primary fallopian tube cancer
Introduction
Introduction to primary fallopian tube cancer Primary fallopian tube cancer is a rare malignant tumor of the female reproductive tract. It was first reported by Renaud in 1847. In 1888, Dr. Orthomann made a complete description and report on primary fallopian tube cancer in Germany. Since then, reports on the disease have gradually increased, and about 1400 cases have been reported around the world. The actual number of actual cases far exceeds this number, as many cases have not been reported, and some advanced cases are often classified as ovarian cancer metastasis. basic knowledge Sickness ratio: 0.0001% Susceptible people: women Mode of infection: non-infectious Complications: abdominal pain, tubal adhesions
Cause
Primary fallopian tube cancer
(1) Causes of the disease
The pathogenesis of fallopian tube cancer is not fully understood. Because patients are often accompanied by chronic salpingitis, the proportion of infertility is high. In the past, there was often a history of acute salpingitis. There were chronic inflammatory cells in the fallopian tube specimens. Therefore, infertrating tubal chronic inflammation was inferred. May be related to the incidence of fallopian tube cancer, but chronic salpingitis is a more common gynecological disease, the incidence of fallopian tube cancer is not seen in people with high incidence of salpingitis, after all, fallopian tube cancer is a rare Malignant tumors, in the pathological examination, the common side is accompanied by chronic salpingitis, while the other side has no obvious inflammation. Therefore, it is also possible that the inflammatory changes of the fallopian tube are secondary to the fallopian tube cancer. In addition, there are reports that the fallopian tube cancer and the fallopian tube tuberculosis coexist. Fallopian tube cancer occurs after tubal ligation, and these may also be the cause of fallopian tube cancer.
(two) pathogenesis
The majority of primary fallopian tube cancer is papillary adenocarcinoma, accounting for 90%. Other tissue types include clear cell carcinoma, squamous cell carcinoma, adenoma, adenosquamous carcinoma, mucinous carcinoma and endometrioid carcinoma.
1. Gross-type fallopian tube cancer has different manifestations on tumor size and growth site, but it has different manifestations on the specimens. The total is thickened, irregular or spindle-shaped. When the early tumor is confined to the mucosa, it is only seen during surgery. The fallopian tube nodules are thickened and the palpation can be soft nodules. If the muscle layer is invaded, the nodule or the mass of the mass increases. If the serosal layer is not invaded, the serosa surface is smooth. When the lumen is filled with tumor tissue, the fallopian tube It can be in the shape of sausage or sausage. The oviduct profile is filled with cauliflower-like tissue in the cavity, and sometimes necrotic mass is seen.
2. Histological classification Hu, Taymor and Hertig et al. classify the histological classification of fallopian tube cancer into three grades, which is the most used tissue classification today.
Grade 1 papillary type, the tumor is confined to the mucosa, no muscle layer infiltration, the tumor is papillary to the cavity, the nipple is covered with columnar cubic epithelium, the layers are arranged, the shape is irregular, the polarity disappears, and the nuclear stain is deep. Splitting, often seen in the transition zone between normal mucosa and cancer.
Grade 2 papillary alveolar (papillary alveolar), the structure of the nipple still exists, but the cell differentiation is poor, the atypia is obvious, and there is a small acinar or glandular cavity formation, often accompanied by tubal myometrial invasion.
Grade 3 adenullary medullary, poor cell differentiation, many mitotic figures, diffuse cells into pieces, sometimes acinar structure, muscle infiltration.
These three types of tissue are gradually evolving processes. The papillary type is often an earlier lesion with a lower degree of malignancy, while the papillary acinar and acinar myeloid type tend to be more advanced and more malignant, sometimes in the same It can be seen in one specimen that three types exist at the same time, depending on which type is dominant.
Oviductal carcinoma in situ was also reported occasionally. It was found that the fallopian tube was resected for other reasons. The lesions were often small and limited. The mucosal epithelium was characterized by severe atypical hyperplasia, deep nuclear staining, disordered cell arrangement, and easy nuclear fission. Elephant carcinoma in situ should be distinguished from reactive atypical hyperplasia. The former is focal and the latter is often diffuse, with differences in nuclear morphology, nuclear staining and nuclear division.
Various tissue types in ovarian cancer are also seen in fallopian tube cancer, such as serous papillary carcinoma, mucinous adenocarcinoma, endometrioid carcinoma, transitional cell carcinoma, and clear cell carcinoma.
In addition to these types of tissues, there are some less common types of tissues, such as squamous cell carcinoma, adenosquamous carcinoma, ground glass cell carcinoma, and borderline cystadenoma.
The most common site of fallopian tube cancer is the tubal ampulla, followed by the umbrella end, which accounts for 10% to 26% of bilateral.
3. Histological diagnosis of primary fallopian tube cancer diagnosis should at least meet the following two:
(1) The tumor of the fallopian tube is not connected with the tumor of other parts.
(2) The tissue performance of fallopian tube tumors is significantly different from that of other sites.
(3) Tumors of the fallopian tubes are significantly larger or longer than tumors of other parts.
(4) The degree of malignancy and stage of the tumor of the fallopian tube exceeds that of other parts of the tumor.
4. Staging and transfer routes
(1) Staging: Regarding the staging of fallopian tube cancer, there has been no uniform staging standard in the world for a long time. As early as 1967, Zrez et al. and Schiller and Silverberg in 1971, it was suggested that the fallopian tube is a hollow organ with endometrium and muscle. Layer tissue, similar to the colon, is infiltrating and spreading differently from ovarian tumors in tumor development, so it is recommended to refer to Duke's colorectal cancer staging system to establish the staging of fallopian tube cancer (Table 1).
Because the fallopian tube is adjacent to the ovary, and many biological behaviors are similar to the ovary, many scholars have always referred to the clinical stage of ovarian cancer for the staging of fallopian tube cancer. In September 1991, the International Federation of Obstetrics and Gynecology (FIGO) officially recommended the fallopian tube cancer. Staging method (Table 2), both staging methods are surgical staging.
(2) Metastatic route: The metastasis pathway of fallopian tube cancer is similar to ovarian cancer, and there are usually three transfer pathways.
1 direct diffusion: fallopian tube cancer can spread through the umbrella end to the peritoneum and ovary, etc., or because the fallopian tube serosa is penetrated and spread to the pelvic cavity, another way is through the fallopian tube peristalsis to the uterine cavity, the cervix or even the contralateral side The fallopian tube spreads.
2 lymphatic metastasis: the fallopian tube and ovary have the same lymphatic drainage pathway. The pelvic lymph and para-aortic lymph are the main lymphatic metastasis sites of fallopian tube cancer. Because there are few cases of fallopian tube cancer, there is no routine lymphatic dissection during treatment, so the exact The rate of lymph node metastasis is not clear. It is estimated that the total lymph node metastasis of oviduct cancer accounts for about half of each stage, and the para-aortic lymph node metastasis accounts for about 1/3. The rate of para-aortic lymph node metastasis found in autopsy is higher. In addition, there are a few reports of inguinal lymph nodes or supraclavicular lymph node metastasis, and lymph node metastasis can occur in cancers with small or limited lesions.
3 blood transfer: advanced cancer can be transferred to the lungs, brain, liver, kidney and other organs through the blood.
Prevention
Primary fallopian tube cancer prevention
Early detection, early treatment, close follow-up, follow-up: recurrence of fallopian tube cancer occurs more in the pelvic and abdominal cavity, especially within 2 years after treatment, regular pelvic and abdominal examination, including double examination, B-ultrasound and CT examination Etc. It is very important to observe the CA125 value and its dynamic changes during follow-up, in order to find early recurrence and metastasis cases. The frequency of follow-up should be similar to ovarian cancer. Check within 2 to 3 months within 2 years. Once, the interval between follow-ups can be extended appropriately.
Complication
Primary fallopian tube cancer complications Complications abdominal pain tubal adhesions
The occurrence of complications is mainly related to the sooner or later detection of the disease and the treatment measures, which can lead to tubal adhesions, inflammatory infections, and bleeding. Local metastasis and trauma of the surgery itself cause pelvic tissue adhesion to the ovary, leading to ovarian function changes, causing endocrine abnormalities, metastasis to the endometrium, causing non-menstrual bleeding, metastasis to the kidneys and fallopian tubes, bladder, leading to hematuria, renal dysfunction, Distant metastasis causes liver metastases, lung metastases, and the like.
Symptom
Primary fallopian tube cancer symptoms Common symptoms Vaginal bleeding abdominal pain severe pain abdominal distension lower abdominal cramps fallopian tube mass pelvic mass urinary urgency urgency
Early fallopian tube cancer is asymptomatic, and the following symptoms and signs may appear as the lesion progresses:
1. Vaginal drainage cancer tissue grows in the fallopian tube, exudation is more, and the umbrella end of the fallopian tube is often blocked and closed, so it discharges into the uterine cavity and flows out through the vagina. This is an important clinical symptom of fallopian tube cancer, about 50 More than % of patients have vaginal discharge, the discharge of liquid is mostly serous or serous blood, the amount is more, there are reports as much as 1000ml or more, sometimes the discharge of liquid is also mixed with necrotic tissue fragments, lower abdominal cramps with intermittent Sexual vaginal discharge, abdominal pain after vaginal discharge is relieved, and the fallopian tube mass shrinks or disappears. This is the performance of hydrops tube profluens, which is caused by fallopian tube filling and emptying caused by fallopian tube cancer. This symptom accounts for about 9% and is easily misdiagnosed as genitourinary tract.
2. vaginal bleeding tumor necrosis or erosion of blood vessels leading to bleeding, but this amount of bleeding is not much, if mixed in the secretion of liquid, it is serous blood, fallopian tube cancer is high in the near menopause or late menopause, at this time the vaginal bloody fluid should Caused high vigilance, abnormal vaginal bleeding of fallopian tube cancer accounted for about 62%, if the irregular vaginal bleeding in the high-onset age and the diagnosis is negative, should consider the possibility of fallopian tube cancer.
3. Abdominal pain The fallopian tube mass can cause discomfort or dull pain in the lower abdomen. If the fallopian tube is twisted or the overflow of the fallopian tube is stagnant, severe pain or cramping occurs. There are few patients with severe abdominal pain, and about half of them have different degrees of abdominal pain or discomfort. .
4. Infertility Because of the high incidence of chronic salpingitis, the history of primary or secondary infertility is common, but this is not a specific symptom.
5. The pelvic mass attachment lumps are important signs of fallopian tube cancer. Preoperative examination found that pelvic masses accounted for 61% to 65%, and larger lumps could be touched by themselves.
6. Other symptoms Due to the enlargement and development of the tumor, some symptoms of compression of the surrounding organs and symptoms caused by tumor metastasis, such as abdominal distension, frequent urination, urgency, gastrointestinal discomfort and cachexia, etc., typical fallopian tube cancer is " Triad disease, that is, abdominal pain, pelvic mass, serous vaginal fluid, also proposed another group of "triple syndrome" for vaginal bleeding, vaginal fluid and lower abdominal pain, for those with pelvic mass with a large amount of vaginal fluid, can also be called For the "two syndromes" of fallopian tube cancer, people with triple or double disease should pay attention.
Because of the low incidence of fallopian tube cancer, there is no specific and reliable diagnostic method in clinical practice. Therefore, it is often neglected or misdiagnosed as ovarian tumor or other diseases before surgery. In 1898, Falk punctures the cancerous fluid from the fallopian tube. Diagnosis, this is the first case in the world to be diagnosed before surgery. Only 2 of 71 cases reported by Eddy et al. were preoperatively diagnosed. Later, with the improvement of the understanding of this disease, the comprehensive literature reported that only the preoperative diagnosis was only 4.7%, most of the patients who can be diagnosed before surgery can have triple disease, double disease, or doctors have rich experience. The pelvic mass or vaginal discharge is the most important symptom of fallopian tube cancer. When both are present, the fallopian tube should be carefully excluded. cancer.
Examine
Primary fallopian tube cancer examination
1. Exfoliated cytology examination The fallopian tube communicates with the uterine cavity. The fluid in the tube is discharged into the uterine cavity with the peristalsis of the fallopian tube, and there are also exfoliated cells. Therefore, the cytological examination of the vaginal fluid can often find the fallopian tube cancer cells and the fallopian cells of the fallopian tube cancer. The characteristics are that the cells are spherical or papillary, the amount of malignant cells is scarce, the cells are degraded, and there are no cell debris in the background. The positive rate of exfoliative cytology of fallopian tube cancer varies from 0 to 18%, and a few reports are as high as 40% to 60%. %, cytology-positive people should be diagnosed to exclude endometrial cancer. If the cytology is positive and the diagnosis is negative, it is likely to be fallopian tube cancer. When the tumor penetrates the serosa layer or has a pelvic cavity, then It is possible to find malignant cells in the peritoneal fluid or rinse solution.
2. Imaging examination Currently commonly used imaging examinations include B-ultrasound, CT, MRI, etc. These examinations can suggest pelvic masses and can distinguish cystic or solid masses. They are an indispensable means for diagnosing fallopian tube cancer, of course not three. All kinds of examinations must be done. You can choose one or two. If the fallopian tube cancer is small (<2cm), the imaging examination may not be accurate. However, because the ovary is small, the imaging is not easy to prompt. Tubal lumps are mistaken for ovarian tumors. Imaging examination of fallopian tube cancer is difficult to distinguish from tubal abscess, ectopic pregnancy and ovarian tumor. Vaginal ultrasound color Doppler flow imaging (vaginal ultrasound) can show that the attachment is sausage-shaped. Real mixed mass, blood flow resistance index (RI) is 0.29 ~ 0.4, significantly lower than the normal RI of the fallopian tube tissue, vaginal ultrasonography can significantly improve the diagnosis rate of preoperative fallopian tube cancer.
3. Serum CA125 determination CA125 is present in mesothelial tissue, Miller tube epithelium and its derived tumors. In ovarian cancer, fallopian tube cancer, endometrial cancer and mesothelioma, the CA125 value can be measured. Niloff et al. and Lootsma-Miklosova have reported an increase in the CA125 value of fallopian tube cancer. In the continuous monitoring, the preoperative CA125 value was as high as 145-535 U/ml, and decreased to 5 U/ml after the initial treatment. Two patients with recurrence CA125 The value is increased, so the determination of CA125 can be used as an important reference for the diagnosis, curative effect and prognosis of fallopian tube cancer. Raised found that the increase of CAl25 value (30U/ml) is 3-11 months earlier than the clinical symptoms. The determination of CA125 has Conducive to early diagnosis.
1. Endoscopy Hysteroscopy and laparoscopy can be used as preoperative examination for suspected fallopian tube cancer. Finikiotis et al. have described yellow plaques located in the posterior wall of the uterus under hysteroscopy and subsequently confirmed as fallopian tube cancer. They think that this may be the characteristics of fallopian tube cancer in the uterus. In hysteroscopy, special attention should be paid to the opening of the fallopian tube, and the liquid in the fallopian tube should be taken for cytological examination. The biopsy of the suspected part is beneficial for early diagnosis. Laparoscopy can be used. Direct observation of changes in the fallopian tubes and ovaries can be helpful in diagnosis, as well as intraperitoneal fluid cytology.
2. Endometrial examination of endometrial cancer, uterine submucosal fibroids often have vaginal fluid, in order to rule out the above diseases need to be diagnosed to detect intrauterine conditions, but the fallopian tube cancer is often negative, but with Except for those who have intrauterine transfer.
Diagnosis
Diagnosis and diagnosis of primary fallopian tube cancer
Should pay attention to the identification of the following diseases:
1. Ovarian cancer Ovarian cancer is mostly spherical or lobulated, without vaginal fluid phenomenon, while the fallopian tube is often sausage-shaped or oval, very small, except for laparoscopy, general examination is extremely difficult before surgery The difference between ovarian cancer and the clinical manifestations of fallopian tube cancer is very similar to that of ovarian cancer. The difference is that patients with ovarian cancer are mostly advanced at the time of diagnosis, while those with fallopian tube cancer are diagnosed at 2/3 early. This may be due to the initiation of fallopian tube cancer. In the oviduct cavity, the diseased fallopian tube is often locked, thus preventing the cancer tissue from rapidly spreading to the abdominal cavity. In addition, due to the spasm and contraction of the fallopian tube, the symptoms of abdominal pain appear earlier, causing the patient to be vigilant and timely check, so often The disease is earlier.
2. Endometrial cancer may have vaginal fluid, but more common for vaginal bleeding, through the diagnosis of scraping or endometrial biopsy, the positive is often endometrial cancer.
3. Attachment inflammatory mass tubal hydrops, tubal ovarian hydrops and fallopian tube abscess, etc., in the appearance of difficult to identify with fallopian tube cancer, but inflammatory mass often accompanied by peripheral adhesions, yellow liquid or pus in the lumen, no nipples Shaped or myeloid tissue, the specimen can be distinguished from the fallopian tube cancer.
4. Tubal pregnancy Tubal pregnancy often has a history of menopause, abdominal pain and internal bleeding and other acute abdomen manifestations, elevated blood HCG, open the fallopian tube see embryo sac or placenta tissue, it is not difficult to identify after laparotomy.
