Tuba Ovarian Abscess

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PRIMARY TUBA CARCINOMA THAT WAS OPERATED BY REASON OF

PRELIMINARY DIAGNOSS OF TUBAOVARIAN ABSCESS: A CASE REVIEW

Murat BOZKURT1, Duygu KARA 2 , Y. Tahsin AYANOGLU3

1

Department of Obstetrics and Gynecology, Universal Hospitals Group, Malatya, Turkey

2Department of Radiology, Yeditepe University Hospital, stanbul, Turkey

3Department of Obstetrics and Gynecology, Taksim Education and Research Hospital,

stanbul, Turkey

Corresponding Author: Murat BOZKURT, MD

Adress:Universal Malatya Hastanesi Turgut zal Bulvar Ankara Asfalt 6 km No:219 44000

MALATYA /TURKEY

Tel: 904222382828/1546

Fax: 904222382600

E-Mail:[email protected]
mailto:[email protected]:[email protected]:[email protected]


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ABSTRACT

Primary tuba carcinoma is a rare carcinoma type and it is quite difficult to diagnose it

preoperatively. The patient who was operated by reason of preliminary diagnosis of tubaovarian

abscess in our clinic, was diagnosed as primary tuba adenocarcinoma histopathologically. The

patient was assessed as in stage IIc and she received chemotherapy and radiotherapy. She developed

recurrence after a remission period, and her illness aggrevated into stage IV. After 36 months from

diagnosis our case died because of respiratory failure.

Key words:Primary tuba carcinoma, preoperative diagnosis, tubaovarian abscess


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BODY TEXT

INTRODUCTION

Primary tuba carcinomas represent 0.15 %-1.8% of all female genital system carcinomas and are

extremely rare (1). Incidence is 3.6/1.000.000 (2). It was firstly reported in 1847 and until

approximately year of 2000, 1600 cases have been reported and every year 20-30 new cases are

being reported (3). Average age changes between 55-60. 6% of the cases that suffer from primary

tuba carcinoma, is younger than 40 years old (4). Clinical presentation, staging and treatment

approach look like that are for ovary carcinomas. Indeed, both two carcinomas have some common

features: similar age spectrum, both frequent in nulliparous females, frequently in type of serous

papillary histology, relation between stage and prognosis, relation between residual tumour volume

and time of life and good responses to platinum based chemotherapy during initial period (5). We

aimed to present a case that was postoperatively diagnosed as primary tubacarcinoma in our clinic

and to check this case in comparison with literature.

CASE PRESENTATION:

N.Y.57 years old, applied to Taksim Education and Research Hospital, Gynecology and Obstetrics

Department in 24/12/2002 and was presented with prolapsed uteri and pollakiuria. Her complaint

started 5-6 months ago. She has been in menopause for 6 years. Pregnancy 2, Parity 2, Abortus 0,

Curettage 0. She had a history of pelvic inflammatory disease and compensated diabetes mellitus

type 2. Vaginal examination showed 2. degree prolapse both on anterior-posterior wall of vagina

with effort. There was an atrophic collum with unvisible fornixes. Corpus uteri had a largeness like

9-10 weekly, and was anteverted. There was a myoma with 5-6 cm diameter in posterior wall. Both


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two adnexal regions were sensitive. Transvaginal ultrasonography (TVUSG) showed larger uterus

sizes, anteversion and anteflexion of uterus, and in posterior wall an intramural -subserous myoma

with 52x53 mm diameter. Left ovary was normal in size. There were hypo and hyperechogen areas

with 4x5 cm diameter in right adnexal region. Cervicovaginal smear that was obtained one week

before the operation was reported as inflammatory smear. A patient with a preoperative diagnosis of

a tubo-ovarian abscess with abdominal pain, tenderness and an eleveated fever with leukocytes

underwent urgent laparotomy.In exploration, there was a myoma in posterior wall of uterus with 5 -

6 cm diameter. Both two ovaries were normal. Right tuba showed hydrosalpinx with 5-6 cm

diameter. There was little fluid in abdomen, it was assessed as reactive and aspirated for

postoperatively pathologic observation. Total abdominal hysterectomy+bilateral salpingo-

oophorectomy (TAH+BSO) +colporrhaphy anterior+ colporrhaphy posterior was performed. She

received 1 unit blood transfusion postoperatively and didnt have any complication during follow-

up. Her suturas were taken out and she was discharged in 6 th day. After pathologic diagnosis CA -

125 was 375.5 U/ml. She started to be followed by oncology department and it was planned a

sistemic chemotheraphy with 5 cure Cisplatin 60mg/m2, cyclophosphamide 600mg/m2. The patient

couldnt tolerate chemotheraphy and it could be performed 4 cure.Accordance with the opinion of

the Council of oncology, the patient underwent a complete irradiation with cobalt or photon

energies of 23 MV (administering a daily dose of 2 Gy resulted in a total of 4552 Gy in the pelvic

areas) for palliative purpose. After these treatments CA-125 decreased to 14 U/ml. The patient

applied to Oncology clinic in 21/9/04 with abdominal pain, abdominal distension and difficulty fordefecation. 10x12 cm pelvic mass and diffuse ascites were viewed by computerized tomography

and ultrasonography (USG). By the way CA-125 increased to 111.7 U/ml. Paracentesis was

performed and when she didnt accept the offer for second-look, she received radiotheraphy thereby

we could not restaged. After one month 6 cure sistemic chemotheraphy with taxol and carboplatin

was performed. On 2/9/05 she was scanned by Magnetic Resonance Imaging because of increased

tumour markers and irregular vaginal cuff. Multiple lymphadenopathies the biggest of which was


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3x2 cm sized were viewed in both two inguinal regions. There was diffuse edema in inguinal

region. Thorax computerize tomography (CT) showed a few pretracheal lymph nodes with 5 mm

diameter. There were nodules with approximately 5 mm diameter in left lung superior lobe anterior

side and in inferior lobe superior segment. The case was assessed as in stage 4. Chemotheraphy was

planned but she didnt accept the offer.

DISCUSSION:

Average age for primary tuba carcinoma is between 55-60 in series that already published. Low

parity number, late menopause time, chronic salpingitis, infertility are frequently associated with

carcinoma (6). Our case was multipara and she didnt give a history of late menopause time. Her

most important risk factor was the history of pelvic inflammatory disease. Benjamin and et al.

estimated the average parity as 2.5 in their series that is formed with 11 cases, and reported that

there is lower relation between tuba carcinoma and parity in comparison the relations with

endometrial and ovarian carcinoma. And also they reported hypertension, diabetes mellitus and

cerebrovascular event histories in their group. These diseases are frequent in old populations so they

suggested that these diseases are not risk factors themselves, they are just in a state which they

accompany to age (7). Also our case had compensated DM-2. The most frequent symptoms of tuba

carcinoma are abdominal pain, vaginal discharge and bleeding. The pain is colic, and it can be

continuous or like knife jabbing. The reason for colic pain is increased peristaltism, and lumen

distension causes the pain to be continuous by disguising character (8). Latzko named the triad astubae profluence that is formed with large watery vaginal discharge, colic pain in lower abdomen

and adnexal mass. And this is pathognomonic for tuba carcinoma. And today this triad is found in 3-

14% of cases and this is a low ratio (9). Our case had inguinal pain. She didnt have vaginal

bleeding and discharge. In literature there are some cases that when they were investigating for the

etiology of ascites, they determined tuba carcinoma (10). In advanced cases ascites can be found.

Our case didnt have ascites in preoperative period. It is very difficult to diagnose a tuba carcinoma


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preoperatively. Our patient with a preoperative diagnosis of a tubo-ovarian abscess with abdominal

pain, tenderness and an eleveated fever with leukocytes underwent urgent laparotomy.Mc Goldrich

has reported that only one of 376 cases was diagnosed in preoperative period (11). Eddy has

reported 2 of 74 patients and Podratz has reported 3 of 47 patients were diagnosed preoperatively in

their series (12,13). From our country Ayhan and et al. has reported that there was nobody who was

diagnosed preoperatively in their series with 8 cases (14). Two cases which were operated because

of Saundra Meigs syndrome and acute hemoperitoneum, were diagnosed with frozen section (15).

Atypic masses which are suspected and originated from tuba, can be sent to frozen and this can help

for diagnosis. Our case was not diagnosed preoperatively. Tuba adenocarcinoma in right side was

assessed preoperatively as if it was a tubaovarian abscess, and during the operation as if it was

hydrosalpinx. Because there was an inflammatory and purulent reaction in the tube that was

adherent to the posterior uterus. And no abnormalities in the digestive tract were identified. Frozen

was not performed because this diagnosis wasnt considered. Due to its rarity, preoperative

diagnosis of primary fallopian tube carcinoma is rarely made. It is usually misdiagnosed as ovarian

carcinoma, tuba-ovarian abscess or ectopic pregnancy. Primary tuba carcinoma can appear as if it is

acute pelvic peritonitis (16). Transvaginal ultrasonography provides important informations to

assess tuba wall structure, luminal substance and the relations with pelvic structures. Kurjak and et

al. firstly diagnosed stage 1 tuba carcinoma by using colored and pulsed doppler USG (17). And a

60 years old case was assessed with doppler USG; in papillary projections and solid areas of the

mass rezistance index (RI) was 0.39 and pulsative index (PI): 0.45. According to Doppler criteriatuba carcinoma was suspected diagnosis and pathology confirmed this diagnosis (18). Podobnik et

al. defined a 69 years old patient with right low quadrant pain and excessive watery vaginal

discharge. They performed USG and determined 6x2x2.5 cm complex mass next to right ovary.

RI:0.34 and PI:0.62. Vascularization of other ovary was normal. During USG diameter and

substance of the mass changed and passage of the fluid to cavitas uteri was viewed. On the strength

of these findings diagnosis of tuba carcinoma was considered and histological diagnosis was


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reported as clear cell carcinoma of tuba (19). Kurjak and et al. diagnosed 8 tuba carcinomas

preoperatively. All of these different types of carcinomas showed low vascular flow and complex

masses were defined. RI was between 0.29 and 0.40. They suggested in their articles that

transvaginal colored Doppler was more reliable than other expensive methods (17). We didnt

perform Doppler to our case. But we think that Doppler USG assessment of clinically complex

masses can make contributions for suspected diagnosis. CA 125 levels can help for diagnosis, too;

especially advanced stage cases shows increased levels. Authors are unanimous that it is more

beneficial for follow up of remission and recurrence (20,21). In our case CA 125 levels, which

decreased after chemotheraphy, increased when recurrence occured. And also decreased CA 125

levels after chemotheraphy showed that response for treatment was successful. Diagnosis is usually

with histopathologic observation. In 1950 Hu and et al. suggested criteria to differantiate tuba

uterina carcinomas from other malignancies. And this criteria was modified by Sedlis in 1978.

Macroscopically tuba appears swollen as gross. To diffentiate from hydrosalpinx and tubaovarian

abscess is possible with uncovering of specimen. Lumen is generally full of with papillary or solid

necrotic tumours and it is dilated (22,23). In our case tuba showed a cystic appearance with 4 cm

diameter in its largest region. In its cross-section there was tumour proliferation in a papillary and

solid style in lumen. Microscopic observation of this macroscopically defined lesion showed

tumour proliferation, some of them were necrotic, there were solid development in papillaries and

wall, small nucleolus, big, oval- circular, vesicular nucleus, some of them with bizarre nucleus,

columnar-

cuboid cells with eosinophilic cytoplasm (Figure 1, 2, 3). There were tumour invasions incervix, in myometrium, in both ovaries and in opposite tuba uterina inside the lymphatics. There

were malignant epithelial tumour cells in abdominal elution fluid, too. The case was diagnosed as

middle degree differentiated serous papillary adenocarcinoma. According to FIGO classification

system our case was assessed as in stage II c because there were ovary and/or uterus invasions and

tumour cells in ascites and peritoneal washings. The place of pap smear for diagnosis of primary

tuba carcinoma controversial. However there are different results for smear in literature, some of


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them are associated with very optimistic ratios such as >%25 positive result (24). If psammoma

bodies are viewed in cervicovaginal smear and the age of the patient is suitable, absolutely

possibility of tuba carcinoma should be considered (25). Treatment approach for primary tuba

carcinoma looks like the approach for ovary carcinoma. Basic of the treatment is bilateral salpingo-

oophorectomy and abdominal hysterectomy. However if staging is wanted to be defined clearly

these contibutions to surgery should be done: peritoneal washings, ascites sampling if present,

biopsies from surface of diaphagm, infracolic omentectomy, and retroperitoneal lymph node

sampling (26). Cytoreductive surgery in stage 3 and stage 4 patients provides significiant

contribution for prognosis (27). Postoperative chemotheraphy is currently intravenous taxol and

cisplatin combination as it is used with ovary carcinomas (28). 24 patients with advanced stage tuba

adenocarcinoma (Stage 3:14, Stage 4:10) received cyclophosphamide, adriamycin, cisplatin

combination in phase II study and 10 patients responsed completely and 6 patients partially

(response ratio:95%, confidence interval (45%-84%)). Response ratios are assessed as moderate,

and adverse effects are acceptable (29). TAH+BSO was performed. Postoperative chemotheraphy

responsed partially and second line chemotheraphy was performed for subsequent recurrence.

Despite the size of the mass became smaller, it was not a satisfactory response. Postoperative

radiotherapy is not recommended because efficiency is little and serious complications are not rare

(30). We used radiotheraphy for palliative purpose in our case and ther was not any complication.

Initially radiotheraphy is performed frequently but this theraphy cant prevent the spreading to

upper abdomen (31). In our case radiotheraphy couldnt control the disease so it spread to upperabdomen. In cases with tuba carcinoma survival for 5 years is between 30-50%, regardless of stage

(32).The most important factor that affects the survival is the stage of the disease at the time of

diagnosis. Benedet and Miller have estimated survival for 5 years in their metaanalyse which

contains 6 series with 278 patients: Stage 1 62%, Stage 2 36%, Stage 3 17%, Stage 4 0% (8). Rosen

and et al. have estimated 5 yearly survival in their retrospective analyses with 115 patients: Stage 3

and 4:13,6%; Stage 1 and 2: 50.8%. And it is reported that to leave >2 cm tumour tissue after


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debulking detoriates the prognosis (33). Our case died after 36 months from diagnosis by reason of

respiratory failure.

CONCLUSION:

Carcinoma of the fallopian tube should be considered in the differential diagnosis of the tubo-

ovarian abscess in those who presented with abdominal pain, pelvic tenderness and an eleveated

fever with leukocytes.

FIGURES:

Figure 1: Adenocarcinoma areas that contains, small nucleolus, big, oval- circular, vesicularnucleus, some of them with bizarre nucleus, columnar-cuboid cells with eosinophilic cytoplasm.


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Tuba Ovarian Abscess