Cancer Association of South Africa (CANSA)

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1 Cancer Assciatin f Suth Africa (CANSA) Fact Sheet n Fallpian Tube Cancer Intrductin The Fallpian tubes, als knwn as viducts, uterine tubes, and salpinges (singular salpinx) are tw very fine tubes lined with ciliated epithelia (cells with fine hair-like structures called cilia which aids t prpel va frm the varies t the uterus), leading frm the varies f the female int the uterus, via the uter-tubal junctin. [Picture Credit: Ciliated Epithelium] [Picture Credit: Fallpian Tubes] In a wman's bdy the fallpian tube allws passage f the egg (vum) frm the vary t the uterus. Its different segments are (lateral t medial): The infundibulum with its assciated fimbriae near the vary The ampullary regin that represents the majr prtin f the lateral tube The isthmus which is the narrwer part f the tube that links t the uterus The interstitial (als knwn as intramural) part that transverses the uterine musculature. The tubal stium is the pint where the tubal canal meets the peritneal cavity The uterine pening f the Fallpian tube is the entrance int the uterine cavity, the uter-tubal junctin. (Wikipedia; Encyclpaedia Britannica). The fallpian tubes are named after their discverer, the 16th century Italian anatmist, Gabriel Fallpius. [Picture Credit: Gabriel Fallpius] Researched and Authred by Prf Michael C Herbst May 2017 Page 1

2 Fallpian Tube Cancer Fallpian tube cancer is cancer that ccurs in any part f the fallpian tube. Primary fallpian tube cancer means the cancer first started t grw in this area. Smetimes cancers that start in ther areas, such as the varies, wmb r cervix, can spread t the fallpian tubes. This is knwn as a secndary fallpian tube cancer and is treated accrding t where the cancer started (the primary cancer). There are different types f fallpian tube cancer. The mst cmmn type is adencarcinma, which starts in the cells that frm part f the lining f the fallpian tubes. Other types f fallpian tube cancer are very rare and include Transitinal cell transitinal cells are stretchy cells fund in the fallpian tube lining Sarcma this affects the muscular part f the fallpian tube (MacMillan Cancer Supprt; Cancer Research UK). Incidence f Fallpian Tube Cancer in Suth Africa The Natinal Cancer Registry (2012) des nt prvide any infrmatin n the incidence f Fallpian Tube Cancer. Risk Factrs fr Fallpian Tube Cancer? Given its rarity, the causes and risk factrs fr develping primary fallpian tube cancer are nt clearly defined. There has been sme assciatin f the cancer with chrnic infectin and/r inflammatin f the fallpian tubes (due t untreated sexually transmitted diseases, fr example), althugh a cause-effect relatinship has nt been definitively established. There are several genetic mutatins that have been reprted in anywhere frm 16-43% f wmen with primary fallpian tube cancer. The mutatins invlve the hereditary breast and varian cancer genes, and particularly BRCA1. Given the relative rarity f fallpian cancer, any wman diagnsed with this disease shuld underg thrugh family histry assessment, and be ffered genetic cunselling. Cnversely, if a wman knws that she carries a BRCA mutatin, rigrus screening fr fallpian cancer shuld be cnsidered in rder t increase chances fr early detectin. (Onclink). Signs and Symptms f Fallpian Tube Cancer Wmen with fallpian tube cancer may experience the fllwing symptms r signs. Smetimes, wmen with fallpian tube cancer d nt shw any f these symptms. Or, these symptms may be caused by a medical cnditin that is nt cancer. Irregular r heavy vaginal bleeding, especially after menpause r in between perids A swllen abdmen Occasinal abdminal r pelvic pain r feeling f pressure Vaginal discharge, which may be clear, white, r tinged with bld Researched and Authred by Prf Michael C Herbst May 2017 Page 2

3 A pelvic mass r lump As a tumur in the fallpian tube grws, it can push against the walls f the tube and cause abdminal pain. If untreated, the cancer can spread int and thrugh the walls f the fallpian tubes and eventually int the pelvis (lwer abdmen) and stmach areas. This can cause ther symptms as well. (Cancer.Net; MacMillan Cancer Supprt). Diagnsis f Fallpian Tube Cancer Because fallpian tube cancer is s rare, and its symptms can resemble ther prblems, it can be difficult t diagnse. Additinally, in sme cases, wmen dn't learn they have fallpian tube cancer until a tube has been remved surgically during an peratin t treat anther illness r prblem. Hwever, there are several tests that may be perfrmed in rder t make a definite diagnsis f the cnditin. First yur dctr will start by asking abut any symptms yu may be experiencing, as well as reviewing yur medical histry and cnducting a thrugh physical exam. Other tests that may be perfrmed include: Pelvic Examinatin - This test invlves feeling the uterus, vagina, varies, fallpian tubes, bladder and rectum t find any abnrmality in their shape r size. CA125 Test - This is a bld test that checks levels f a bld prtein knwn as CA125, which is a tumur marker fr gynaeclgical diseases such as fallpian tube cancer. An estimated 85 percent f wmen with gynaeclgical disease have increased levels f CA125. Hwever, it is imprtant t nte that increased levels f CA125 may nt necessarily mean that a wman has cancer, since CA125 levels als may be increased during pregnancy, menstruatin, in the presence f ther nncancerus gynaeclgic diseases r cancers affecting ther parts f the bdy. Cmputed Tmgraphy (CT) Scan - This imaging test takes a series f detailed pictures f areas inside the bdy. The pictures are created by a cmputer, which is linked t an X-ray machine. A special dye may be injected int a vein r swallwed t help the rgans r tissues shw up mre clearly. Ultrasund - An ultrasund f the pelvis may be perfrmed. This test invlves the use f high-frequency sund waves t create images f rgans and systems within the bdy. These waves, which cannt be heard by humans, create a pattern f eches called a sngram. Healthy tissues, fluid-filled cysts, and tumurs lk different n this picture. Transvaginal ultrasund a special wand is inserted in the vagina which gives ff ultrasund waves that can be read n the ultrasund screen. Bipsy Cells are remved frm the fallpian tubes and lked at under a micrscpe. This is the nly way t find ut fr sure if a persn has fallpian tube cancer. It usually requires surgery. (University f Califrnia San Francisc; MD Andersn Cancer Center). Researched and Authred by Prf Michael C Herbst May 2017 Page 3

4 Staging f Fallpian Tube Cancer Staging f any cancer is very imprtant as the stage f the cancer determines the type f anti-cancer treatment that is given. There are currently tw (2) different types f staging fr fallpian tube cancer, namely the FIGO and TNM systems: I Fallpian Tube Cancer FIGO Descriptin TNM I Tumur is cnfined t ne r bth fallpian tube(s) T1 IA Tumur limited t ne fallpian tube T1a N tumur n the fallpian tub surface N malignant cells in the ascites r peritneal washings IB Tumur limited t bth fallpian tubes T1b N tumur n fallpian tube surface N malignant cells in the ascites r peritneal washings IC Tumur limited t ne r bth fallpian tubes with any f the fllwing: T1c IC1 IC2 IC3 Surgical spill intra-peratively Capsule ruptured befre surgery r tumur n fallpian tube surface Malignant cells in the ascites r peritneal washings FIGO II Fallpian Tube Cancer TNM Descriptin II Tumur invlves ne r bth fallpian tubes with pelvic extensin (belw pelvic brim) T2 IIA Extensin and/r implants n the uterus and/r fallpian tubes and/r varies T2a IIB Extensin t ther pelvic intra-peritneal tissues T2b IIC Pelvic extensin (IIA r IIB) with malignant cells in ascites r peritneal washings T2c FIGO III IIIA IIIA1 IIIA2 IIIB IIIC III Fallpian Tube Cancer Descriptin Tumur invlves ne r bth fallpian tubes, r primary peritneal cancer, with cytlgically r histlgically cnfirmed spread t the peritneum utside the pelvis and/r metastasis (spread) t the retrperitneal lymph ndes Metastasis (spread) t the retrperitneal lymph ndes with r withut micrscpic peritneal invlvement beynd the pelvis Psitive retrperitneal lymph ndes nly (cytlgically r histlgically prven) IIIA (i) Metastasis 10mm in greatest dimensin IIIA (ii) Metastasis > 10mm in greatest dimensin Micrscpic extrapelvic (abve the pelvic brim) peritneal invlvement with r withut psitive retrperitneal lymph ndes Macrscpic peritneal metastases beynd the pelvic brim 2cms in greatest dimensin, with r withut metastasis t the retrperitneal lymph ndes Macrscpic peritneal metastases beynd the pelvic brim >2cms in greatest dimensin, with r withut metastases t the retrperitneal ndes (includes extensin f tumur t capsule f liver and spleen withut parenchymal invlvement f either rgan) TNM T3 T1, T2 T3aN1 T3a, T3aN1 T3b T3bN1 T3c/T3cN1 Researched and Authred by Prf Michael C Herbst May 2017 Page 4

5 FIGO IV IVA IVB (AGO) IV Fallpian Tube Cancer Descriptin Distant metastasis excluding peritneal metastases Pleural effusin with psitive cytlgy Metastases t extra-abdminal rgans (including inguinal lymph ndes and lymph ndes utside f the abdminal cavity) Nte: Parenchymal metastases are IVB TNM Any T, Any N, M1 Gruping f Fallpian Tube Cancer The fllwing depicts the Gruping fr fallpian tube cancer: FIGO T N M IA T1a N0 M0 IB T1b N0 M0 IC T1c N0 M0 IIA T2a N0 M0 IIB T2b N0 M0 IIC T2c N0 M0 IIIA T3a N0 M0 IIIB T3b N0 M0 IIIC T3c N0 M0 IV Any T Any N M1 (AGO). Treatment f Fallpian Tube Cancer As always, the ptimal treatment regimen shuld ultimately be individualized as much as pssible. It shuld take int accunt the patient's stage f disease, ther medical histry, and persnal preference, amng ther things. Surgery - fallpian tube cancer is typically diagnsed with surgery. The new FIGO staging system requires an extensive surgical prcedure very similar t the ne used fr varian cancer. It includes sampling f pelvic fluid, pelvic and abdminal washings, trans-abdminal remval f uterus (hysterectmy), remval f bth varies and fallpian tubes (bilateral salping-phrectmy), remval f sme cnnective tissue flds (mentectmy), selective remval f pelvic lymph ndes (lymphadenectmy), and selective bipsies f the lining f the abdminal walls and rgans (peritneum). In cases f very advanced disease, the gal f surgery is primarily t remve as much tumur bulk as safely pssible (cytreductin). Sme surgens als advcate perfrming a secnd-lk surgery, in which a repeat abdminal surgery is dne t lk fr residual r recurrent disease at a later time. Radiatin Therapy - accrding t a natinal retrspective study that cmpared pstperative chemtherapy t pstperative whle abdmen-pelvis radiatin therapy in patients with early stage disease, there was n significant difference in survival between the tw treatment grups. Hwever, this is nt a randmized study, and s the ability t make cnclusins frm this data is limited. Unfrtunately, there are n randmized trials cmparing the efficacy f abdminpelvic raditherapy and cisplatin-cntaining chemtherapy in the pstperative Researched and Authred by Prf Michael C Herbst May 2017 Page 5

6 setting; given the rarity f this cancer, randmized data may never be available. Treatment after surgery shuld be determined by the patient and physicians tgether, based n lcatin f any remaining disease, as well as the patient s lifestyle and verall health. Chemtherapy - fallpian tube cancer is fairly respnsive t multi-drug regimens cntaining the agent cisplatin, as cmpared t nn-cisplatin single agents r multi-drug regimens. Again, an individual chemtherapeutic regimen shuld be develped by the nclgist with the patient s specific needs in mind. Hrmnal Therapy - the rle f hrmnal treatment fr fallpian tube cancer is nt clear, althugh bth medrxyprgesterne acetate and megestrl acetate have been used tgether with chemtherapy with varying degrees f success. Cmbined Mdality - the latest in cmbined mdality appraches fr advanced disease cnsists f cytreductive surgery, pst-surgical chemtherapy t reduce remaining tumur burden t micrscpic levels, and pssible radiatin t the abdmen and pelvis fllwing chemtherapy. Abut Clinical Trials Clinical trials are research studies that invlve peple. These studies test new ways t prevent, detect, diagnse, r treat diseases. Peple wh take part in cancer clinical trials have an pprtunity t cntribute t scientists knwledge abut cancer and t help in the develpment f imprved cancer treatments. They als receive state-f-the-art care frm cancer experts. Types f Clinical Trials Cancer clinical trials differ accrding t their primary purpse. They include the fllwing types: Treatment - these trials test the effectiveness f new treatments r new ways f using current treatments in peple wh have cancer. The treatments tested may include new drugs r new cmbinatins f currently used drugs, new surgery r radiatin therapy techniques, and vaccines r ther treatments that stimulate a persn s immune system t fight cancer. Cmbinatins f different treatment types may als be tested in these trials. Preventin - these trials test new interventins that may lwer the risk f develping certain types f cancer. Mst cancer preventin trials invlve healthy peple wh have nt had cancer; hwever, they ften nly include peple wh have a higher than average risk f develping a specific type f cancer. Sme cancer preventin trials invlve peple wh have had cancer in the past; these trials test interventins that may help prevent the return (recurrence) f the riginal cancer r reduce the chance f develping a new type f cancer Screening - these trials test new ways f finding cancer early. When cancer is fund early, it may be easier t treat and there may be a better chance f lng-term survival. Cancer screening trials usually invlve peple wh d nt have any signs r symptms f cancer. Hwever, participatin in these trials is ften limited t peple wh have a higher than average risk f develping a certain type f cancer because they have a family histry f that Researched and Authred by Prf Michael C Herbst May 2017 Page 6

7 type f cancer r they have a histry f expsure t cancer-causing substances (e.g., cigarette smke). Diagnstic - these trials study new tests r prcedures that may help identify, r diagnse, cancer mre accurately. Diagnstic trials usually invlve peple wh have sme signs r symptms f cancer. Quality f life r supprtive care - these trials fcus n the cmfrt and quality f life f cancer patients and cancer survivrs. New ways t decrease the number r severity f side effects f cancer r its treatment are ften studied in these trials. Hw a specific type f cancer r its treatment affects a persn s everyday life may als be studied. Where Clinical Trials are Cnducted Cancer clinical trials take place in cities and twns in dctrs ffices, cancer centres and ther medical centres, cmmunity hspitals and clinics. A single trial may take place at ne r tw specialised medical centres nly r at hundreds f ffices, hspitals, and centres. Each clinical trial is managed by a research team that can include dctrs, nurses, research assistants, data analysts, and ther specialists. The research team wrks clsely with ther health prfessinals, including ther dctrs and nurses, labratry technicians, pharmacists, dieticians, and scial wrkers, t prvide medical and supprtive care t peple wh take part in a clinical trial. Research Team The research team clsely mnitrs the health f peple taking part in the clinical trial and gives them specific instructins when necessary. T ensure the reliability f the trial s results, it is imprtant fr the participants t fllw the research team s instructins. The instructins may include keeping lgs r answering questinnaires. The research team may als seek t cntact the participants regularly after the trial ends t get updates n their health. Clinical Trial Prtcl Every clinical trial has a prtcl, r actin plan, that describes what will be dne in the trial, hw the trial will be cnducted, and why each part f the trial is necessary. The prtcl als includes guidelines fr wh can and cannt participate in the trial. These guidelines, called eligibility criteria, describe the characteristics that all interested peple must have befre they can take part in the trial. Eligibility criteria can include age, sex, medical histry, and current health status. Eligibility criteria fr cancer treatment trials ften include the type and stage f cancer, as well as the type(s) f cancer treatment already received. Enrlling peple wh have similar characteristics helps ensure that the utcme f a trial is due t the interventin being tested and nt t ther factrs. In this way, eligibility criteria help researchers btain the mst accurate and meaningful results pssible. Natinal and Internatinal Regulatins Natinal and internatinal regulatins and plicies have been develped t help ensure that research invlving peple is cnducted accrding t strict scientific and ethical principles. In these regulatins and plicies, peple wh participate in research are usually referred t as human subjects. Researched and Authred by Prf Michael C Herbst May 2017 Page 7

8 Infrmed Cnsent Infrmed cnsent is a prcess thrugh which peple learn the imprtant facts abut a clinical trial t help them decide whether r nt t take part in it, and cntinue t learn new infrmatin abut the trial that helps them decide whether r nt t cntinue participating in it. During the first part f the infrmed cnsent prcess, peple are given detailed infrmatin abut a trial, including infrmatin abut the purpse f the trial, the tests and ther prcedures that will be required, and the pssible benefits and harms f taking part in the trial. Besides talking with a dctr r nurse, ptential trial participants are given a frm, called an infrmed cnsent frm, that prvides infrmatin abut the trial in writing. Peple wh agree t take part in the trial are asked t sign the frm. Hwever, signing this frm des nt mean that a persn must remain in the trial. Anyne can chse t leave a trial at any time either befre it starts r at any time during the trial r during the fllw-up perid. It is imprtant fr peple wh decide t leave a trial t get infrmatin frm the research team abut hw t leave the trial safely. The infrmed cnsent prcess cntinues thrughut a trial. If new benefits, risks, r side effects are discvered during the curse f a trial, the researchers must infrm the participants s they can decide whether r nt they want t cntinue t take part in the trial. In sme cases, participants wh want t cntinue t take part in a trial may be asked t sign a new infrmed cnsent frm. New interventins are ften studied in a stepwise fashin, with each step representing a different phase in the clinical research prcess. The fllwing phases are used fr cancer treatment trials: Phases f a Clinical Trial Phase 0. These trials represent the earliest step in testing new treatments in humans. In a phase 0 trial, a very small dse f a chemical r bilgic agent is given t a small number f peple (apprximately 10-15) t gather preliminary infrmatin abut hw the agent is prcessed by the bdy (pharmackinetics) and hw the agent affects the bdy (pharmacdynamics). Because the agents are given in such small amunts, n infrmatin is btained abut their safety r effectiveness in treating cancer. Phase 0 trials are als called micr-dsing studies, explratry Investigatinal New Drug (IND) trials, r early phase I trials. The peple wh take part in these trials usually have advanced disease, and n knwn, effective treatment ptins are available t them. Phase I (als called phase 1). These trials are cnducted mainly t evaluate the safety f chemical r bilgic agents r ther types f interventins (e.g., a new radiatin therapy technique). They help determine the maximum dse that can be given safely (als knwn as the maximum tlerated dse) and whether an interventin causes harmful side effects. Phase I trials enrl small numbers f peple (20 r mre) wh have advanced cancer that cannt be treated effectively with standard (usual) treatments r fr which n standard treatment exists. Althugh evaluating the effectiveness f interventins is nt a primary gal f these trials, dctrs d lk fr evidence that the interventins might be useful as treatments. Phase II (als called phase 2). These trials test the effectiveness f interventins in peple wh have a specific type f cancer r related cancers. They als cntinue t lk at the Researched and Authred by Prf Michael C Herbst May 2017 Page 8

9 safety f interventins. Phase II trials usually enrl fewer than 100 peple but may include as many as 300. The peple wh participate in phase II trials may r may nt have been treated previusly with standard therapy fr their type f cancer. If a persn has been treated previusly, their eligibility t participate in a specific trial may depend n the type and amunt f prir treatment they received. Althugh phase II trials can give sme indicatin f whether r nt an interventin wrks, they are almst never designed t shw whether an interventin is better than standard therapy. Phase III (als called phase 3). These trials cmpare the effectiveness f a new interventin, r new use f an existing interventin, with the current standard f care (usual treatment) fr a particular type f cancer. Phase III trials als examine hw the side effects f the new interventin cmpare with thse f the usual treatment. If the new interventin is mre effective than the usual treatment and/r is easier t tlerate, it may becme the new standard f care. Phase III trials usually invlve large grups f peple (100 t several thusand), wh are randmly assigned t ne f tw treatment grups, r trial arms : (1) a cntrl grup, in which everyne in the grup receives usual treatment fr their type f cancer, r 2) an investigatinal r experimental grup, in which everyne in the grup receives the new interventin r new use f an existing interventin. The trial participants are assigned t their individual grups by randm assignment, r randmisatin. Randmisatin helps ensure that the grups have similar characteristics. This balance is necessary s the researchers can have cnfidence that any differences they bserve in hw the tw grups respnd t the treatments they receive are due t the treatments and nt t ther differences between the grups. Randmisatin is usually dne by a cmputer prgram t ensure that human chices d nt influence the assignment t grups. The trial participants cannt request t be in a particular grup, and the researchers cannt influence hw peple are assigned t the grups. Usually, neither the participants nr their dctrs knw what treatment the participants are receiving. Peple wh participate in phase III trials may r may nt have been treated previusly. If they have been treated previusly, their eligibility t participate in a specific trial may depend n the type and the amunt f prir treatment they received. In mst cases, an interventin will mve int phase III testing nly after it has shwn prmise in phase I and phase II trials. Phase IV (als called phase 4). These trials further evaluate the effectiveness and lng-term safety f drugs r ther interventins. They usually take place after a drug r interventin has been apprved by the medicine regulatry ffice fr standard use. Several hundred t several thusand peple may take part in a phase IV trial. These trials are als knwn as pst-marketing surveillance trials. They are generally spnsred by drug cmpanies. Smetimes clinical trial phases may be cmbined (e.g., phase I/II r phase II/III trials) t minimize the risks t participants and/r t allw faster develpment f a new interventin. Althugh treatment trials are always assigned a phase, ther clinical trials (e.g., screening, preventin, diagnstic, and quality-f-life trials) may nt be labelled this way. Researched and Authred by Prf Michael C Herbst May 2017 Page 9

10 Use f Placebs The use f placebs as cmparisn r cntrl interventins in cancer treatment trials is rare. If a placeb is used by itself, it is because n standard treatment exists. In this case, a trial wuld cmpare the effects f a new treatment with the effects f a placeb. Mre ften, hwever, placebs are given alng with a standard treatment. Fr example, a trial might cmpare the effects f a standard treatment plus a new treatment with the effects f the same standard treatment plus a placeb. Pssible benefits f taking part in a clinical trial The benefits f participating in a clinical trial include the fllwing: Trial participants have access t prmising new interventins that are generally nt available utside f a clinical trial. The interventin being studied may be mre effective than standard therapy. If it is mre effective, trial participants may be the first t benefit frm it. Trial participants receive regular and careful medical attentin frm a research team that includes dctrs, nurses, and ther health prfessinals. The results f the trial may help ther peple wh need cancer treatment in the future. Trial participants are helping scientists learn mre abut cancer (e.g., hw it grws, hw it acts, and what influences its grwth and spread). Ptential harms assciated with taking part in a clinical trial The ptential harms f participating in a clinical trial include the fllwing: The new interventin being studied may nt be better than standard therapy, r it may have harmful side effects that dctrs d nt expect r that are wrse than thse assciated with standard therapy. Trial participants may be required t make mre visits t the dctr than they wuld if they were nt in a clinical trial and/r may need t travel farther fr thse visits. Crrelative research studies, and hw they are related t clinical trials In additin t answering questins abut the effectiveness f new interventins, clinical trials prvide the pprtunity fr additinal research. These additinal research studies, called crrelative r ancillary studies, may use bld, tumur, r ther tissue specimens (als knwn as bispecimens ) btained frm trial participants befre, during, r after treatment. Fr example, the mlecular characteristics f tumur specimens cllected during a trial might be analysed t see if there is a relatinship between the presence f a certain gene mutatin r the amunt f a specific prtein and hw trial participants respnded t the treatment they received. Infrmatin btained frm these types f studies culd lead t mre accurate predictins abut hw individual patients will respnd t certain cancer treatments, imprved ways f finding cancer earlier, new methds f identifying peple wh have an increased risk f cancer, and new appraches t try t prevent cancer. Clinical trial participants must give their permissin befre bispecimens btained frm them can be used fr research purpses. Researched and Authred by Prf Michael C Herbst May 2017 Page 10

11 When a clinical trial is ver After a clinical trial is cmpleted, the researchers lk carefully at the data cllected during the trial t understand the meaning f the findings and t plan further research. After a phase I r phase II trial, the researchers decide whether r nt t mve n t the next phase r stp testing the interventin because it was nt safe r effective. When a phase III trial is cmpleted, the researchers analyse the data t determine whether the results have medical imprtance and, if s, whether the tested interventin culd becme the new standard f care. The results f clinical trials are ften published in peer-reviewed scientific jurnals. Peer review is a prcess by which cancer research experts nt assciated with a trial review the study reprt befre it is published t make sure that the data are sund, the data analysis was perfrmed crrectly, and the cnclusins are apprpriate. If the results are particularly imprtant, they may be reprted by the media and discussed at a scientific meeting and by patient advcacy grups befre they are published in a jurnal. Once a new interventin has prven safe and effective in a clinical trial, it may becme a new standard f care. (Natinal Cancer Institute). Medical Disclaimer This Fact Sheet is intended t prvide general infrmatin nly and, as such, shuld nt be cnsidered as a substitute fr advice, medically r therwise, cvering any specific situatin. Users shuld seek apprpriate advice befre taking r refraining frm taking any actin in reliance n any infrmatin cntained in this Fact Sheet. S far as permissible by law, the Cancer Assciatin f Suth Africa (CANSA) des nt accept any liability t any persn (r his/her dependants/estate/heirs) relating t the use f any infrmatin cntained in this Fact Sheet. Whilst CANSA has taken every precautin in cmpiling this Fact Sheet, neither it, nr any cntributr(s) t this Fact Sheet can be held respnsible fr any actin (r the lack theref) taken by any persn r rganisatin wherever they shall be based, as a result, direct r therwise, f infrmatin cntained in, r accessed thrugh, this Fact Sheet. Researched and Authred by Prf Michael C Herbst May 2017 Page 11

12 Surces and References AGO GO-Klass_IMH_19JUN2013.pdf Cancer.Net Cancer Research UK Ciliated Epithelium Encyclpaedia Britannica Fallpian Tubes Gabriel Fallpius m=isch&sa=x&ei=ok0wvolna8xb7aaesygadg&sqi=2&ved=0cayq_auaq&dpr=0.9#f acrc=_&imgdii=_&imgrc=kakrml4df9cr9m%253a%3bc29iyfefmk- HbM%3Bhttp%253A%252F%252Fimgc.allpstersimages.cm%252Fimages%252FP %252F45%252F4546%252FAYDDG00Z%252Fpsters%252Fgabriel-fallpiusitalian-medical.jpg%3Bhttp%253A%252F%252Fwww.allpsters.cm%252Fsp%252FGabriel-Fallpius-Italian-Medical-Psters_i _.htm%3B366%3B488 MD Andersn Cancer Center Natinal Cancer Institute Onclink University f Califrnia San Francisc Wikipedia Researched and Authred by Prf Michael C Herbst May 2017 Page 12