Primary fallopian tube cancer (PFTC) is a rare malignancy with an incidence of 0.14-1.8% of all genital malignancies. Presentationsof fallopian tube cancer are mostly nonspecific and include abdominal pain, profuse watery or serosanguinous discharge. Here, wepresent the case of a 51-year-old patient with FIGO stage 1A PFTC. It was diagnosed as hematosalpinx intraoperatively, during totallaparoscopic hysterectomy and diagnosed as PFTC on histopathology. Further management was by laparoscopic staging. A high indexof suspicion is needed in peri and postmenopausal women who present with unexplained uterine bleeding, profuse discharge, pelvicpain, adnexal mass or abnormal pap smear

Balasubramaniam, Devi

Balasubramanium, Aravinth

Duraisamy, Kavitha Yogini

Ravi, Karthikha

English

Atharva Scientific Publications (E-Jounals)

Case Report
Vol 5 | Issue 2 | Mar - Apr 2019 Indian J Case Reports    148
Laparoscopic management of early stage primary fallopian tube carcinoma
Kavitha Yogini Duraisamy1, Devi Balasubramaniam2, Karthikha Ravi3, Aravinth Balasubramanium4
From 1Head of Department, 2Consultant, 3Resident, Department of Endogynaecology, 4Consultant, Department of Pathology, Gem Hospital and 
Research Centre, Coimbatore, Tamil Nadu, India
Correspondence to: Dr. Karthikha Ravi, Department of Endogynaecology, Gem Hospital and Research Centre, 45, Pankaja Mills 
Road, Ramanathapuram, Coimbatore - 641045, Tamil Nadu, India. E-mail: karkate29@yahoo.co.in
Received - 02 February 2019 Initial Review - 21 February 2019 Accepted - 31 March 2019
ABSTRACT
Primary fallopian tube cancer (PFTC) is a rare malignancy with an incidence of 0.14-1.8% of all genital malignancies. Presentations 
of fallopian tube cancer are mostly nonspecific and include abdominal pain, profuse watery or serosanguinous discharge. Here, we 
present the case of a 51-year-old patient with FIGO stage 1A PFTC. It was diagnosed as hematosalpinx intraoperatively, during total 
laparoscopic hysterectomy and diagnosed as PFTC on histopathology. Further management was by laparoscopic staging. A high index 
of suspicion is needed in peri and postmenopausal women who present with unexplained uterine bleeding, profuse discharge, pelvic 
pain, adnexal mass or abnormal pap smear. 
Keywords: Histopathology, Primary fallopian tube cancer, Staging laparoscopy.
Primary fallopian tube cancer (PFTC) is the least common of all gynecological malignancies with an incidence of about 3.6 per million women per year. It accounts for 0.14-
1.8% of all female genital malignancies [1]. More than 90% of 
fallopian tube carcinomas are serous or high‐grade endometrioid 
adenocarcinoma. The peak incidence is between 60-64 years 
of age, with a mean age of incidence of 55 years (range 17-
88 years) [2]. Etiology remains unclear and it could be due to 
hormonal, reproductive or genetic factors. There is a correlation 
with nulliparity, infertility, and pelvic inflammatory disease. High 
parity has been reported to be protective while the use of oral 
contraceptives and pregnancy decreases the risk of PFTC [1]. 
Hereditary factors constitute 10 % of fallopian tube cancer and 
include mutations in BRCA1 (20-50%), BRCA 2(10-20%), type 
2 Lynch syndrome, an inherited mutation in ARID1 [3]. Hence, 
patients with a strong family history are advised to have risk-
reducing bilateral salphingo-oophorectomy after completing 
childbirth. The incidence of PFTC in risk-reducing surgeries 
in BRCA was 5.7% and distal fallopian tube seemed to be the 
dominant site of malignancy [4].
Early stage PFTC is very rare as most fallopian tube cancers 
are identified at later stages. A high index of suspicion is needed 
in peri and postmenopausal women presenting with recurrent 
vaginal discharge with normal endometrial histopathology. We 
present the case of a 51-year-old patient with PFTC.
CASE REPORT
A 51-year-old P3L2A1 woman, postmenopausal since 3 years 
presented with complaints of blood-stained discharge per vagina 
for 2 months and was not associated with pruritus or foul-smell. 
She had no history of abdominal pain, postmenopausal bleeding 
or perimenopausal abnormal uterine bleeding (AUB). Bowel and 
bladder habits were normal. She was on treatment for palpitation 
and hypothyroidism. History of open sterilization 23 years ago 
and laparoscopic cholecystectomy 10 years ago were present. She 
has no family history of malignancy. She attained menarche at 
12 years of age, married at 18 years of age, attained menopause 
at 48 years of age. The obstetric score was P3L2A1, NVD, last 
childbirth (LCB) at 28 years, age at first childbirth was 19 years 
of age.
She was overweight on examination with Body mass 
index (BMI) 29. There was no pallor, no pedal edema or 
lymphadenopathy. The blood pressure was 130/80 mmHg, pulse 
rate 92/min andSpO2-97% in room air. Abdominal examination 
showed 3 cm suprapubic transverse scar. On per speculum 
examination, the cervix was healthy and no discharge was noted. 
On bimanual pelvic examination, the uterus was bulky, no adnexal 
mass or tenderness was present.  
Pap smear was negative for intraepithelial lesion or malignancy, 
endometrial biopsy showed proliferative endometrium. 
Ultrasound (USG) revealed bulky uterus with 2 small intramural 
fibroids. Computed Tomography (CT) scan showed bulky uterus 
with small fibroid and ovaries were normal.
In view of persistent blood stained discharge, the patient was 
advised total laparoscopic hysterectomy (TLH) with bilateral 
salpingo-oophorectomy. She was counseled regarding the rare 
chance of malignancy and need for revision surgery. TLH with 
bilateral salpingo-oophorectomy and uterosacral colpopexy was 
done. Intraoperative findings were as follows: uterus was bulky, 
multiple small fibroids were present, and the largest fibroid was 
in the anterior wall of about 3 x 2cm in size. Right tube and both 
Early stage fallopian tube cancer: Laproscopic Management
Vol 5 | Issue 2 | Mar - Apr 2019 Indian J Case Reports    149
Duraisamy et al.  Early stage fallopian tube cancer: Laproscopic Management
ovaries were normal. Left tube was enlarged in size (3 x 2 cm), 
which was suggestive of hydrosalpinx (Fig. 1). 
The specimen was sent for histopathology. Macroscopic 
findings on histopathological examination (HPE) were leiomyoma 
uterus, 5 x 2cm left tube and 2 x 2 cm mass occupying the center 
of the fallopian tube. It was pale, homogenous with cystic and 
hemorrhagic degeneration. Microscopic examination shows 
that the left fallopian tube serosa was intact and there was high-
grade serous carcinoma with no surface involvement P (T1aNx), 
(Fig. 2).
Staging laparoscopy with transperitoneal high paraaortic 
lymphadenectomy (A2, B1), bilateral pelvic lymphadenectomy 
with infracolic omentectomy, peritoneal washing, and peritoneal 
biopsy was done on the 9th postoperative day (POD). CA125 done 
was 65.1 mU/ml. Histopathology of lymph node was negative for 
malignancy. As it was diagnosed as PFTC stage 1A, high-grade 
serous, postoperatively chemotherapy was advised. A follow-up 
of the patient was scheduled after 3 months but unfortunately, the 
patient lost to follow-up.
DISCUSSION
Clinical presentations of fallopian tube cancer are non-specific 
and include abdominal pain, profuse watery or pinkish discharge, 
adnexal mass, and abnormal vaginal bleeding. Latzko’s triad 
of symptoms consisting of intermittent profuse serosanguinous 
vaginal discharge, colicky abdominal pain relieved by discharge 
and abdominal or pelvic mass has been reported in 15% of 
cases. Hydrops tubae profluens, a pathognomonic feature is 
characterized by intermittent discharge of clear or blood-tinged 
fluid spontaneously or on pressure followed by shrinkage of 
the adnexal mass and occurs in 5% of patients [5]. The rate of 
preoperative diagnosis is very less and is about 0-10% [6]. In our 
case, only profuse discharge was present.
As PFTC has a worse prognosis compared to Epithelial 
Ovarian Cancer (EOC) in advanced stages, a high index of 
suspicion is needed for the diagnosis of PFTC. It has been 
previously presumed that fallopian tube malignancies were rare. 
However, it has now been challenged and studies show that many 
tumors that were classified as serous carcinomas of the ovary 
or peritoneal cancers appear to have their origin in the fallopian 
tube. This led to the International Federation of Gynaecology and 
Obstetrics (FIGO) to stage all three carcinomas similarly. Hence, 
there is a strict criterion for the diagnosis of PFTC. The diagnostic 
criteria for PFTC were first established by Hu et al and modified 
by Sidles.  PFTC is diagnosed if: grossly, the main tumor is in 
the tube and arises from the endo salpinx; the histological pattern 
reproduces the epithelium of tubal mucosa; transition from 
benign to malignant tubal epithelium should be demonstrated and 
ovaries and endometrium should be either normal or have a much 
smaller tumor volume than that of the tube [7].
Preoperative diagnosis may be picked up by imaging. On USG, 
findings of tubal carcinoma are nonspecific and appear similar to 
an ovarian tumor or tubo-ovarian abscess. Suspicious findings are 
a cystic mass with spaces and mural nodules, a sausage-shaped 
mass or a multilobular mass with a cog-and-wheel appearance [8]. 
CT and magnetic resonance imaging (MRI) are better modalities 
in the diagnosis of PFTC. MRI may also be helpful in 
detecting adjacent soft tissue involvement. Serum CA125done 
preoperatively has been found to be an additional independent 
prognostic factor in overall survival rate and disease-free 
interval [9]. It also has a high sensitivity (92%) and specificity 
(90%) for follow-up. 
Initial management of PFTC is surgical, similar to that 
of ovarian carcinoma management. After surgical staging, 
postoperative chemotherapy with a platinum-based regimen 
is usually recommended in patients, except in those diagnosed 
with well-differentiated Stage IA and B disease. In cases of 
incidentally picked up PFTC in specimen done for benign cases, 
completion staging must be done. In patients with apparent early-
stage carcinoma not willing for surgery, adjuvant chemotherapy 
is recommended, as there is a 33% incidence of upstaging [10]. 
Figure 1: Intraoperative finding of the left fallopian tube with 
primary fallopian tube carcinoma
Figure 2: Histology showing tumor confined to the mucosa
Duraisamy et al.  Early stage fallopian tube cancer: Laproscopic Management
Vol 5 | Issue 2 | Mar - Apr 2019 Indian J Case Reports    150
In advanced stages, treatment is optimal cytoreductive surgery 
followed by adjuvant platinum-based chemotherapy. Surgical 
staging, optimal cytoreduction, grade, lymph node status and 
pathologic type are important factors in influencing the survival 
rate. Also, pelvic lymphadenectomy [11] and para-aortic 
lymphadenectomy [12] is necessary for comprehensive staging 
and improves survival rate. The lymphatic flow from the fallopian 
tubes drains to the pelvic nodes through lymphatic channels 
located near the proximal part of the uterus and the distal part 
of the tubes and fimbria have lymphatic channels connected to 
the para-aortic nodes. Even though there are few studies on the 
lymphatic spread of PFTC, it is estimated that pelvic and para-
aortic lymphadenectomy was equally significant for halting the 
lymphatic spread. Sometimes para-aortic lymphadenectomy 
might be more important than pelvic lymphadenectomy [12].
Most of the reports in the literature include surgery by 
laparotomy. We have managed our case with TLH with bilateral 
salphing-oophorectomy and followed it up with staging 
laparoscopy. It has been demonstrated that laparoscopy is as 
efficacious as laparotomy in the management of selected patients 
of early ovarian carcinoma [13] and fallopian tube carcinoma. 
The 5-year survival rate as per FIGO is 65%in stage 1, 50-60% 
in stage 2 and 10-20% for stage 3 and 4. Follow-up is by history, 
clinical examination, imaging with USG or CT and CA125. 
Follow up is done 3 monthly for the first 2 years, 6 monthly till 5 
years and then annually.
CONCLUSION
Primary fallopian tube carcinoma is a rare malignancy that 
accounts for less than 1% of gynecological malignancies. 
Preoperative diagnosis of fallopian tube carcinoma is difficult 
due to nonspecific symptoms and is usually diagnosed on 
histopathology. PFTC histologically and clinically resembles 
epithelial ovarian carcinoma and is now included in the same 
staging system as per FIGO staging. A high index of suspicion 
is needed in peri and postmenopausal women who present with 
unexplained uterine bleeding and discharge.
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Funding: None; Conflict of Interest: None Stated.
How to cite this article: Duraisamy KY, Balasubramaniam D, Ravi K, 
Balasubramanium A. Laparoscopic management of early stage primary 
fallopian tube carcinoma. Indian J Case Reports. 2019;5(2):148-150.
Doi: 10.32677/IJCR.2019.v05.i02.018


Laparoscopic management of early stage primary fallopian tube carcinoma

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Laparoscopic management of early stage primary fallopian tube carcinoma

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