Fallopian Tube Cancer: The Basics

What is cancer of the fallopian tube(s)?
It is an abnormal growth of malignant cells (neoplasm, tumor) in one or both of a woman's fallopian tubes. The fallopian tubes are a pair of skinny ducts that transport a woman's eggs (ova) from her ovaries (where they are housed) to her uterus (aka "womb", where they are either fertilized by male sperm or discarded during menstruation). Typically, an egg is released from one of the ovaries into the adjacent fallopian tube once each month during ovulation, which occurs in reproductive-age women. The tube helps to move the egg along its journey to the uterus with small hair-like projections called cilia that line the tube's insides.
The tubes are named after a famous Italian physician named Gabriele Fallopio (1523–1562), who first described them.
What are the different types of fallopian tube cancer?
The vast majority (>95%) of fallopian tube cancers are papillary serous adenocarcinomas. Very occasionally, these tumors can be sarcomas (leiomyosarcomas) or transitional cell carcinomas.
How common is fallopian tube cancer?
Primary fallopian tube cancer is the rarest (only about 1%) of all gynecologic. The annual incidence of is about 3.6 per million women per year.
Who gets fallopian tube cancer?
The peak incidence is in women who are 60 - 64 years of age, but can continue to occur in women who are in their early- to mid- 80's. The diagnosis is more common in Caucasian women than in Black women, although the cause for this is not well understood.
What are the risk factors for fallopian tube cancer?
Given its rarity, the causes and risk factors for developing primary fallopian tube cancer are not clearly defined. There has been some association of the cancer with chronic infection and/or inflammation of the fallopian tubes (due to untreated sexually transmitted diseases, for example), although a cause-effect relationship has not been definitively established.
What are the symptoms of fallopian tube cancer?
The most common symptoms are vaginal bleeding, vaginal discharge, and/or pelvic pain. As a general rule, any vaginal bleeding in a postmenopausal women should be quickly and carefully evaluated. The vaginal discharge may be blood-tinged and does not appear to be infection-related and does not respond to antibiotic treatment. Finally, pelvic pain may occur because of trapped fluid blocking and distending the fallopian tube.
There is a syndrome called "hydrops tubae profluens" which consists of: 1) a pelvic mass, 2) profuse watery or honey-colored vaginal discharge, and 3) pelvic pain that essentially goes away upon sudden disappearance of the mass. Although this triad is rarely found in practice, it a classic diagnostic syndrome for fallopian tube disease.
How is fallopian tube cancer diagnosed?
Both in light of its rarity and the difficulty of seeing something abnormal growing on the inside of a tube, fallopian tube cancer can be a difficult diagnosis to make.
One of the most important steps in evaluating any patient with a gynecologic complaint is a proper pelvic examination. The healthcare provider (HCP) should examine the uterus, ovaries, fallopian tubes, and vagina. A p elvic mass is the most common physical finding, seen in about two-thirds of patients. Pelvic fluid (ascites) together with a mass is not as common, occurring in only about 15%.
Having said this, fallopian tube cancers are so rare that the finding of a pelvic mass is hardly enough to make a diagnosis of fallopian tube cancer. Furthermore, radiologic studies of the genitourinary and gastrointestinal tracts are not very helpful in making the diagnosis, either.
Microscopic analysis (as is done to look for cervical cancer, for example) of cervical and/or vaginal fluid has not in itself been a very reliable technique, with reports of only 40 - 60% of women with fallopian tube cancer having abnormal smears. A stronger tool is the combination of finding adenocarcinoma cells in cervical/vaginal fluid samples together with a negative in-depth exam and biopsy of the uterus (aka "dilatation and curettage").
Over the past 10 years or so, there has been increasing use of ultrasound, looking for the typical finding of a sausage-shaped mass with growths inside the fluid-filled center of the tube (so-called "cogwheel" appearance). The use of both transvaginal color and pulsed Doppler ultrasound seems to be an especially promising strategy.
Ultimately, most physicians feel that the diagnosis requires surgery to evaluate the tubes and obtain definitive tissue specimens.
* Serum levels of a marker called CA-125 can be abnormally high in patients with gynecologic diseases, both cancer and non-cancer types (ie: pelvic inflammatory disease, endometriosis, early pregnancy). Although this makes CA-125 pretty non-specific, checking a preoperative level is often recommended in a postmenopausal woman with a pelvic mass, if for no other reason than to establish a baseline value for later comparison and assessment of response to therapy.
Once it is diagnosed, how is fallopian tube cancer staged?
The following is adapted from the Federation of Gynecology and Obstetrics ( FIGO) staging system for fallopian tube carcinoma.
Stage 0
Carcinoma in situ (limited to tubal mucosa)
Stage I
Growth limited to the fallopian tubes
Stage IA
Growth limited to one tube with extension into submucosa and/or muscularis but not penetrating the serosal surface, no ascites
Stage IB
Growth limited to both tubes with extension into submucosa and/or muscularis but not penetrating the serosal surface, no ascites
Stage 1C
Tumor either stage 1A or 1B with tumor extension through or onto the tubal serosa OR with ascites containing malignant cells OR with positive peritoneal washings
Stage II
Growth involving one or both fallopian tubes with pelvic extension
Stage IIA
Extension and/or metastasis to the uterus and/or ovaries
Stage IIB
Extension to other pelvic tissues
Stage IIC
Tumor either stage IIA or IIB AND with ascites containing malignant cells OR with positive peritoneal washing.
Stage III
Tumor involving one or both fallopian tubes with peritoneal implants outside of the pelvis and/or positive retroperitoneal or inguinal nodes. Superficial liver metastases equals stage III. Tumor seems limited to the true pelvis with negative nodes but with histologically proved malignant extension to the small bowel or omentum
Stage IIIA
Tumor grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces
Stage IIIB
Tumor involving one or both tubes with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter. Lymph nodes negative
Stage IIIC
Abdominal implants greater than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes
Stage IV
Growth invading one or both fallopian tubes with distant metastases. If pleural effusion is present, there must be positive cytology to be stage IV. Parenchymal liver metastases equal stage IV
How is fallopian tube cancer treated?
As always, the optimal treatment regimen should ultimately be individualized as much as possible. It should take into account the patient's stage of disease, other medical history, and personal preference, among other things.
Surgery
As mentioned earlier, fallopian tube cancer is typically diagnosed with surgery. The new FIGO staging system requires an extensive surgical procedure very similar to the one used for ovarian cancer. It includes sampling of pelvic ascites fluid, pelvic and abdominal washings, transabdominal removal of uterus (hysterectomy), removal of both ovaries and fallopian tubes (bilateral salpingoo-ophorectomy), removal of some connective tissue folds (omentectomy), selective removal of pelvic lymph nodes (lymphadenectomy), and selective biopsies of the lining of the abdominal walls and organs (peritoneum).
In cases of very advanced disease, the goal of surgery is primarily to remove as much tumor bulk as safely possible (cytoreduction). Some surgeons also advocate performing a "second-look" surgery, in which a repeat abdominal surgery is done to look for residual or recurrent disease at a later time.
Radiation Therapy
According to a national retrospective study that compared postoperative chemotherapy to postoperative whole abdomen-pelvis radiation therapy, there was no significant difference in survival between the two treatment groups. However, this is not a randomized study, and so the ability to make conclusions from this data is limited. Unfortunately, there are no randomized trials comparing the efficacy of abdominopelvic radiotherapy and cisplatin-containing chemotherapy in the postoperative setting; given the rarity of this tumor, there likely never will.
For patients with more advanced disease, postoperative abdominopelvic radiation therapy can be recommended for patients with either microscopic or no residual disease in the upper abdomen and less than 1-cm of residual disease in the pelvis.
Chemotherapy
Fallopian tube cancer is fairly responsive to multi-drug regimens containing the agent cisplatin, as compared to non-cisplatin single agents or multi-drug regimens.
Hormonal Therapy
The role of hormonal treatment for fallopian tube cancer is not clear, although both medroxyprogesterone acetate and megestrol acetate have been used together with chemotherapy with varying degrees of success.
Combined Modality
The latest in combined modality approaches for advanced disease consists of cytoreductive surgery, post-surgical chemotherapy to reduce remaining tumor burden to microscopic levels, and possible post-chemotherapy abdominopelvic irradiation.
What is the prognosis?
Outcome is strongly dependent on stage, extent of postoperative residual disease, and treatment.
Fallopian tube carcinoma is a very rare form of gynecologic cancer and therefore, there are few patients to develop a general prognosis. A recent population based study (a way of combining all known cases to have larger numbers) found the 5-year survival (the percentage of patients alive 5 years after their diagnosis) to be 95% for patients with Stage I disease, 75% for stage II, 69% for stage III, and 45% for stage IV. In general, patients with fallopian tube cancer have a slightly better prognosis than those with ovarian cancer.