 3A and 3B), invading the gastric muscular layer, but not the mucosa. When analyzing her left fallopian tube, the same adenocarcinoma type was found in the lumen (9mm in size) but it had not invaded the muscular layer (Additional file 1: Figure S1 – A, B). Intraepithelial neoplastic segments were found in other parts of the tubal mucosa. Her left ovary was normal. Immunohistochemical analysis, using p53 and Ki-67 index, matched the tumor tissue in the abdominal implants with the tumor in her fallopian tube (Additional file 2: Figure S2), which led us to reach the conclusion of PFTC (higher differentiation of the tubal neoplasia and presence of intraepithelial neoplastic areas). The patient was then enrolled for six cycles of paclitaxel with carboplatin without complications.
(Enlarge Image)
Figure 2.
Positron emission tomography scan. Multiple ganglion metastases with several small implants on the pelvic and abdominal cavities (slides 1 and 3 – coronal section; slide 5 – sagittal section).
(Enlarge Image)
Figure 3.
Primary fallopian tube carcinoma. Hematoxylin and eosin stain showing total inclusion of tubal neoplasia growing inside the lumen (A); papillary serous adenocarcinoma with solid areas (B); moderate nuclear atypia (C).
Case Presentation
This case report presents a 66-year-old Caucasian female housekeeper. Her background includes squamous carcinoma of the nose treated with surgery (14 years ago), hypertension and appendectomy (at a young age). She was nulliparous and had no previous known gynecological problems (menarche and menopause at normal ages, no combined hormonal contraceptives or hormonal replacement therapy). Her only symptom was diffuse abdominal pain, more intense on the flanks, progressing for 3 months and with increasing intensity. The family doctor requested a computed tomography scan that suggested peritoneal carcinomatosis, moderate ascites, with no reference to the primary tumor site. When further examined, a complete and thorough examination showed:
No vaginal discharge, endocervical polyp (no dysplasia) and normal cervical-vaginal cytology.
Blood work: elevation of CA-125 (515UI/mL), CA-19.9 and carcinoembryonic antigen within normal range, hepatic enzymes slightly elevated.
Diagnostic paracentesis: no malignant cells.
Gastrointestinal tract study: normal upper and lower endoscopy.
Abdominopelvic magnetic resonance imaging (MRI): moderate ascites, peritoneal thickening around transverse mesocolon and omental involvement ("omental cake") (Figure 1) and a large, calcified uterine fibroid.
(Enlarge Image)
Figure 1.
Abdominopelvic magnetic resonance imaging. Axial T2-weighted image. Heterogeneous soft-tissue thickening of the greater omentum ("omental cake") (arrow). Moderate ascites (arrowhead).
The patient's case was reviewed by the Gynecology team at the Portuguese Institute of Oncology of Oporto and an exploratory laparotomy was decided. The intra-operatory findings showed diffuse parietal peritoneal implants (pelvic and abdominal) with a voluminous mass involving her epiploon, from the hepatic hilum to the splenic hilum, invading the great gastric curvature. An anterior abdominal wall implant was removed and sent for extemporary examination which revealed high-grade adenocarcinoma. Ascitic fluid was collected; atypical gastrectomy, omentectomy and myomectomy were performed. When reviewing the adnexial area, a small dilation and purple color were noticed on her left fallopian tube. The surgery was completed with left adnexectomy. Macroscopic residual disease (>2cm) was present at the end of surgery. During the postoperatory period, a positron emission tomography scan revealed multiple ganglion metastases with several small implants on her pelvic and abdominal cavities (Figure 2). The pathology report showed infiltrative serous adenocarcinoma of epiploon and gastric curvature (papillary pattern Figures 3A and 3B), invading the gastric muscular layer, but not the mucosa. When analyzing her left fallopian tube, the same adenocarcinoma type was found in the lumen (9mm in size) but it had not invaded the muscular layer (Additional file 1: Figure S1 – A, B). Intraepithelial neoplastic segments were found in other parts of the tubal mucosa. Her left ovary was normal. Immunohistochemical analysis, using p53 and Ki-67 index, matched the tumor tissue in the abdominal implants with the tumor in her fallopian tube (Additional file 2: Figure S2), which led us to reach the conclusion of PFTC (higher differentiation of the tubal neoplasia and presence of intraepithelial neoplastic areas). The patient was then enrolled for six cycles of paclitaxel with carboplatin without complications.
(Enlarge Image)
Figure 2.
Positron emission tomography scan. Multiple ganglion metastases with several small implants on the pelvic and abdominal cavities (slides 1 and 3 – coronal section; slide 5 – sagittal section).
(Enlarge Image)
Figure 3.
Primary fallopian tube carcinoma. Hematoxylin and eosin stain showing total inclusion of tubal neoplasia growing inside the lumen (A); papillary serous adenocarcinoma with solid areas (B); moderate nuclear atypia (C).
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