The age range of this disease has been
reported to be from 18 to 87years, with most occurrences in the fifth and
sixth decades of life. In a review of the literature of 393 patients, a mean
age of 55 years was described. This is consistent with the mean age of
56.7years in a metaanalysis of 577 patients more recently computed.The clinical profile
of these patients reveals a relative low parity rate, with a mean parity of 1 to
1.7.By virtue of the mean age of incidence, most patients are postmenopausal.
Pelvic inflammatory disease and tuberculous salpingitis were once believed to be
causative factors in the development of fallopian tube malignancies. If this were the
case, one would expect a higher incidence of tubal malignancies given the prevalence of
pelvic inflammatory disease. No study to date has proven this theory.
Natural History
The primary spread of disease is similar to that of ovarian
cancers in that there is local extension of tumor to adjacent structures to involve the
peritoneum, omentum, bowel, and ovaries.However, 70% of patients
with fallopian tube tumors have disease confined to the pelvis at presentation, compared
with 48% of patients with ovarian malignancies, and up to 50% of patients are diagnosed
with stage I disease.This is probably a result of the early presentation of
abnormal bleeding and pain with distention of a small tubal lumen, which is absent in the
anatomy of the ovary. Many authors believe that local extension is followed in frequency
by lymphatic or hematogenous spread.However, in view of inconsistent staging and the
advent of improved surgical resection with exploration and lymph node sampling, early
lymphatic and vascular invasion may play a more prominent role in disease progression than
previously thought -- that is, periaortic spread may precede intraabdominal dissemination.
Lymph node positivity has been found to be 75% at autopsy. In a review of 67 patients,
Sedlis reported that tubal musculature was rarely involved when lymphatic metastases were
present. Far less common in fallopian tube cancer are distant metastases toliver and lung,
which occur most often by local extension outside the peritoneal cavity by means of nodal
versus transdiaphragmatic and hematogenous spread. Distant metastases are more
important as a site of treatment failure in ovarian cancer, in which more than 50% of
recurrences occur outside the peritoneal cavity along with intraperitoneal disease. With this difference between ovarian and fallopian tube cancer, one
could argue for aggressive postsurgical adjuvant treatment in fallopian tube carcinoma.
Clinical Presentation
Unlike ovarian malignancies, tumors of the fallopian tube cause early clinical signs and
symptoms. Although the triads of pelvic pain, pelvic mass, and leukorrhea or vaginal
bleeding, vaginal discharge, and lower abdominal pain have been described as
pathognomonic, the highest percentage of patients presenting with such a triad of symptoms
has been only 11%. Another classic sign, hydrops tubae profluens,
which is a sudden emptying of accumulated fluid in the distended fallopian tube that
causes profuse, watery, serosanguinous discharge to be released from the vagina,
accompanied by a decrease in pelvic mass size on physical examination, was attributed to
only 9% in a metaanalysis of 122 patients.In many other series it was been specifically
reported that neither a triad nor hydrops tubae profluens was present in any of the
patients reviewed. Despite these inconsistencies in symptoms, the most common
presenting sign is metrorrhagia, followed by pain and vaginal discharge. The most common
physical sign is a pelvic mass, which occurs in 12% to 66% of patients.
Pathologic Classification
The most common histopathology of fallopian tube malignancies is serous
papillary adenocarcinoma, similar to that found in the ovary. Benign tumors are
found even less frequently than malignant neoplasms. Rare histologic subtypes are found:
endometrioid, clear cell, transitional cell, squamous cell, malignant mixed mullerian
tumors, and leiomyosarcomas. Tumors previously graded as papillary (pure),
papillary-alveolar, and alveolar-medullary are now routinely classified as well,
moderately, and poorly differentiated (grades I, II, and III, respectively). Disease is
bilateral in approximately 5% to 30% of patients at the time of initial diagnosis. This is
considered to be a multicentric primary. Malignancies are distributed equally between the
left and right fallopian tubes.
General Management
Primary treatment of adenocarcinoma of the fallopian tube is
surgical resection at the time of initial diagnosis. Extensive surgical resection
and staging should be performed (total abdominal hysterectomy, omentectomy, and bilateral
salpingectomy), as well as sampling of ascitic fluid or peritoneal washings and peritoneal
sampling of diaphragm, bladder, and bowel. Recent reports advocate lymph node sampling,
because nodal involvement may occur early in the course of disease spread, even earlier
than the extent of pelvic spread may indicate. Numerous authors have observed that
the amount of residual tumor left behind at primary resection (> 2 cm) has major
prognostic implications. Some investigators have reported satisfactory results with
conservative surgical treatment (unilateral salpingectomy only) if tumor has not invaded
beyond the mucosa. Most patients, however, require some form of adjuvant treatment
postoperatively to combat bulky residual disease or to treat assumed microscopic
involvement.
More recently, combination chemotherapeutic regimens have
been used in response to the poor results obtained with single agents. However, it has
been suggested that these initial poor responses were caused by their use for recurrence
after primary treatment failure. Deppe and colleagues reported a surgically
documented response by second-look laparotomy for the use of cisplatin-based combination
chemotherapy. A later study retrospectively compared results in patients treated with and
without cisplatin in combination and with single agent therapy. Peters and co-workers
observed an overall response rate of 81% in 12 of 14 patients who
received the cisplatin-based regimen. However, more patients with recurrence and
failure received the less-aggressive treatment. Of patients who were free of disease at
second-look laparotomy, 33% subsequently had relapses. In the only prospective trial, 18
patients receiving at least 6 to 12 cycles of cisplatin, doxorubicin, and cyclophosphamide
achieved response rates of 53%, similar to the results seen in ovarian carcinoma.
Radiation Therapy
Postoperative radiation therapy has been a traditional form of
therapy for fallopian tube carcinoma dissemination and recurrence. It has been
recommended by some authors and questioned by others. It is also difficult to evaluate
results in the past literature because of variability in staging, surgical staging
techniques, treatment volume, dose fractionation, and type of radiation used. All reported
studies are retrospective and usually involve small numbers of patients treated over long
periods.
Several early, small studies observed promising results with techniques similar to those
used in treatment of ovarian carcinoma These authors suggested that use of whole-abdomen
external beam irradiation or intraperitoneal administration of radioactive colloids
(**32P, **198Au) results in better survival rates than does surgery alone. Some
investigators observed that there are too few data to support the use of radioactive
colloids and that there is no role in patients with bulky disease. The best results were
achieved when total dose greater than 50 Gy in 5 to 6 weeks was used with megavoltage as
opposed to orthovoltage therapy. McMurray and Brown stated that recurrence of
early-stage disease (I and II) was likely to be in the upper abdomen if only pelvic
irradiation was performed and that areas at risk, such as the abdomen and paraaortics,
should be included within the initial treatment volume. Other studies noted a 50% relapse
rate when early-stage disease was treated with surgery alone or with surgery plus pelvic
irradiation, compared with a greater than 50% 5-year survival rate when the abdomen and
paraaortic areas were treated.
Wolfson and associates reported on 72 patients with carcinoma of the fallopian tube
(24 stage I, 20 stage II, 24 stage III, and 4 stage IV) treated at six medical centers.
Adjuvant chemotherapy was administered to 54 and postoperative irradiation to 22 patients.
Of the latter group, 14 received whole-pelvis external irradiation, 5 whole-abdomen
irradiation, 2 **32P instillation, and 1 vaginal brachytherapy only. The 5-, 8-, and
15-year survival rates were 44%, 24%, and 19%, respectively, for patients treated with
chemotherapy and 27%, 17%, and 14% for those treated with irradiation. Significant
prognostic factors included stage I versus more advanced stage and age at diagnosis
(younger or older than 60 years). Patterns of failure included 2 vaginal, 5 pelvic, 24
abdominal, and 15 distant metastases. Abdominal failures were 21% in patients with stage I
disease versus 79% in stages II, III, and IV. Patients experiencing abdominal relapse were
more likely to die (83%) than those without abdominal relapse (39%).
A recent study using the new FIGO staging system for fallopian tube carcinoma compared the
outcome in carcinoma in situ versus stage I with use of either irradiation or
cisplatin-based chemotherapy tumor penetration through the basement membrane
(invasive carcinoma) reduced survival by 50%. Stage I patients treated by irradiation
showed a significantly better prognosis than patients treated by chemotherapy. A few
studies reported disappointing results with the use of radiation therapy to treat
early-stage fallopian tube carcinoma. However, these studies contained small numbers, used
treatment to the pelvis only, and had inconsistent or incomplete surgical resection
and staging.Many series that showed no benefit with irradiation used orthovoltage therapy,
which is unable to deliver high doses to the deeper pelvic structures.
Little information exists regarding combination or concomitant use of chemotherapy and
irradiation as postoperative treatment. In most studies, a single modality was used, and
the other approach was attempted after failure occurred. Because both modalities have
shown response when used together or separately, randomized, prospective study might be of
help in this regard. |
