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Fallopian tubes

Reviewer: Nicole Riddle, M.D. (see Reviewers page)
Editor: Jamie Shutter, M.D.
Revised: 24 May 2013, last major update IN PROGRESS
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

Table of contents
General: primary references   normal anatomy/histology   embryology   salpingitis

Benign/non-neoplastic: amyloidosis   Arias-Stella   decidual reaction   ectopic tissue   ectopic (tubal) pregnancy   endometriosis   endosalpingiosis   Enterobius   epithelial hyperplasia   extratubal secondary trophoblastic implants   heat artifact   hilar cells   mesonephric remnants   metaplastic changes   metaplastic papillary tumor   paratubal cysts   pigmentosis tubae   placental site nodule   post-tubal ligation   prolapse   salpingitis isthmica nodosa   torsion   Walthard cell nests

Tumors: adenomatoid tumor   borderline tumor   carcinoma   endometrioid polyp   female adnexal tumor of probable wolffian origin   lymphoma   malignant mixed mullerian tumor   metastases/secondary tumors   mucinous lesions   papillary cystadenoma of mesosalpinx   serous adenofibroma   teratoma

Broad ligament: ependymoma   leiomyoma   leiomyosarcoma   papillary cystadenoma   serous tumors

Miscellaneous: staging   features to report

Primary references
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AJCC Cancer Staging Manual (7th ed)
Websites with images: PathoPic   USCAP (virtual slides)   WebPathology.com


Benign or non-neoplastic conditions

Paratubal cysts

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Common incidental findings

Called hydatids of Morgani if large and near fimbriae or broad ligament

Gross: attached to fimbriated end of tube by a pedicle, thin walled, clear content

Gross images: image1

Micro: usually tubal-type lining, may have plica

 

Pigmentosis tubae

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Presence of hemosiderin-laden macrophages within plical stroma

Associated with surgery for sterilization, chronic pain or benign masses, Archives 2002;126:951

Micro images: figure2

 

Placental site nodule

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Benign lesion of intermediate trophoblast; remnant of placental implantation site

Rarely in fallopian tube

Positive stains: cytokeratin, placental alkaline phosphatase, human placental lactogen, focal human chorionic gonadotropin, EMA

Reference: Hum Path 1996;27:1243

 

Post-tubal ligation

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Dilation of proximal tube, attenuation of plica with pseudopolyp formation and chronic inflammation, plical thickening in distal tube

 

Prolapse

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80% associated with vaginal hysterectomy

Case report of prolapse into urinary bladder, resembling carcinoma, Archives 1983;107:613

Gross: resembles granulation tissue, visible at vaginal apex

 

Salpingitis isthmica nodosa

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Young women, mean 26 years

85% bilateral

Pathogenesis is analogous to uterine adenomyosis

Associated with infertility in 50%; may lead to ectopic pregnancy

Also associated with glandular inclusions in lymph nodes, AJSP 1981;5:353

Gross: well-delimited yellow-white nodular enlargement of isthmus

Micro: regularly spaced, cystically dilated glands surrounded by hypertrophied muscle (actually diverticula that communicate with tubal lumen); no stromal response, but may be accompanied by salpingitis; occasional glands surrounded by endometrial-type stroma; no atypia

DD: carcinoma (irregular distribution of glands, atypia, stromal response)

 

Torsion

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Usually due to inflammation or tumor, occasionally no known abnormality

Often accompanies torsion of adjacent ovary with moderate sized cyst

Occurs in women of all ages

May resolve or tube may become necrotic and calcified with autoamputation of tube and ovary

2/3 involve right tube

Gross: swollen, dusky

 

Walthard cell nests

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May represent mesothelial hyperplasia

Gross: white/yellow nodules or cysts up to 2 mm, resemble granulomas

Micro: well-circumscribed, small, glistening, round collections of flat/cuboidal cells, resembling urothelium, on tubal serosa; minimal atypia, no/rare mitotic figures; cells have prominent nuclear groove, 1-2 small nucleoli; may see inspissated eosinophilic secretion or mucin within lumina

DD: serosal tumor implants

 

 

Tumors

Adenomatoid tumor

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Most common benign tumor of fallopian tube, aka benign mesothelioma

Similar to paratesticular tumor

Gross: usually incidental tumor of myosalpinx (muscle layer), 2 cm or less; circumscribed, gray-white-yellow, firm; usually unilateral

Micro: tubular / glandular spaces of various sizes composed of flattened cells resembling endothelium or large cells with eosinophilic cytoplasm; may have vacuoles; may have mucinous secretions or infiltrative-like margins; often smooth muscle hyperplasia; cells also in clusters or small cords; rare mitotic figures; minimal atypia; often lymphocytic follicles

Negative stains: CEA

DD: lymphangioma, adenomyoma (more prominent smooth muscle), carcinoma (not circumscribed, invasive, atypia, mitotic activity)

 

Borderline tumor

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Rare cases, mostly mucinous tumors, which may represent spread of appendiceal mucinous cystic tumor

Case report of borderline papillary serous tumor in 31 year old woman, AJSP 1996;20:30

 

Carcinoma

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Rare, 0.3 to 1.0% of genital tract malignancies

Mean age 57 years, rarely teenagers; usually incorrect preoperative diagnosis

High stage with pelvic extension or positive peritoneal cytology

To call primary in fallopian tube, should arise from mucosa (endosalpinx), have tubal histologic pattern, involve the lumen, uterus and ovaries must be normal or have foci of malignancy that resemble metastases or independent primaries; if tubal wall is involved, should detect a transition between benign and malignant tubal epithelium

5 year survival: Stage 1 - 77%, Stage 3 - 20%; usually recur intra-abdominally

Associated with BRCA1 and BRCA2 mutations; for patients with known mutation or family history of breast or ovarian cancer, should  submit entire fallopian tube and ovary for microscopic examination, AJSP 2002;26:171, AJSP 2001;25:1283

50% serous, 25% endometrioid, 20% transitional or undifferentiated

Symptoms: vaginal bleeding or discharge (2/3), pain, adnexal mass (triad in 50%); endometrial smear positive in 10%

Gross: enlarged tube, with solid or papillary tumor filling the lumen; tumors occasionally are primary in the fimbriae; 80-97% unilateral; hemorrhage, necrosis and cysts common

Micro: invasive papillary adenocarcinoma; may resemble ovarian serous adenocarcinoma with complex papillary architecture

Endometrioid tumors may be non-invasive, have squamous metaplasia, be associated with endometriosis, contain spindled epithelial cells; may have small, closely packed cells with numerous glandular spaces of varying sizes, containing PAS+ dense colloid-like secretion, resembling female adnexal tumor of probably wolffian origin (but usually intraluminal, typical endometrioid carcinoma elsewhere, more mitotic activity and atypia, mucin present)

 

Carcinoma in situ

Rare without invasive carcinoma

May be preceded with tubal intraepithelial neoplasia at distal fibrimia; associated with BRCA+ patients, who often have p53 signatures in fimbrial epithelium in prophylactic TAH/BSO specimens that represents serous carcinoma in-situ (Curr Opin Obstet Gynecol 2007;19:3, Clin Med Res 2007;5:35, Am J Surg Pathol 2007;31:161)

Micro: flat or minimally papillary lesions, not grossly noted, cells have obvious malignant nuclear features

Micro images: intraepithelial carcinomap53 staining

DD: metastases to fallopian tube

 

Endometrioid polyp

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Common

 

Female adnexal tumor of probable wolffian origin

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Rare, ~ 40 cases reported

Mean age 47, range 15 to 72 years

Nonspecific symptoms or incidental mass

Usually benign, no known features predictive of malignancy

Malignant case in 81 year old woman, Archives 1994;118:310

Gross: solid tumor within or hanging from broad ligament or fallopian tube by a pedicle; mean 8 cm, rounded with bosselated external surface; solid or cystic cut surface; gray-white, tan or yellow, firm to rubbery; hemorrhage or necrosis is rare

Micro: diffuse, trabecular, tubular or sieve like patterns; cells are cuboidal to columnar with minimal cytoplasm; rarely abundant pale cytoplasm; nuclei small, round/oval, pale; may have prominent hyalinized stroma or fibrous bands that creates lobular appearance; sheets of tumor cells may have a spindly appearance

Positive stains: AE1/AE3

Negative stains: EMA, CEA, S100, B72.3

EM: thick peritubular basal lamina, no/minimal cilia; Golgi apparatus, secretory granules and glycogen favor Wolffian origin

 

Lymphoma

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Tubes often affected by disseminated lymphoma, although less common than ovarian involvement

No cases of primary tubal lymphoma reported

 

Malignant mixed mullerian tumor

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Rare, < 70 cases reported

Similar age and clinical presentation as primary tubal carcinoma

p53 positive in one study of two tumors, Mod Path 1994;7:619

Gross: large, polypoid mass protruding into lumen

Micro: similar to MMMT of uterus; homologous and heterologous stromal component may be present

DD: endometrioid carcinoma with spindle cells, immature teratoma

Reference: Archives 1987;111:386

 

Metastases / secondary tumors

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Tubal involvement often by ovarian borderline tumors and carcinomas, cervical and endometrial carcinoma (invasive or in-situ) and pseudomyxoma peritonei

Metastases from extra-genital site are rare

Micro images: figure3

 

Mucinous lesions

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Rare, associated with mucinous lesions elsewhere in female genital tract and Peutz-Jeghers syndrome

Mucinous metaplasia and neoplasia of fallopian tube may indicate multifocal mucinous neoplasia, AJSP 1994;18:1205

Micro images: figure5

 

Papillary cystadenoma of mesosalpinx

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Associated with von Hippel Lindau disease

 

Serous adenofibroma

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Similar to ovarian counterpart

 

Teratoma

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Rare, ~ 50 cases reported, almost all benign and cystic

Case report of struma salpingis associated with struma ovarii, AJSP 1993;17:1187

Gross: usually attached by a pedicle to tubal mucosa; 0.7 to 2.0 cm

Micro: usually cystic and mature

 

Staging

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Widespread intra-abdominal disease is common, so multiple biopsies of commonly involved sites are required for staging

 

Primary tumor (T) and FIGO stage in ( )

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TX: Primary tumor cannot be assessed

T0: No evidence of primary tumor

Tis: Carcinoma in situ (limited to tubal mucosa)

 

T1 (I): Tumor limited to fallopian tube(s)

T1a (IA): Tumor limited to one tube, without penetrating the serosal surface; no ascites

T1b (IB): Tumor limited to both tubes, without penetrating the serosal surface; no ascites

T1c (IC): Tumor limited to one or both tubes, with extension onto or through the tubal serosa, or with malignant cells in ascites or peritoneal washings

 

T2 (II): Tumor involves one or both fallopian tubes with pelvic extension

T2a (IIA): Extension or metastasis to the uterus or ovaries

T2b (IIB): Extension to other pelvic structures

T2c (IIC): Pelvic extension with malignant cells in ascites or peritoneal washings

 

T3 (III): Tumor involves one or both fallopian tubes, with peritoneal implants outside the pelvis

T3a (IIIA): Microscopic peritoneal metastasis outside the pelvis

T3b (IIIB): Macroscopic peritoneal metastasis outside the pelvis 2 cm or less in greatest dimension

T3c (IIIC): Peritoneal metastasis outside the pelvis and more than 2 cm in diameter

 

Notes

- Liver capsule metastasis is T3/Stage III

- Liver parenchymal metastasis is M1/Stage IV

- Pleural effusion must have positive cytology for M1/Stage IV

 

Regional lymph nodes (N) and FIGO stage in ( )

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NX: Regional lymph nodes cannot be assessed

N0: No regional lymph node metastasis

N1 (IIIC): Regional lymph node metastasis

 

Distant Metastasis (M) and FIGO stage in ( )

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M0: No distant metastasis

M1 (IV): Distant metastasis (excludes metastasis within the peritoneal cavity)

 

Stage grouping

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Stage 0: T1s N0 M0

Stage I: T1 N0 M0

Stage IA: T1a N0 M0

Stage IB: T1b N0 M0

Stage IC: T1c N0 M0

Stage II: T2 N0 M0

Stage IIA: T2a N0 M0

Stage IIB: T2b N0 M0

Stage IIC: T2c N0 M0

Stage III: T3 N0 M0

Stage IIIA: T3a N0 M0

Stage IIIB: T3b N0 M0

Stage IIIC: T3c N0 M0  or  any T N1 M0

Stage IV: M1

 

Notes:

FIGO no longer includes Stage 0 (Tis)

 

Tumor features to report

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Histologic type

Grade

Size

Depth of invasion (i.e. layers of tube involved)

Location in segment of tube

Extension to adjacent tissue

Angiolymphatic invasion

Resection margins

Pathologic findings for other tissue submitted

Additional findings (salpingitis, endometriosis)

Reference: Archives 1999;123:33

 

 

Broad ligament tumors

Ependymoma

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3 cases reported, ages 13, 45, 47 years, sizes 1.0, 9.5, 13 cm

Resemble ependymoma of central nervous system

Positive stains: GFAP

 

Leiomyoma

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Most common soft tissue tumor of broad ligament

 

Leiomyosarcoma

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Most common sarcoma of broad ligament

 

Papillary cystadenoma

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Associated with von Hippel-Lindau disease

Tumors often bilateral

 

Serous tumors

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Mean age 33 years

Gross: unilateral, unilocular cysts up to 13 cm

Micro: resemble ovarian counterparts, with ovarian-type stroma; no ova, no ovarian follicles


End of Fallopian Tubes chapter