Fallopian
Tube
Protocol applies to all
carcinomas of the fallopian tube.
Procedures
Cytology
Excision of Tubal Fragment(s)
Hysterectomy with Salpingo-oophorectomy
I.
Cytologic material back Top Main Page
1. Patient identification
a. Name
b. Identification number
c. Age (birth date)
2. Responsible physician(s)
3. Date of procedure
4. Other clinical information
a. Relevant history
(1) abnormal uterine bleeding pattern
(2) discharge per vaginam (Note A)
(3) pregnant or non-pregnant
(4) prior therapy (hormonal, radiation,
chemotherapy)
(5) prior tumors and operations of possible
relevance
b. Other relevant findings (eg, radiologic
findings, laboratory data)
c. Clinical diagnosis
d. Operative findings
e. Type(s) or site(s) of specimen(s):
(1) ascitic fluid
(2) peritoneal washings (specify site)
(3) brushings (specify site)
(4) cyst fluid (specify site)
(5) fine needle aspirate (specify site)
(6) cytology preparation of tissue (touch
preparation) (specify site)
(7) other
1. Specimen
a. Unfixed/fixed (specify fixative)
b. Number of slides received, if appropriate
c. Quantity and appearance of fluid specimen, if
appropriate
d. Other (eg, cytologic preparation from tissue)
e.
Results of intraprocedural consultation
2. Material submitted for microscopic evaluation
(eg, smear; cytocentrifuge, touch or filter preparation; cell block)
3. Special studies (specify) (eg, cytochemistry,
immunocytochemistry)
1. Adequacy of specimen (if unsatisfactory for evaluation, specify
reason)
2. Tumor, if present
a. Histologic type, if possible (Note
B)
b. Histologic grade, if possible (Note
C)
c. Other features (eg, necrosis)
3. Additional cytologic findings, if present
4. Results/status of special studies (specify)
5. Comments
a. Correlation with intraprocedural
consultation, as appropriate
b. Correlation with other specimens, as
appropriate
c. Correlation with clinical information, as
appropriate
II.
Excision of Tubal Fragment(s)
1. Patient identification
a. Name
b. Identification number
c. Age (birth date)
2. Responsible physician(s)
3. Date of procedure
4. Other clinical information
a. Relevant history
(1) abnormal uterine bleeding pattern
(2) discharge per vaginam (Note A)
(3) pregnant or non-pregnant
(4) prior therapy (hormonal, radiation,
chemotherapy)
(5) prior tumors and operations of possible
relevance
b. Other relevant findings (eg, radiologic
findings, laboratory data)
c. Clinical diagnosis
d. Procedure
e. Operative findings
f. Anatomic site(s) of specimen(s)
1. Specimen
a. Unfixed/fixed (specify fixative)
b. Number of pieces
c. Size or size range
d. Descriptive features
e. Results of intraoperative consultation
2. Submit entire specimen for microscopic
evaluation (unless saved for special studies)
3. Special studies (specify) (eg,
histochemistry, immunohistochemistry)
1. Tumor
a. Histologic type (Note B)
b. Histologic grade (Note C)
c. Depth of invasion (Note D)
d. Other features of possible prognostic or
therapeutic significance
2. Additional pathologic findings, if present
a. Other lesions (specify)
b. Relation to tumor, if pertinent
3. Results/status of special studies (specify)
4. Comments
a. Correlation with intraprocedural
consultation, as appropriate
b. Correlation with other specimens, as
appropriate
c. Correlation with clinical information, as
appropriate
III. Unilateral
salpingectomy or salpinogo-oophorectomy
1. Patient identification
a. Name
b. Identification number
c. Age (birth date)
2. Responsible physician(s)
3. Date of procedure
4. Other clinical information
a. Relevant history
(1) abnormal uterine bleeding pattern
(2) discharge per vaginam (Note A)
(3) pregnant or non-pregnant
(4) prior therapy (hormonal, radiation,
chemotherapy)
(5) prior tumors and operations of possible
relevance
b. Relevant findings (eg, radiologic findings,
laboratory data)
c. Clinical diagnosis
d. Procedure
e. Operative findings
f. Anatomic site(s) of specimen(s)
1. Specimen
a. Organs/tissues received
b. Unfixed/fixed (specify fixative)
c. Number of pieces
d. Dimensions (measure attached tissues
individually)
e. Orientation (if indicated by surgeon)
f. Results of intraoperative consultation
2. Tube or tube-ovary if fused into single mass*
a. Dimensions
b. Outer surface
(1) descriptive features (eg, adhesions,
roughening, granularity)
(2) extent of findings (in two dimensions or
proportion of total area involved)
c. Fimbriated end of tube (Note E)
(1) open
(2) closed
d. Sectioned surface of specimen or opened
cyst(s)
e. Contents of lumen of tube or cyst(s)
f. Tumor
(1) location:
i. fimbria(e)
ii. ampulla
iii. isthmus
iv. interstitial portion
v. combination
(2) extent of invasion, if discernible
i. intraluminal polypoid or papillary and
attached to mucosal surface
ii. intramural
iii. serosal
iv. ovarian spread
v. combination
(3) dimensions, if different from size of entire
specimen
(4) descriptive features
(5) adhesions suspicious for tumor
g. Resection margins(s), describe relation to or
involvement by tumor
h. Additional pathologic findings, if present
*If
fused ovary and tube separately identifiable on sectioning, describe tumor in
each, including relation to one another
3. Non-fused ovary or ovaries
a. Outer surface
b. Sectioned surface
c. Tumor
(1) location
(2) dimensions
(3) descriptive features
d. Additional pathologic findings, if present
4. Tissues submitted for microscopic evaluation (Note F)
5. Special studies, specify (eg, histochemistry,
immunohistochemistry, electron microscopy)
1. Tube or tube-ovary if fused into single mass
a. Tumor (Note D)
(1) histologic type (Note B)
(2) histologic grade (Note C)
(3) location:
i. fimbria(e)
ii. ampulla
iii. isthmus
iv. interstitial portion
v. ovary
vi. combination
(4) extent of invasion
i. intraluminal (polypoid or papillary and attached
to mucosal surface)
ii. intramural
iii. serosa
(5) blood/lymphatic vessel invasion
(6) extent and distribution in tube and ovary if
also involved
(7) site(s) of origin (Note G)
(8) total extent (eg, with invasion of; metastasis
to, etc.)
b. Other features of possible prognostic or
therapeutic significance
c. Resection margins, as appropriate
d. Additional pathologic findings, if present
(1) salpingitis (Note H)
(2) endometriosis (Note H)
(3) relation to tumor, if pertinent
2. Non-fused ovary or ovaries
a. Tumor (Note D)
(1) histologic type (Note B)
(2) histologic grade (Note C)
(3) location
(4) site(s) of origin (Note G)
(5) extent of invasion
b.
Other features of possible prognostic or
therapeutic significance
c. Resection margins, if pertinent
d. Additional pathologic findings, if present
(1) salpingitis (Note H)
(2) endometriosis (Note H)
(3) relation to tumor, if pertinent
3. Results/status of special studies (specify)
4. Comments
a. Correlation with intraoperative consultation,
as appropriate
b. Correlation with other specimens, as
appropriate
c. Correlation with clinical information, as
appropriate
IV.
Hysterectomy with salpingo-oophorectomy (with or without
pelvic exenteration)
1. Patient identification
a. Name
b. Identification number
c. Age (birth date)
2. Responsible physician(s)
3. Date of procedure
4. Other clinical information
a. Relevant history
(1) abnormal uterine bleeding pattern
(2) discharge per vaginam (Note A)
(3) pregnant or non-pregnant
(4) prior therapy (hormonal, radiation,
chemotherapy)
(5) prior tumors and operations of possible
relevance
b. Other relevant findings (eg, radiologic
findings, laboratory data)
c. Clinical diagnosis
d. Procedure
e. Operative findings
f. Anatomic site(s) of specimen(s)
1. Specimen
a. Organs/tissues received (specify)
b. Unfixed/fixed (specify fixative)
c. Number of pieces
d. Dimensions (measure attached tissues
individually)
e. Orientation (if indicated by surgeon)
f. Results of intraoperative consultation
2. Tube or tube-ovary if fused into single mass*
a. Dimensions
b. Outer surface
(1) adhesions, roughening, granularity
(2) extent in two dimensions or proportion of
total area involved
c. Fimbriated end of tube (Note E)
(1) open
(2) closed
d. Sectioned surface of specimen or opened
cyst(s)
e. Contents of lumen of tube or cyst(s)
f. Tumor
(1) Location:
i. fimbria(e)
ii. ampulla
iii. isthmus
iv. interstitial portion
v. combination
(2) Depth of invasion, if discernible
i. intraluminal polypoid or papillary and
attached to mucosal surface
ii. intramural
iii. serosal
iv. ovarian spread
v. combination
(3) Dimensions, if different from size of entire
specimen
(4) Descriptive features of tumor tissue
(5) Adhesions suspicious for tumor
f. Resection margin(s), describe relation to or
involvement by tumor
g. Additional pathologic findings, if present
*If
fused ovary and tube separately identifiable on sectioning, describe tumor in
each, including relation to one another
3. Contralateral fallopian tube
a. Dimensions
b. Tumor
(1) dimensions
(2) location
(3) descriptive features
c. Additional pathologic findings, if present
4. Non-fused ovary or ovaries
a. Dimensions
b. Outer surface
c. Sectioned surface
d. Tumor
(1) dimensions
(2) location
(3) descriptive features
e. Additional pathologic findings, if present
5. Uterus
a. Dimensions
b. Tumor
(1) dimensions
(2) location
(3) descriptive features
(4) relation to tubal tumor (separate or
continuous)
c. Additional pathologic findings, if present
6. Omentum
a. Dimensions
b. Tumor
(1) number of nodules if easily counted
(2) size range
(3) descriptive features
(4) size and gross appearance of confluent
mass(es)
c. Additional pathologic findings, if present
7. Regional lymph nodes
a. Number and size range at each designated
location
b. Tumor
(1) dimensions
(2) location
(3) descriptive features
c. Additional pathologic findings, if present
8. Other staging biopsy specimens (label
separately if so designated)
9. Other organ(s)/tissue(s) removed
a. Type, dimensions, and other gross features
b. Tumor
(1) location and relation to tubal tumor (separate
or adherent)
(2) size and distribution within organ or tissue
c. Resection margins if applicable
d. Additional pathologic findings, if present
10. Tissues submitted for microscopic evaluation (Note F)
11. Special studies (specify) (eg, histochemistry,
immunohistochemistry, electron microscopy)
1. Tube or tube-ovary if fused into single mass
a. Tumor (Note D)
(1) histologic type (Note B)
(2) histologic grade (Note C)
(3) location:
i. fimbria(e)
ii. ampulla
iii. isthmus
iv. interstitial portion
v. ovary
vi. combination
(4) depth of invasion
i. intraluminal polypoid or papillary and
attached to mucosal surface
ii. intramural
iii. serosa
(5) extent and distribution in tube and ovary if
also involved
(6) site(s) of origin (Note G)
(7) total extent (eg, with invasion of; metastasis
to, etc.)
(8) blood/lymphatic vessel invasion
(9) other features of possible prognostic or
therapeutic significance
b. Status of resection margins
c. Additional pathologic findings, if present
(1) salpingitis (Note H)
(2) endometriosis (Note H)
(3) relation to tumor, if pertinent
2. Non-fused ovary or ovaries
a. Tumor, if present
(1) histologic type
(2) histologic grade
(3) location
b. Additional pathologic findings, if present
3. Uterus
a. Tumor, if present
(1) histologic type
(2) histologic grade
(3) location
(4) relation to tubal tumor
b. Status of resection margins if pertinent
c. Additional pathologic findings, if present
d. Endometrium uninvolved by tumor
4. Omentum
a. Tumor, if present
(1) histologic type
(2) histologic grade
b. Additional pathologic findings, if present
5. Lymph nodes at each location if separately
designated (Note D)
a. Tumor, if present
(1) histologic type
(2) histologic grade
b. Additional pathologic findings, if present
(eg, inclusion glands or cysts [endosalpingiosis])
6. Other staging biopsy specimens at each
location if so designated
a. Tumor, if present
(1) histologic type
(2) histologic grade
b. Additional pathologic findings, if present
(eg, endosalpingiosis)
7. Other organs or tissue removed
a. Tumor, if present (Note D)
(1) histologic type
(2) histologic grade
(3) location
(4) extent
(5) distribution
b. Resection margins if applicable
c. Additional pathologic findings, if present
(specify)
8. Results/status of special studies (specify)
9. Comments
a. Correlation with intraoperative consultation,
as appropriate
b. Correlation with other specimens, as
appropriate
c. Correlation with clinical information, as
appropriate
EXPLANATORY NOTES
A. Discharge Per Vaginam back Top Main Page
The
occurrence of a gush of cholesterol-rich, clear fluid per vaginam accompanied
by abdominal pain and reduction in the size of an abdominal mass is suggestive
of but not specific for carcinoma of the fallopian tube.
B.
Histologic type back Top Main Page
Carcinoma in situ
Serous carcinoma
Mucinous carcinoma
Endometrioid carcinoma
Clear cell carcinoma
Transitional cell carcinoma
Squamous cell carcinoma
Undifferentiated carcinomas
C.
Histologic Grade back Top Main Page
No
specific grading system for tubal cancers is recommended. For the sake of
uniformity, however, it is suggested that four grades be used, with grade 4
(undifferentiated) applied to tumors with no differentiation or minimal
differentiation that is discernible in only rare tiny foci.
GX Cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated
The
TNM Staging System for fallopian tubes endorsed by the American Joint Committee
on Cancer (AJCC) and the International Union Against Cancer (UICC) and the
parallel system formulated by the International Federation of Gynecology and
Obstetrics (FIGO) are recommended as shown below.(1,2)
TNM FIGO
Categories Stage Definition
TX (--) Primary tumor cannot be
assessed
T0 (--) No evidence of primary tumor
Tis Stage 0 Carcinoma in situ (limited to tubal
mucosa**)
T1 Stage I Tumor limited to fallopian tube(s)
T1a Stage IA Tumor limited to one tube without
penetrating the serosal surface; no ascites
T1b Stage IB Tumor limited to both tubes without
penetrating the serosal surface; no ascites
T1c Stage IC Tumor limited to one or both tube(s)
with extension onto or through the tubal serosa; or with malignant cells in
ascites or peritoneal washings
T2 Stage II Tumor involves one or both fallopian tube(s) with pelvic extension
T2a Stage IIA Extension and/or metastasis to the
uterus and/or ovaries
T2b Stage IIB Extension to other pelvic structures
T2c Stage IIC Pelvic extension (2a or 2b) with
malignant cells in ascites or peritoneal washings
T3 and/or
N1 Stage III Tumor involves one or both fallopian tube(s) with peritoneal implants
outside of the pelvis and/or positive regional nodes
T3a Stage IIIA Microscopic peritoneal metastasis
outside the pelvis
T3b Stage IIIB Macroscopic peritoneal metastasis outside
the pelvis 2 cm or less in greatest dimension
T3c and/or
N1 Stage IIIC Peritoneal metastasis > 2 cm in greatest dimension and/or
positive regional lymph nodes
M1 Stage IV Distant metastasis (excludes
peritoneal metastasis)
*By
AJCC/UICC convention, the designation T refers to a primary tumor that has
not been previously treated. The symbol p refers to the pathologic
classification of the TNM, as opposed to the clinical classification and is
based on gross and microscopic examination. pT entails a resection of the
primary tumor or biopsy adequate to evaluate the highest pT category; pN
entails removal of nodes adequate to validate lymph node metastasis; and pM
implies microscopic examination of distant lesions. Clinical classification (cTNM) is usually carried out by the
referring physician before treatment during initial evaluation of the patient
or when pathologic classification is not possible.
Tumor
remaining in a patient after therapy with curative intent (eg, surgical
resection for cure) is categorized by a system known as R classification, shown
below.
RX Presence of residual tumor cannot be
assessed
R0 No residual tumor
R1 Microscopic residual tumor
R2 Macroscopic residual tumor.
For
the surgeon, the R classification may be useful to indicate the known or
assumed status of the completeness of a surgical excision. For the pathologist, the R classification is
relevant to the status of the margins of a surgical resection specimen. That is, tumor involving the resection
margin on pathologic examination may be assumed to correspond to residual tumor
in the patient and may be classified as macroscopic or microscopic according to
the findings at the specimen margin(s).
In
contrast, tumor remaining in a resection specimen from a patient who has
undergone previous (neoadjuvant) treatment of any type (radiation therapy
alone, chemotherapy therapy alone, or any combined modality treatment) is
codified by the TNM using a prescript y (eg, ypT1). Thus, yTNM indicates the
post-treatment status of the tumor. For
many neoadjuvant therapies, the classification of residual disease may be a
strong predictor of postoperative outcome. In addition, the ypTNM
classification provides a standardized framework for the collection of data
needed to accurately evaluate new neoadjuvant therapies.
In
contrast to residual tumor, classification of a tumor as recurrent requires
a documented disease-free interval after definitive therapy. Recurrent tumor may also be classified
according to the TNM categories, but the prefix r (eg, rpT1) is used to
indicate the recurrent status of the tumor.
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph nodes metastasis
N1 Regional lymph node metastasis
Distant Metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Stage
0 Tis N0 M0
Stage
IA T1a N0 M0
Stage
IB T1b N0 M0
Stage
IC T1c N0 M0
Stage
IIA T2a N0 M0
Stage
IIB T2b N0 M0
Stage
IIC T2c N0 M0
Stage
IIIA T3a N0 M0
Stage
IIIB T3b N0 M0
Stage
IIIC T3c N0 M0
Any T N1 M0
Stage
IV Any T Any N M1
E.
Fimbriated End back Top Main Page
Although
most investigators have not commented on the possible prognostic significance
of the status of the fimbriated end, in one series of cases of tubal carcinoma(3) closure of the
fimbriated end was an important factor in improvement of the survival rate.
F.
Selection of Specimens for Microscopic Examination back
Top Main
Page
1.
Primary tumor
Sections adequate to
demonstrate extent of tumor, including maximal depth of invasion.
Adhesions of tumor and resection margins, if
pertinent, sampled and labelled
specifically if necessary for microscopic identification.
Sections to determine
relation of tubal and ovarian or tubal and uterine components if present.
Tissue fragments frozen for
intraoperative consultation.
2.
Uterus
Tumor grossly present
sections necessary to determine its extent, including depth of invasion of
myometrium if tumor originates in endometrium, and to determine relation to
tubal tumor (for primary tumors of endome-trium see CAPs endometrial cancer
protocol).
3.
Non-fused ovary or ovaries
No tumor or other abnormalities single representative section.
Tumor sections to determine relation to tubal tumor(s).
4.
Omentum
Representative sampling of grossly identifiable tumor.
(Multiple
sections are generally optimal when no tumor is detected grossly because of the
possible impact of microscopically detected disease on prognosis and therapy.)
5.
Lymph nodes
Representative sections of
grossly positive lymph nodes are generally adequate.
(If
lymph nodes appear to be free of tumor, an attempt should be made to identify
and sample every node in the specimen[s].)
6.
Other staging biopsy specimens
Submit entirely (unless
grossly positive, when a representative section usually suffices).
7. Other excised organ(s) or tissue(s)
Sections adequate to
determine presence or absence and location and extent of tumor, if present.
Resection margins, if applicable.
G.
Site of Origin back Top Main Page
When
a tumor involves both the fallopian tube and the ovary it may be difficult to
determine the primary site of the tumor in some cases. Typically, the primary
tumor predominates and obviously originates from one or the other organ.
Occasionally, however, the tube and ovary are fused to form a solid or cystic
mass with destruction of most or all landmarks. In such cases, the tumor is almost
always assumed to be a primary ovarian cancer because its frequency is much
greater than that of tubal cancer. Microscopic examination may be helpful
because most tubal cancers resemble serous carcinomas of the ovary, with tubal
carcinomas of other cell types being relatively rare. Finding what appears to
be in situ carcinoma in the tube adjacent to the main tumor mass is not always
a reliable criterion for origin in the tube since carcinoma that has extended
into the tube from elsewhere can grow along its mucosal surface and simulate
closely carcinoma in situ.
H.
Other Lesions back Top Main Page
Severe
salpingitis, including tuberculous salpingitis, can be associated with
pseudocarcinomatous changes in the tube.(4)
Carcinoma is rarely associated with severe salpingitis. Therefore, the presence
of severe salpingitis should alert the pathologist to the possibility of a pseudocarcinomatous
change. Endometriosis may be present in the background of endometrioid
carcinoma of the tube.(5,6)
1. Fleming ID, Cooper JS, Henson DE, et
al, eds. AJCC Manual for Staging of
Cancer. 5th ed. Philadelphia, Pa:
Lippincott Raven; 1997.
2.
Pettersson F. Staging rules for
gestational trophoblastic tumors and fallopian tube cancer. Acta Obstet Gynecol. 1992;71:224-225.
3.
Green TH, Scully RE. Tumors of the
fallopian tube. Clin Obstet Gynecol.
1962;5:886-906.
4.
Cheung AN, Young, RH, Scully, RE.
Pseudocarcinomatous hyperplasia of the fallopian tube associated with
salpingitis. Am J Surg Pathol.
1994;8:1125-1130.
5.
Lisa JR, Gioia JD, Rubin IC.
Observations of the interstitial portion of the fallopian tube. Surg Gynecol Obstet. 1954;99:159-169.
6.
Rubin IC, Lisa JR, Trinidad S.
Further observations on ectopic endometrium of the fallopian tube. Surg Gynecol Obstet. 1956;103:469-474.
BIBLIOGRAPHY
Benedet
JL, Miller DM. Tumors of fallopian tube: Clinical features, staging and
management. In: Coppleston M, ed. Gynecological
Oncology. 2nd ed. Vol. 2. Edinburgh: Churchill Livingstone; 1991:853-860.
Scully
RE, Young RH, Clement PB. Tumors of the Ovary, Maldeveloped Gonads, Fallopian
Tube, and Broad Ligament. Atlas of Tumor Pathology. 3rd series. Fascicle 22.
Washington, DC: Armed Forces Institute of Pathology; in press.
Sedlis
A. Primary carcinoma of the fallopian tube. Obstet
Gynecol Surv. 1961;16:209-226.
Wheeler
JE. Diseases of the fallopian tube. In: Kurman RJ, ed. Blausteins Pathology of the Female Genital Tract. 4th ed. New
York, NY: Springer-Verlag; 1994:529-561.
Woodruff
JD, Pauerstein CJ. The Fallopian Tube.
Baltimore, Md: Williams and Wilkins; 1969:237-306.
Authors:
Robert
E. Scully, MD; Donald Earl Henson,
MD; Mary L. Nielsen, MD; Stephen G.
Ruby, MD
Contributors:
back Top Main Page
CAP
Cancer Committee; David M. Gershenson, MD; Arthur L. Herbst, MD; Jaime E.
Wheeler, MD