DOI:10.2214/AJR.05.0491
AJR 2006; 186:1046-1050
© American Roentgen Ray Society
Bilateral Primary Fallopian Tube Carcinoma: Findings on Sequential MRI
Chisa Hosokawa1,
Mitsuo Tsubakimoto2,
Yuichi Inoue3 and
Tetsuo Nakamura2
1 Department of Radiology, Kosaiin Hospital, 6-2-1, Furue-dai, Suita-shi, Osaka,
565-0874, Japan.
2 Sumiyoshi Municipal Hospital, Osaka, Japan.
3 Osaka City University Graduate School of Medicine, Osaka, Japan.
Received March 19, 2005;
accepted after revision April 29, 2005.
Address correspondence to C. Hosokawa.
Keywords: fallopian tube carcinoma • MRI • pelvic imaging
Introduction
Hydrops tubae profluens is the 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,
1C, and
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,
1F, and
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.
Contrast-enhanced 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).
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Fig. 1A —51-year-old woman with bilateral primary fallopian tube carcinoma.
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).
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Fig. 1B —51-year-old woman with bilateral primary fallopian tube carcinoma.
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.
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Fig. 1C —51-year-old woman with bilateral primary fallopian tube carcinoma.
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.
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Fig. 1D —51-year-old woman with bilateral primary fallopian tube carcinoma.
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.
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Fig. 1E —51-year-old woman with bilateral primary fallopian tube carcinoma.
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.
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Fig. 1F —51-year-old woman with bilateral primary fallopian tube carcinoma.
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.
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Fig. 1G —51-year-old woman with bilateral primary fallopian tube carcinoma.
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.
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Fig. 1H —51-year-old woman with bilateral primary fallopian tube carcinoma.
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.
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Fig. 1I —51-year-old woman with bilateral primary fallopian tube carcinoma.
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.
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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.
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Fig. 1K —51-year-old woman with bilateral primary fallopian tube carcinoma.
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, x 100)
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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 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 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 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.
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.
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 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.
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Introduction
Case Report
