Fallopian Tubes
Last revised 21 May 2007
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Fallopian tube
Primary references, normal anatomy, 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
AJCC Cancer Staging Manual (6th Ed)
American Journal of Surgical Pathology (AJSP), June 1981 to Feb 2003
Archives of Pathology and Laboratory Medicine (Archives), Oct 1975 to Jan 2003
Human Pathology (Hum Path), Mar 1970 to Dec 2002
Modern Pathology (Mod Path), Jan 1988 to Feb 2003
Rosai: Ackerman’s Surgical Pathology (8th edition); Mosby-Year Book, Inc., 1996
Sternberg: Diagnostic Surgical Pathology (2nd edition); Lippincott Williams & Wilkins, 1999
Please refer to these primary references for more detailed discussions and photographs
Fallopian Tube
Hollow structure 11 cm long
Connected to broad ligament by mesovarium (double fold of peritoneum), to uterine cornu by utero-ovarian ligament, to lateral pelvic sidewall by infundibulopelvic (suspensory) ligament
Extends from posterior superior uterine fundus laterally and anterior to ovary
Lymphatic drainage to para-aortic, internal iliac, external iliac, common iliac and inguinal nodes
Segments: intramural (within wall of uterus), isthmus (thick walled), ampulla (thin walled), infundibulum (trumpet shaped end lined by fimbriae, attaches to ovary)
Plica: delicate folds of mucosa on inner aspect of tube; contain ciliated columnar cells, secretory cells (non-ciliated) and intercalated (peg) cells which may be inactive secretory cells; plica merge with fimbriae
Epithelium secretes amylase, Archives 1982;106:17
Normally contains neutrophils at menstruation and post-partum (don’t call salpingitis)
Muscle usually has 2 smooth muscle layers, 3 in isthmus near cornua
Covered by surface epithelium (a modified mesothelium aka coelomic or germinal), closely related to mullerian duct lining epithelium
Stroma resembles fibroblasts, in whorled / storiform pattern, surrounded by dense reticulin network; positive for actin and desmin
Stroma also contains luteinized stromal cells, decidual cells, smooth muscle, fat, neuroendocrine cells, endometrial stroma-like cells
Intramuscular edema associated with postpartum period; intramuscular mast cells common, Archives 2002;126:951
Germ cells arise from yolk sac at 4 weeks, migrate to urogenital ridge at 5-6 weeks, then mesothelium of urogenital ridge proliferates to form epithelium and stroma of gonad, incorporating the germ cells
At 6 weeks, lateral mullerian ducts (paramesonephric ducts) form from fusion of coelomic lining epithelium, proximal portion forms fallopian tubes, caudal portion fuses to form uterus, upper vagina
Urogenital sinus forms lower vagina and vestibule, fuses with mullerian ducts
Note: mucosa of uterus, tubes & ovaries is derived from coelomic epithelium
In male fetus, testes produce mullerian inhibitory substance, which causes regression of mullerian ducts and persistence of paired wolffian (mesonephric) ducts, which form epididymis and vas deferens
In female fetus (or male without functioning testis), mullerian structures persist and mesonephric duct regresses; vestiges may persist as epithelial inclusions; in cervix/vagina, are Gartner duct cysts
Development affected by clomiphene, tamoxifen and to a lesser extent DES, Hum Path 1987;18:1132, Hum Path 1982;13:190
Acute salpingitis (see suppurative salpingitis below)
Bacterial infection common; may cause infertility
Causes: sexual transmission (Neisseria gonorrheae, Chlamydia, Mycoplasma) most common; also post instrumentation, post-IUD, post-pregnancy or abortion
N. gonorrhea isolation decreases with increasing episodes of salpingitis
Coliforms commonly recovered from tubo-ovarian abscesses
Gross: pyosalpinx (pus), hematosalpinx; enlarged, erythematous, edematous; may have fibrinous exudate; tubo-ovarian abscess common
Micro: marked neutrophilic infiltrate, congestion and edema; mucosal ulceration; reactive epithelial changes
Micro images: image1
DD: ectopic pregnancy, hydrosalpinx (transudate, follows purulent salpingitis), menstruation / pregnancy (neutrophils common, but usually don’t invade muscularis, no necrosis, no ulceration, no chronic inflammatory infiltrate)
Chronic salpingitis
Gross: enlarged distorted tube adherent to ovary; may be associated with hydrosalpinx or pyosalpinx that transforms to a tubo-ovarian cyst
Micro: blunted, shortened, fibrotic plica contain chronic inflammatory cells; fused plica may produce a pseudoglandular pattern (chronic follicular salpingitis) that resembles malignancy
Micro images: figure1
Cysticercosis
Case report of focally calcified larva in 50 year old woman, Hum Path 1982;13:665
Foreign body salpingitis
Causes: lubricant jelly, mineral oil, radiographic contrast media, starch, talc
Note: lipoid granulomas may occur with gonococcal or TB salpingitis
Gross: yellow or chocolate brown resembling endometriosis
Micro: foamy histiocytes (if due to lipid), foreign body giant cell reaction extending to serosa
Granulomatous salpingitis
Causes: Actinomyces, Crohn’s disease, endometriosis, Enterobius, foreign bodies (see above), giant cell arteritis, malakoplakia, Mycobacterium tuberculosis or bovis, post-diathermy, post-radiation, sarcoidosis, Schistosomiasis, xanthogranulomatous salpingitis
Actinomyces
Associated with intrauterine devices; bilateral in 50%; ovaries often involved
Gross: changes of acute and chronic salpingitis plus small yellow “sulfur granules” within luminal exudate; may have fistulous tract with bowel, bladder, skin
Micro: clusters of gram positive filamentous bacteria surrounded by a purulent exudate
Enterobius vermicularis
Aka pinworm
Often migrates from lower female genital tract
Gross: nodular thickening of tubal wall, tubercle-like nodules in peritoneum
Micro: worms / ova and necrotic debris are surrounded by granulomatous inflammation with eosinophils, giant cells, fibrous tissue, granulation tissue
Fungi
Rare; blastomycosis and coccidiomyosis most common in US
Peritoneal surfaces may have tubercle-like nodules
Often tubo-ovarian mass or abscess
Schistosomiasis
Common throughout world, usually S. haematobium; rare in US
Gross: fibrosis related scarring and nodularity
Micro: ova with granulomatous reaction
Tuberculous salpingitis
Usually bilateral; hematogenous spread
Associated with young infertile patients with endometrial involvement, rare in US
Micro: caseating granulomas within mucosa, extreme adenomatous proliferation may resemble carcinoma; chronic inflammation and fibrosis in muscularis; Schaumann bodies often present
DD: leprous salpingitis
Xanthogranulomatous salpingitis
Rare, <20 cases reported
Diffuse infiltration of mucosa by histiocytes
May represent hemorrhage in endometriotic foci; may have infectious etiology
May simultaneously affect ovary
Symptoms: lower abdominal or suprapubic pain, fever, menorrhagia, vaginal bleeding, with adnexal tenderness and pelvic mass
Gross images: figure2
Micro: lipid-containing macrophages, lymphocytes, plasma cells, neutrophils; variable multinucleated giant cells
Micro images: figures 3/4
DD: malakoplakia (Michaelis-Gutmann bodies)
Reference: Archives 2001;125:260
Ligneous salpingitis
Ligneous: resembles wood or marble
Rare, may cause infertility
Associated with involvement of female genital tract and conjunctiva
Micro: amorphous hyaline eosinophilic material
Pelvic inflammatory disease
Generic term for pelvic inflammation centered on fallopian tubes
Pseudoxanthomatous salpingiosis
Localized deposition of lipofuscin-laden macrophages in lamina propria of fallopian tube
Associated with chronic endometriosis in 2 cases, Mod Path 1993;6:53
Suppurative salpingitis (see acute salpingitis above)
60% due to gonorrhea, also chlamydia (lymphoid follicles), peptostreptococci, peptococci, Bacteroides fragilis, case report of S. pneumoniae (Hum Path 1990;21:1288)
Gross images: image1
Benign or non-neoplastic conditions
Case report of beta 2 microglobulin amyloidosis in renal dialysis patient presenting as bilateral ovarian masses with involvement of fallopian tubes, AJSP 2002;26:130
Present in 16% with ectopic tubal pregnancy
Rarely associated with intrauterine pregnancy
Micro: large epithelioid cells with atypical nuclei; rarely clear cytoplasm
Common at time of cesarean section (with accompanying tubal ligation) or after hormonal therapy, Hum Path 1980;11(5 Suppl):583
Serosal decidua formation common finding (5.5%) after tubal ligation, AJSP 1987;11:526
Micro: small nodules of decidual cells covered by flattened or inflamed epithelium; affects stromal cells of lamina propria
Encapsulated adrenal cortical tissue in 23%
Case report of ectopic pancreatic tissue
Gross: adrenal cortical tissue-small yellow nodules in infundibulopelvic ligament
Micro: all 3 layers of adrenal cortex, but no medullary cells
Aka eccyesis; due to chronic salpingitis that destroys the lining folds and traps the ovum
Also due to congenital abnormalities, functional tubal disturbances, salpingitis isthmica nodosa, endometriosis, small tumor
Often a history of infertility
Should sample intratubal blood clot generously to identify products of gestation
Note: use hCG, HPL or keratin stains to find trophoblastic elements if necessary
Note: death of embryo or fetus may cause expulsion of endometrial decidual cast, regeneration of epithelium and normal appearing endometrium; thus presence of cycling endometrium does not rule out a tubal pregnancy if adnexal mass present
Often rupture of maternal vessels (week 8) into gestational sac
Case report of term tubal pregnancy with fetal death, Archives 1986;110:250
Treatment: salpingectomy; usually can conserve ovary
Gross: distension of ampullary segment of tube with thin or ruptured wall, dusky red serosa and hematosalpinx
Gross images: animation, image1, image2
Micro: intraluminal chorionic villi and extravillous trophoblast (may be degenerated); variable fetal parts; decidual change in lamina propria in 1/3; mesothelial reactive proliferation with papillary formation and psammoma bodies
Uterus - gestational hyperplasia with Arias-Stella reaction, no enlarged, hyalinized spiral arteries, no fibrinoid matrix
DD: missed / incomplete abortion (no fetal parts, no chorionic villi, no trophoblastic cells)
Nodules in wall or serosa of tube; may focally replace tubal mucosa
Muscularis is usually not involved
Endometriosis is usually present elsewhere in the pelvis
May represent extension of endometrium from uterine cornu (10% of women have extension to isthmus)
Associated with intratubal polyps, causing infertility or ectopic pregnancy
Also occurs in 20-50% of tubes after ligation, particularly if short stumps, electrocautery, long interval since ligation
Tubal epithelium outside the tube, analogous to endometriosis
Usually on ovarian surface close to fimbriae; may follow surgery or be associated with salpingitis, AJSP 1982;6:109
Also represents a peritoneal process with proliferation of mesothelium forming small cystic structures of tubal form, associated with ovarian serous tumors
May present as a tumor mass, AJSP 1999;23:166
Micro image: contributed by Col Dr Shahid Jamal, Army Medical College, Rawalpindi, Pakistan - enterobius
Present in women with estrogen producing ovarian tumors
May also be associated with ovarian serous borderline tumors
Often an incidental microscopic finding
Ages 17-40 (patients with pseudocarcinomatous hyperplasia)
May be associated with severe inflammation and scarring and resemble adenocarcinoma
Micro: papillary, gland-like or cribriform patterns, lined by epithelial cells with mild to moderate nuclear pleomorphism, loss of polarity, stratification, crowding, hyperchromatism and mitotic figures; changes may be transmural; may be accompanied by atypical mesothelial proliferation with cuboidal cells lined up in rows with mild nuclear atypia; no invasion
DD: carcinoma (grossly evident, older age, solid epithelial proliferation, brisk mitotic activity, severe atypia)
Reference: AJSP 1994;18:1125
Extratubal secondary trophoblastic implants
Rare complication of conservative laparoscopic procedures for tubal ectopic pregnancies
Patients have persistent elevated beta-hCG titers postoperatively
Probably due to disruption of ectopic pregnancy at salpingostomy or morcellation of fallopian tube at salpingectomy
Gross: may have extensive omental implants, 0.3 cm red-black nodules
Micro: nodules are degenerating chorionic villi associated with implantation changes in the surrounding tissue
Reference: Hum
Path 1998;29:184
Marked pseudostratification and dark nuclear staining
Due to cautery or heating of specimen after removal
Present in 0.5% of fallopian tubes or paratubal tissue, usually in fimbriae
In broad ligament
Micro: small tubules lined by low columnar to cuboidal cells without cilia; surrounded by prominent smooth muscle; may be cystic
Mucinous metaplasia associated with mucinous tumors of cervix or ovary and Peutz-Jeghers syndrome
Positive stains: serotonin and somatostatin
Transitional and squamous metaplasias are rare
Rare, incidental finding usually in pregnant and post-partum women
May be metaplastic and not neoplastic
Benign behavior
Gross: microscopic size; involves only part of circumference of mucosa
Micro: papillae with small rounded cysts; composed of large, stratified, epithelial cells with abundant eosinophilic cytoplasm, may contain mucin and large vesicular nuclei; no / rare mitotic figures
DD: primary tubal carcinoma (larger, invasive, atypia)
Reference: Archives 1989;113:545
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
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
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
Dilation of proximal tube, attenuation of plica with pseudopolyp formation and chronic inflammation, plical thickening in distal tube
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
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)
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
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
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)
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
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
Micro: flat or minimally papillary lesions, not grossly noted, cells have obvious malignant nuclear features
DD: metastases to fallopian tube
Common
Female adnexal tumor of probable wolffian origin
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
Tubes often affected by disseminated lymphoma, although less common than ovarian involvement
No cases of primary tubal lymphoma reported
Malignant mixed mullerian tumor
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
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
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
Associated with von Hippel Lindau disease
Similar to ovarian counterpart
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
Widespread intra-abdominal disease is common, so multiple biopsies of commonly involved sites are required for staging
Primary tumor (T)
TX: primary tumor cannot be assessed
T0: no evidence of primary tumor
Tis (FIGO 0): carcinoma in situ (limited to tubal mucosa)
T1 (FIGO I): tumor limited to fallopian tube(s)
T1a (FIGO IA): tumor limited to one tube, without penetrating the serosal surface; no ascites
T1b (FIGO IB): tumor limited to both tubes, without penetrating the serosal surface; no ascites
T1c (FIGO 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 (FIGO II): tumor involves one or both fallopian tubes with pelvic extension
T2a (FIGO IIA): extension or metastasis to the uterus or ovaries
T2b (FIGO IIB): extension to other pelvic structures
T2c (FIGO IIC): pelvic extension with malignant cells in ascites or peritoneal washings
T3 (FIGO III): tumor involves one or both fallopian tubes, with peritoneal implants outside the pelvis
T3a (FIGO IIIA): microscopic peritoneal metastasis outside the pelvis
T3b (FIGO IIIB): macroscopic peritoneal metastasis outside the pelvis 2 cm or less in greatest dimension
T3c (FIGO IIIC): peritoneal metastasis more than 2 cm in diameter
Note: Liver capsule metastasis is T3/FIGO III; liver parenchymal metastasis is M1/FIGO IV. Pleural effusion must have positive cytology for M1/FIGO IV.
Regional lymph nodes (N)
NX: regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1(FIGO IIIC): regional lymph node metastasis
Distant Metastasis (M)
MX: distant metastasis cannot be assessed
M0: no distant metastasis
M1 (FIGO IV): distant metastasis (excludes metastasis within peritoneal cavity)
Stage grouping
Stage 0: T1s N0 M0
Stage 1: T1 N0 M0
Stage 1A: T1a N0 M0
Stage 1B: T1b N0 M0
Stage 1C: T1c N0 M0
Stage 2: T2 N0 M0
Stage 2A: T2a N0 M0