Bilateral Primary Fallopian Tube Carcinoma: Findings on Sequential MRI

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1 Hosokawa et al. MRI in Fallopian Tube Carcinoma Women s Imaging Case Report WOMEN S IMAGING Chisa Hosokawa 1 Mitsuo Tsubakimoto 2 Yuichi Inoue 3 Tetsuo Nakamura 2 Hosokawa C, Tsubakimoto M, Inoue Y, Nakamura T Keywords: fallopian tube carcinoma, MRI, pelvic imaging DOI: /AJR Received March 19, 2005; accepted after revision April 29, Department of Radiology, Kosaiin Hospital, 6-2-1, Furue-dai, Suita-shi, Osaka, , Japan. Address correspondence to C. Hosokawa. 2 Sumiyoshi Municipal Hospital, Osaka, Japan. 3 Osaka City University Graduate School of Medicine, Osaka, Japan. AJR 2006; 186: X/06/ American Roentgen Ray Society Bilateral Primary Fallopian Tube Carcinoma: Findings on Sequential MRI ydrops tubae profluens is the H pathognomonic feature of primary fallopian tube carcinoma. A diagnosis of this cancer is rarely made before an operation because of the rarity of the disease and because imaging shows features similar to those of hydrosalpinx, tuboovarian abscess, and ovarian neoplasm. We report a case of bilateral primary fallopian tube carcinoma and describe the sequential MR findings. Case Report A 51-year-old woman had a 1-year history of intermittent watery discharge, vaginal bleeding, and irregular menstruation. At pelvic examination, the vagina was found to contain a pool of serous fluid, and a palpable mass was found in the left adnexal region. No mass was detected on the other side. Results of cytologic examination of the vaginal discharge were negative. Abdominal sonography showed an elliptic hypoechoic mass in the right adnexal region. A second sonographic examination performed 1 month after the first revealed a 3-cm solid mass associated with a 2.5-cm cystic mass in the left adnexal region (Fig. 1A). MRI revealed bilateral adnexal masses and a dilated uterine cavity and vagina filled with fluid (Figs. 1B 1D). The right adnexal mass appeared to be a hydrosalpinx with irregular walls. The left adnexal mass was a discrete sausagelike solid mass measuring 5 cm in maximum diameter. On T1-weighted images the mass had a signal intensity corresponding to that of the uterus, and T2-weighted images showed homogeneous, mild hyperintensity relative to skeletal muscle. A tubular structure seemed to be continuous with the solid mass. Normal ovaries were not visualized. Ascites or enlarged lymph nodes were not seen. Follow-up MRI 1 month after the first examination showed that the right hydrosalpinx had decreased slightly in size, but the left adnexal mass had enlarged because of development of a new cystic mass contiguous with the anterior part of the solid mass. The amount of fluid in the uterine cavity and vagina had decreased (Figs. 1E 1G). Because of its tubular shape, the new cystic mass was considered to represent a left hydrosalpinx, a finding that suggested the solid mass arose from the fallopian tube. Contrastenhanced T1-weighted images revealed enhancement of the lesion in the wall of the right fallopian tube and the solid left adnexal mass (Figs. 1H and 1I). The preoperative diagnosis was bilateral tubal tumors, possibly bilateral primary tubal carcinoma because of the presence of clinical findings such as watery discharge and imaging evidence of adnexal masses with hydrosalpinx. However, unilateral tubal carcinoma with contralateral metastasis could not be ruled out. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection were performed 20 days after the second MR study. The macroscopic appearance of both tubes was sausagelike enlargement (Fig. 1J). Measurement of the cut specimens showed the right tubal tumor was 1.5 cm in diameter and the left tumor was 5 cm in diameter. Microscopic examination of both tubes showed papillary growth of the mucosa that was composed of columnar cells with a high nucleus-to-cytoplasm ratio (Fig. 1K). The histopathologic diagnosis was poorly to moderately differentiated serous papillary adenocarcinoma of both fallopian tubes. Neither tumor extended into the tubal serosa. Malignant growth was not present in the uterus, ovaries, or lymph nodes. The final diagnosis was bilateral primary serous papillary adenocarcinoma of the fallopian tube (stage IB). The patient received chemotherapy, and no recurrence had been detected 5 years after treatment AJR:186, April 2006

MRI in Fallopian Tube Carcinoma Discussion Primary fallopian tube carcinoma is uncommon and represents approximately 0.3% of all cases of gynecologic malignancy.

1 51-year-old woman with bilateral primary fallopian tube carcinoma. A, Transabdominal sonogram shows 3-cm solid mass (black arrow) associated with 2.

Right adnexal serpentine mass (white arrow, B) has diffusely thickened walls and contains fluid.

Wall of tube has higher signal intensity than that of skeletal muscle, and irregular protrusion is present at posterior aspect (white arrow, C).

2 MRI in Fallopian Tube Carcinoma Discussion Primary fallopian tube carcinoma is uncommon and represents approximately 0.3% of all cases of gynecologic malignancy. Bilateral involvement is reported to occur in 20% of patients [1]. These tumors are considered to arise by the relatively common mechanism of multifocal tumorigenesis of müllerian duct A C Fig year-old woman with bilateral primary fallopian tube carcinoma. A, Transabdominal sonogram shows 3-cm solid mass (black arrow) associated with 2.5-cm cystic mass (white arrow) in left adnexal region. Small nodule seems to be present in cystic mass (arrowhead). B D, T2-weighted axial images obtained during initial diagnostic evaluation. Right adnexal serpentine mass (white arrow, B) has diffusely thickened walls and contains fluid. It is continuous with right uterine horn, and this finding is consistent with diagnosis of hydrosalpinx. Wall of tube has higher signal intensity than that of skeletal muscle, and irregular protrusion is present at posterior aspect (white arrow, C). Left adnexal region contains sausagelike solid mass measuring 5 cm in maximum diameter. Mass is homogeneous and has slightly higher signal intensity than skeletal muscle (black arrow, B). Tubular structure seems to be continuous with left uterine horn in anterior aspect (arrow, D) and with solid mass in posterior aspect (black arrow, C). Tube wall has low signal intensity. Uterine cavity and vagina (stars, D) are dilated and filled with fluid. (Fig. 1 continues on next page) neoplasms. The most common histologic type is adenocarcinoma. The clinical triad of tubal carcinoma is vaginal bleeding, watery discharge, and lower abdominal pain or a pelvic mass, but all of these features are present in only 6% of cases. The pathognomonic feature of hydrops tubae profluens is intermittent discharge of clear or bloody fluid, either spontaneous or caused by pressure, followed by shrinkage of the adnexal mass, but this feature is seen in barely 5% of patients [2]. Vaginal cytologic findings are positive in only 10 20% of patients, making a correct preoperative diagnosis difficult. Because the prognosis is largely related to the stage of the disease, familiarity with the imaging features of B D AJR:186, April

Hosokawa et al. primary tubal carcinoma is important for establishing an early diagnosis and thus improving the prognosis.

Tubal carcinoma usually originates in the ampulla, and its pattern of growth can be nodular, papillary, infiltrative, or massive [2].

A fallopian tube affected by carcinoma may have no alteration in shape or size, or it may feature diffuse swelling; a sausage shape resembling hydro-, hemato-, or pyosalpinx; an unbuttoning pattern

3 Hosokawa et al. primary tubal carcinoma is important for establishing an early diagnosis and thus improving the prognosis. To our knowledge, the serial MR features of primary bilateral tubal carcinoma have not been previously reported. Tubal carcinoma usually originates in the ampulla, and its pattern of growth can be nodular, papillary, infiltrative, or massive [2]. These tumors are relatively confined to the tube and tend to produce large amounts of serous fluid. A fallopian tube affected by carcinoma may have no alteration in shape or size, or it may feature diffuse swelling; a sausage shape resembling hydro-, hemato-, or pyosalpinx; an unbuttoning pattern of solid tumor mushrooming out E G of the tubal ostium; or a true tumor that is either solid or partly solid and cystic. The progress of primary fallopian tube carcinoma is characteristic [3]. Fluid produced by the tumor collects in the tube, and the accumulation leads to the onset of hydrosalpinx. When the fluid volume increases, intratubal pressure rises, and fluid drains through the uterus to cause a watery vaginal discharge if the intramural part of the tube is patent. When the ampullary end is not closed, fluid may drain into the abdominal cavity and cause peritumoral ascites. The signs and symptoms of tubal carcinoma, such as hydrops tubae profluens, correlate with the pathologic process. Fig. 1 (continued) 51-year-old woman with bilateral primary fallopian tube carcinoma. E G, Follow-up T2-weighted axial images show right adnexal mass (white arrow, G), hydrosalpinx, has decreased slightly in size relative to initial findings. In contrast, solid and cystic masses (arrow, E) are present in left adnexal region and are larger than lesion detected on initial MR study. Cystic mass seems to be continuous with left uterine horn in anterior aspect (black arrows, F and G). Volume of fluid in uterine cavity and vagina (stars, G) has decreased. (Fig. 1 continues on next page) CT and MR findings of tubal carcinoma have been described in a few reports [3 7]. In these cases tubal carcinoma manifested as a cystic adnexal mass or a solid and cystic mass that was difficult to differentiate from ovarian tumor. The common associated findings included hydrosalpinx, intrauterine fluid, and peritumoral ascites. Solid masses showed enhancement by contrast medium. The presence or absence of hydrosalpinx affects the imaging of tubal carcinoma. When hydrosalpinx is absent, the tubal carcinoma is seen as a solid lobulated adnexal mass. When hydrosalpinx is present, the lesion looks like a mixed solid and cystic mass that may have a tubular shape. F 1048 AJR:186, April 2006

MRI in Fallopian Tube Carcinoma The sequential MR findings in our patient s case were considered characteristic of primary tubal carcinoma.

The left tubal tumor was seen as a sausagelike solid mass on initial MRI but was seen as an intratubal tumor with hydrosalpinx on the follow-up image.

1 (continued) 51-year-old woman with bilateral primary fallopian tube carcinoma. H and I, Contrast-enhanced T1-weighted axial images obtained during follow-up MR study.

Cystic left adnexal masses are not enhanced. J, Photograph of resected specimen shows sausagelike enlargement of both fallopian tubes.

4 MRI in Fallopian Tube Carcinoma The sequential MR findings in our patient s case were considered characteristic of primary tubal carcinoma. The right tubal tumor was seen as a mural protrusion in a hydrosalpinx, which had decreased in size by the second MR study. The left tubal tumor was seen as a sausagelike solid mass on initial MRI but was seen as an intratubal tumor with hydrosalpinx on the follow-up image. This change was concomitant with a decrease of fluid in the uterine cavity and vagina over a 1-month period, so altered H J Fig. 1 (continued) 51-year-old woman with bilateral primary fallopian tube carcinoma. H and I, Contrast-enhanced T1-weighted axial images obtained during follow-up MR study. Wall of right fallopian tube and mural projection (arrow, H) are diffusely enhanced, and solid left adnexal mass is heterogeneously enhanced after administration of contrast medium (arrow, I). Cystic left adnexal masses are not enhanced. J, Photograph of resected specimen shows sausagelike enlargement of both fallopian tubes. K, Photomicrograph shows papillary growth of tubal mucosa composed of columnar cells with high nucleus-to-cytoplasm ratio. This finding was present in both fallopian tubes. (H and E, 100) fluid production by the tumor caused the new imaging findings. In general, bilateral primary tubal tumors cannot be differentiated from secondary tumors. Metastasis to the tubes is a bilateral process in 80% of cases [2], and ovarian or endometrial cancer is often the primary lesion. To make the diagnosis of primary tubal carcinoma, primary tumors of the ovaries and uterus must be excluded. Neither MRI nor pathologic examination revealed malignant growth in the uterus or ovaries of our patient. The diagnosis of unilateral tubal carcinoma with contralateral metastasis was less likely because the tubal carcinoma in our patient did not extend into the tubal serosa on both sides. However, the possibility of endoluminal metastasis from one side to the other could not be ruled out. In conclusion, to our knowledge, this report is the first in the English-language literature of the use of sequential MRI in the preoperative diagnosis of bilateral primary fallopian tube carcinoma. The MR findings were compatible with the clinicopathologic process of this cancer. I K AJR:186, April

5 Hosokawa et al. References 1. Markman M, Zaino RJ, Fleming PA, Barakat RR. Carcinoma of the fallopian tube. In: Hoskins WJ, Perez CA, Young RC, eds. Principles and practice of gynecologic oncology. Philadelphia, PA: Lippincott Williams & Wilkins, 2000: Honoré LH. Pathology of the fallopian tube and broad ligament. In: Fox H, Wells M. Haines and Taylor obstetrical & gynecologic pathology, 5th ed. New York, NY: Churchill Livingstone, 2003: Shamam OM, Bennett WF, Teteri NJ, Finer RM. Primary fallopian tube adenocarcinoma presenting as a hydrosalpinx: CT appearance. J Comput Assist Tomogr 1988; 12: Slanetz PJ, Whitman GJ, Halpern EF, Hall DA, Mc- Carthy KA, Simeone JF. Imaging of fallopian tube tumors. AJR 1997; 169: Kawakami S, Togashi K, Kimura I, et al. Primary malignant tumor of the fallopian tube: appearance at CT and MRI. Radiology 1993; 186: Kurachi H, Maeda T, Murakami T, et al. A case of fallopian tube carcinoma: successful preoperative diagnosis with MRI. Radiat Med 1999; 17: Kawakami S. Computed tomography and magnetic resonance imaging of the fallopian tube. In: Anderson JC. Gynecologic imaging. London, England: Churchill Livingstone, 1999: AJR:186, April 2006

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