Mucosal epithelial proliferation of the fallopian tube: prevalence, clinical associations, and optimal strategy for histopathologic assessment

Histopathologic and Preneoplastic Changes in Tubal Ligation Materials

Background and Objectives: To investigate histopathological changes and serous carcinoma precursors such as secretory cell outgrowths (SCOUTs) and p53 signature in the bilateral tubal ligation (BTL) materials used during cesarean section (S/C). Materials and Methods: In total, 138 patients underwent S/C and tubal sterilization (TS) between October 2020 and May 2021 at Konya City Hospital. Patients' data were obtained from the hospital's system. All data and findings were investigated and statistically evaluated. Results: The mean age was 34.62 years (22-44), the mean gravity was 4.89 (2-15) and the mean parity was 3.46 (1-10). In total, 5.79% SCOUT, 7.24% atypia and 9.42% p53 signatures were observed. Significant correlations were shown between the epithelial cell lineage and age between Ki-67, SCOUT, and gravity; between the Ki-67 results and gravity and parity; and between the p53 score and age. Conclusions: TS is a common, safe, and effective method worldwide. Today, BTL is increasing along with increasing S/C ratios. In addition to the reduced risk of ovarian cancers with ligation alone, precursor lesions such as hyperplasia, SCOUT, p53 signature, and STIL/Serous tubal intraepithelial carcinoma (STIC) are encountered in the ampulla materials obtained. Considering the low rates of re-anastomosis, tubal excision may be recommended instead of ligation in women of relatively higher gravity and age.

Fallopian tube epithelial cells express androgen receptor and have a distinct hormonal responsiveness when compared with endometrial epithelium

STUDY QUESTION

How does steroid receptor expression, proliferative activity and hormone responsiveness of the fallopian tube (FT) epithelium compare to that of the endometrial epithelium?

SUMMARY ANSWER

Proliferative indices, hormone receptor expression-scores and in vitro response to oestrogen and androgens of the human FT demonstrate a distinct pattern from the matched endometrium.

WHAT IS KNOWN ALREADY

The FT epithelium exists as a continuum of the endometrium, and both express steroid hormone receptors. The ovarian steroid hormones regulate cyclical proliferation and regeneration of the endometrium, but their effects on steroid hormone receptor expression and proliferation in the FT have not yet been fully elucidated.

STUDY DESIGN, SIZE, DURATION

We included women with proven fertility, undergoing hysterectomy and bilateral salpingo-oophorectomy for benign, gynaecological conditions at Liverpool Women's NHS Foundation Trust. They had no known endometrial or tubal pathology and were not on hormonal treatments for at least 3 months preceding sample collection in this prospective observational study (conducted between 2010 and 2018). A full-thickness sample of the endometrium and a sample from the FT were collected from each woman.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The differential protein and mRNA levels of steroid hormone receptors, oestrogen receptors α and β, androgen receptor (AR) and progesterone receptor (PR), and the proliferative marker (Ki67) of the endometrium and the FT tissue samples from 47 healthy women undergoing surgery (37 premenopausal and 10 postmenopausal) were investigated using immunohistochemistry and quantitative real-time PCR. The comparative responsiveness to oestrogen and androgen of the endometrium and the fimbrial end of the FT was analysed using an in vitro short-term explant culture model. The endpoints assessed in the explants were the changes in mRNA and protein levels for AR, PR and the epithelial proliferative index after 24 h treatment with oestradiol (E2) or dihydrotestosterone (DHT).

MAIN RESULTS AND THE ROLE OF CHANCE

The premenopausal endometrial functionalis glands (FG) displayed the well-known cyclic variation in cellular proliferation and steroid receptor scores. Compared with the endometrial FG, the matched FT epithelium (both fimbrial or isthmic ends) displayed a significantly lower proportion of cells expressing Ki67 (2.8% ± 2.2%, n = 18 vs 30.0% ± 26.3%, n = 16, P = 0.0018, respectively) accompanied with a significantly higher AR immunoscores (6.7 ± 2.7, n = 16 vs 0.3 ± 1.0, n = 10, P = 0.0136). The proportion of cells expressing Ki67 and the AR immunoscores of the FT epithelium correlated positively with endometrial luminal epithelium (r = 0.62, P = 0.005, and r = 0.68, P = 0.003, respectively). In vitro experiments suggested the tubal explants to be apparently less responsive to E2 yet more sensitive to DHT compared with the matched endometrium explants.

LIMITATIONS, REASONS FOR CAUTION

The short-term in vitro nature of the tissue explant cultures used in the study may not be representative of how different anatomical regions of the endometrium and FT behave in vivo. Our study included a high proportion of older premenopausal women with a regular menstrual cycle, which may therefore affect extrapolation of findings to a younger group.

WIDER IMPLICATIONS OF THE FINDINGS

Advancing our understanding of tubal and endometrial epithelial cell function has important implications for the diagnosis and treatment of diseases such as infertility, ectopic pregnancy, endometriosis and cancer.

STUDY FUNDING/COMPETING INTEREST(S)

The work included in this article was funded by Wellbeing of Women project grants RG1073 and RG2137 (D.K.H.) and Wellbeing of Women Entry-Level Scholarship ELS706 (A.M). A.M. was also supported by an NIHR ACF fellowship grant. Further support received from Liverpool Women's Hospital NHS Trust (S.M.), University of Liverpool (E.B. and A.W.). All authors declare there are no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Frequency of papillary tubal hyperplasia (PTH), salpingoliths and transition from adenoma to borderline ovarian tumors (BOT): A systematic analysis of 74 BOT with different histologic types

Borderline ovarian tumors (BOT) arise from cystadenomas and represent a transition step within the development of low-grade ovarian carcinomas (Type I tumors). That pathway mirrors the adenoma-to-carcinoma sequence known for colorectal cancer. It has been suggested that papillary tubal hyperplasia (PTH) and salpingoliths may be associated with the development of BOT. To evaluate the frequency of the presence of benign cystadenoma and its transition to BOT in a given patient as well as the presence of PTH and salpingoliths we re-valuated in 74 consecutive cases of BOT with different histologic types. The majority of cases represented serous-BOT (60.8%), followed by mucinous BOT (25.7%), other histologic types were rare. 86.5% showed an adenoma-BOT sequence, which was seen in all mucinous BOT but was missed in 15.6% of serous BOT. Two cases had salpingoliths without associated PTH. PTH was seen in four out of the 74 (5.4%) BOT and occurred only in cases with serous histology. The vast majority of BOT represent a transition from benign cystadenoma to BOT in cases with mucinous and serous histology. Salpingoliths are rarely seen in association with BOT and occurred exclusively in BOT with serous histology. PTH may represent a distinct lesion but is rarely seen in association with BOT, especially in those with non-serous histology. Further studies are needed to evaluate the frequency and pathogenetic association of PTH with BOT.

Procurement and cytological features of human fallopian tube fimbrial cells by ex vivo imprinting and washing

INTRODUCTION

Fallopian tube intraepithelial cancer is a postulated precursor of epithelial ovarian carcinomas. As research continues on epithelial ovarian carcinomas' developmental pathways, representative tubal tissue must be procured for diagnostic, biological, and molecular studies without compromising pathological diagnosis.

MATERIALS AND METHODS

Fallopian tube fimbrial epithelia were harvested from postmenopausal women undergoing surgery for non-neoplastic gynecologic lesions (n = 16) and epithelial ovarian carcinomas (n = 6). Cytological imprints and washings were obtained from each fimbria and stained by Diff-Quik and rapid Papanicolaou for general cytomorphology; by Trypan blue for cell viability; and by rapid immunohistochemistry for evaluation of low molecular weight cytokeratin, MIB-1, p53, and high-mobility group A (HMGA2) expression.

RESULTS

Benign and malignant tubal imprints harvests yielded means of 3.5 × 10⁵ and 1.2 × 10⁶ cells/fimbria, respectively, with viabilities higher than 85%. A mean of 2.5 × 10⁵ cells/fimbria was obtained from fimbrial washings. The mean DNA, RNA, and protein contents of benign imprints were 2.4, 1.5, and 67 μg/fimbria, respectively. Benign cell populations contained nearly 97% cytokeratin-positive and p53/HMGA2-negative cells, which were dispersed within a watery to proteinaceous material and rare microcalcifications. Fimbrial imprints from serous carcinomas involving the fimbriae exhibited abnormal p53 and HMGA2 expression, high proliferation, and diagnostic criteria of malignancy, including prominent nucleoli and cell crowding.

CONCLUSIONS

Ex vivo harvest from operative specimens allows for collection of cell populations representative of native fimbrial epithelium and free of significant contaminants. Tubal harvest facilitates triaging of cellular material for basic, clinical, and translational studies on cancer pathobiology and also represents a potential diagnostic adjunct to emerging in vivo high-resolution optical technologies.

In vitro three-dimensional modeling of fallopian tube secretory epithelial cells

Background

Fallopian tube secretory epithelial cells (FTSECs) have been implicated as a cell-of-origin for high-grade serous epithelial ovarian cancer. However, there are relatively few in vitro models of this tissue type available for use in studies of FTSEC biology and malignant transformation. In vitro three-dimensional (3D) cell culture models aim to recreate the architecture and geometry of tissues in vivo and restore the complex network of cell-cell/cell-matrix interactions that occur throughout the surface of the cell membrane.

Results

We have established and characterized 3D spheroid culture models of primary FTSECs. FTSEC spheroids contain central cores of hyaline matrix surrounded by mono- or multi-layer epithelial sheets. We found that 3D culturing alters the molecular characteristics of FTSECs compared to 2D cultures of the same cells. Gene expression profiling identified more than a thousand differentially expressed genes between 3D and 2D cultures of the same FTSEC lines. Pathways significantly under-represented in 3D FTSEC cultures were associated with cell cycle progression and DNA replication. This was also reflected in the reduced proliferative indices observed in 3D spheroids stained for the proliferation marker MIB1. Comparisons with gene expression profiles of fresh fallopian tube tissues revealed that 2D FTSEC cultures clustered with follicular phase tubal epithelium, whereas 3D FTSEC cultures clustered with luteal phase samples.

Conclusions

This 3D model of fallopian tube secretory epithelial cells will advance our ability to study the underlying biology and etiology of fallopian tube tissues and the pathogenesis of high-grade serous epithelial ovarian cancer.

Pseudocarcinomatous Hyperplasia of the Fallopian Tubes which was Associated with Female Genital Tract Tuberculosis, Histologically Mimicking Tubal Adenocarcinoma: A Diagnostic Challenge

The benign proliferative and reactive processes of the fallopian tubes which are a result of female genital tract tuberculosis can mimick malignant neoplasms, both clinically and pathologically. 'Pseudocarcinomatous hyperplasia' is a term which is applied to the florid form of epithelial hyperplasia with atypical features, that mimicks tubal adenocarcinoma. It may be encountered in the tuberculous and the non tuberculous forms of chronic salphingitis. We are reporting a case of a 30 years old female who presented to our institute with complaints of vaginal discharge and fever. She underwent panhysterectomy for uterine fibroids. Both her fallopian tubes revealed features of florid atypical epithelial hyperplasia, along with widespread caseating granulomatas. Ziehl Neelsen (ZN) staining of the lesion for acid fast bacilli (AFB) was positive. A diagnosis of pseudocarcinomatous hyperplasia of the fallopian tubes which was associated with female genital tract tuberculosis, which histologically mimicked tubal adenocarcinoma was made, which posed a diagnostic dilemma.

Identification of a preneoplastic gene expression profile in tubal epithelium of BRCA1 mutation carriers

Microinvasive carcinomas and high-grade intraepithelial neoplasms are commonly discovered within the fallopian tube of BRCA1 mutation carriers at the time of risk-reducing salpingo-oophorectomy, suggesting that many BRCA1-mutated ovarian carcinomas originate in tubal epithelium. We hypothesized that changes in gene expression profiles within the histologically normal fallopian tube epithelium of BRCA1 mutation carriers would overlap with the expression profiles in BRCA1-mutated ovarian carcinomas and represent a BRCA1 preneoplastic signature. Laser capture microdissection of frozen sections was used to isolate neoplastic cells or histologically normal fallopian tube epithelium, and expression profiles were generated on Affymetrix U133 Plus 2.0 gene expression arrays. Normal-risk controls were 11 women wild type for BRCA1 and BRCA2 (WT-FT). WT-FT were compared with histologically normal fallopian tube epithelium from seven women with deleterious BRCA1 mutations who had foci of at least intraepithelial neoplasm within their fallopian tube (B1-FTocc). WT-FT samples were also compared with 12 BRCA1 ovarian carcinomas (B1-CA). The comparison of WT-FT versus B1-FTocc resulted in 152 differentially expressed probe sets, and the comparison of WT-FT versus B1-CA resulted in 4079 differentially expressed probe sets. The BRCA1 preneoplastic signature was composed of the overlap between these two lists, which included 41 concordant probe sets. Genes in the BRCA1 preneoplastic signature included several known tumor suppressor genes such as CDKN1C and EFEMP1 and several thought to be important in invasion and metastasis such as E2F3. The expression of a subset of genes was validated with quantitative reverse transcription-polymerase chain reaction and immunohistochemistry.

Hereditary Carcinomas of the Ovary, Fallopian Tube, and Peritoneum

Approximately 10% of ovarian cancers are associated with inherited germline mutations, most commonly of the BRCA1 or BRCA2 genes. The majority of BRCA1 and BRCA2 cancers are high-grade serous carcinomas diagnosed at an advanced stage, and there are as yet no histologic features that distinguish these tumors from sporadic serous cancers. Many women identified as being at high genetic risk undergo prophylactic salpingo-oophorectomy, and careful histopathological examination of these specimens may identify occult carcinoma, frequently in the distal fallopian tube. In addition, serous cancer precursors, including tubal intraepithelial carcinoma, have been increasingly recognized in distal and fimbrial epithelium. Little has been documented to date of the histopathological features of the cancers associated with the hereditary nonpolyposis colon cancer syndrome, but it appears these ovarian cancers may include a variety of histologic types, and in contrast to the BRCA cancers, are low grade and early stage.

Pseudoneoplastic Lesions of the Female Genital Tract

Context.—Numerous benign, proliferative, or reactive processes, often related to hormone stimulation or inflammation, occur throughout the female genital tract and may mimic benign or malignant tumors. Several of the more common pseudoneoplastic lesions are discussed in this article, including microglandular hyperplasia of the cervix mimicking well-differentiated endometrial adenocarcinoma, reactive epithelial changes in the fallopian tubes mimicking adenocarcinoma or carcinoma in situ, and pregnancy changes in the ovary including pregnancy luteoma and large solitary luteinized follicular cyst of pregnancy and puerperium that may mimic ovarian neoplasms.

Objectives.—To discuss and illustrate several common lesions of the female genital tract that mimic neoplasms.

Data Sources.—Material derived from consultation cases and review of the literature.

Conclusions.—Many benign hyperplastic or reactive processes that occur in the female genital tract may be mistaken for neoplasms both clinically and pathologically. Awareness of the features of such lesions will aid in their correct diagnosis and prevent overtreatment of benign processes.

Multistep level sections to detect occult fallopian tube carcinoma in risk-reducing salpingo-oophorectomies from women with BRCA mutations: implications for defining an optimal specimen dissection protocol

Risk-reducing salpingo-oophorectomy (RRSO) significantly lowers the incidence of ovarian, tubal, peritoneal, and breast cancer in women who carry BRCA1 or BRCA2 germline mutations. A minority of RRSO specimens from these women will contain occult early-stage carcinoma. Most occult cancer is localized in the fallopian tube fimbriae and is as small as 1 mm in size. Pathologic detection is dependent on thoroughness of tissue examination. Recommended protocols to maximize tumor detection emphasize the role of thinly slicing the tubes and ovaries and embedding the entire specimen for microscopic examination. Additional multistep level sections of tubal fimbriae tissue blocks could theoretically increase detection of occult tubal carcinoma but the value of level sections has not been formally evaluated. This study tests the diagnostic utility of multistep level sections in RRSO specimens from 102 women with BRCA germline mutations. The original diagnoses were based on a single section from each block of thinly sliced (2 to 3 mm intervals) tissues of the entire RRSO specimen. Three multistep level sections were retrospectively obtained from each block containing tubal fimbriae. Clinically occult carcinoma ranging in size from 1 to 13 mm was initially detected in 11 of 102 women (5 in tubal fimbriae only, 1 in tubal isthmus only, 2 in fimbriae and ovary, and 3 in ovary only). Diagnoses in the original fimbrial slides and their level sections were concordant in all cases. All tubal cancers were detected in both the original sections and in the multistep level sections. None of the tubal carcinomas that were noninvasive on the original slides showed invasive growth on additional level sections. No tubal carcinoma was identified in the level sections of any case originally classified as benign. Clinical follow-up among women with benign RRSO findings revealed that 2 women subsequently developed peritoneal carcinomatosis at 22 and 62 months postoperatively. Retrospective exhaustive multistep level sectioning of all remaining tubal and ovarian blocks from both these women confirmed the original benign diagnosis in 1 woman but in the other woman, the deepest levels of 1 ovarian block revealed a single 1-mm nodule of cancer at the base of an ovarian surface epithelial invagination. This specimen was one of the first RRSO cases in our experience and on review of the original report, this ovary was not dissected into multiple slices along its short axis but was only bivalved along its long axis. We propose that there does not seem to be any diagnostic value in automatically performing multistep deeper level sections of RRSO specimens if the tissue is sectioned appropriately and if the specimen is sliced at intervals that are no more than 3 mm thick. Guidelines for evaluation of RRSO specimens should emphasize the use of an optimal dissection protocol and the importance of thin tissue slice intervals.

Candidate serous cancer precursors in fallopian tube epithelium of BRCA1/2 mutation carriers

Occult invasive and intraepithelial carcinomas have been identified in the tubal fimbria of BRCA mutation carriers undergoing prophylactic surgery, and recently described lesions overexpressing p53 in the distal tubes of mutation carriers, and non-carriers, have been proposed as histological precursors of high-grade serous carcinoma. The aim of this study was to confirm these findings in a larger, independent case set, to further characterize the cancer precursor lesions, and to determine their frequency in BRCA mutation-positive (n=176) and control groups (n=64). For the purposes of this study, we excluded cases without documentation of a germline mutation of BRCA1/2, and without histological examination of the entire tube, and cases with a diagnosis of invasive carcinoma. Controls included salpingectomies from women undergoing surgery for reasons other than ovarian malignancy. Diagnostic categories were assigned based on combined histological review and immunostaining results. Histological abnormalities were identified in 23% of the BRCA group and in 25% of the control group, and included localized p53 overexpression in 20% of the BRCA group and 25% of the control group. Tubal intramucosal carcinoma was identified in 8% of the BRCA cases and in 3% of the control group. Four cases of intraepithelial carcinoma (21%) did not overexpress p53. There was no significant difference in the median age, frequency of histological abnormalities, p53 signatures, or tubal intraepithelial carcinoma between the BRCA mutation-positive and control groups. This large, blinded review of tubes from BRCA mutation carriers confirms previous reports of putative cancer precursors in distal tubal mucosa, and that p53 signatures occur with similar frequency in women at low and high genetic risk of tubal/ovarian carcinoma. Tubal intraepithelial carcinoma, which, like invasive serous cancer, usually but not always overexpresses p53 protein, is more frequent in BRCA mutation carriers.

Fallopian tube carcinoma: a review

PURPOSE

Primary fallopian tube carcinoma (PFTC) is a rare tumor that histologically and clinically resembles epithelial ovarian cancer (EOC). The purpose of this study is to review the current available literature data on PFTC.

PATIENTS AND RESULTS

Early clinical manifestation and prompt investigation often lead to diagnosis at an early stage of disease. However, the diagnosis of PFTC is rarely considered preoperatively and is usually first appreciated by the pathologist. Surgical staging/management and the use of chemotherapy follow the concepts used in epithelial ovarian cancer (EOC). In contrast to EOC is the importance of early lymphatic spread in this disease. The earlier diagnosis of PFTC leads to an apparent better survival compared with EOC. However, as with EOC, stage and residual tumor are the most important prognostic variables.

CONCLUSION

Until more extensive clinical research has been performed, ovarian carcinoma management principles should be used in clinical practice.

The tubal fimbria is a preferred site for early adenocarcinoma in women with familial ovarian cancer syndrome

A proportion of adenocarcinomas in prophylactic adnexectomies (bilateral salpingo-oophorectomies [BSOs]) from women with BRCA mutations (BRCA positive) occur in the fallopian tube. We analyzed a consecutive series of BSOs from BRCA-positive women following an index case of fimbrial serous carcinoma. To determine if the fimbria is a preferred site of origin, we followed a protocol for Sectioning and Extensively Examining the FIMbria (SEE-FIM). Immunostaining for p53 and Ki-67 was also performed. Thirteen BRCA-positive women (cases) and 13 women undergoing BSOs for other disorders (controls) were studied. Tubal carcinoma was detected in 4 cases at the initial histologic evaluation and in no controls. A fifth carcinoma was discovered following further sectioning of the fimbriae. Three were BRCA2 positive and two BRCA1 positive. Three were in the fimbria, one in both the fimbria and proximal tube, and one involved the ampulla. Four were serous carcinomas, four were confined to the tube, and three were noninvasive (intraepithelial). No ovarian carcinomas were identified. All tumors were Ki-67 positive (>75% of cell nuclei), and excluding one endometrioid carcinoma, p53 positive (>75% cell nuclei); p53 positivity in the absence of elevated Ki-67 did not correlate with morphologic neoplasia. The fimbria was the most common location for early serous carcinoma in this series of BRCA-positive women. Protocols that extensively examine the fimbria (SEE-FIM) will maximize the detection of early tubal epithelial carcinoma in patients at risk for ovarian cancer. Investigative strategies targeting the fimbriated end of the fallopian tube should further define its role in the pathogenesis of familial and sporadic ovarian serous carcinomas.

BRCA-mutation-associated fallopian tube carcinoma: a distinct clinical phenotype?

OBJECTIVE

To compare clinical and histologic features between fallopian tube cancers in women with germline BRCA mutations and sporadic cases.

METHODS

Twenty-eight patients with fallopian tube cancer had BRCA mutation testing using multiplex polymerase chain reaction and protein truncation testing. Histologic slides were reviewed by 2 pathologists, and immunohistochemical staining for p53, ki67, estrogen receptor, and progesterone receptor was performed on carcinomas and dysplastic and benign tubal epithelia.

RESULTS

Twelve of 28 (43%) women had BRCA mutations: 11 BRCA1, 1 BRCA2. Excluding 4 cases found at prophylactic surgery, the median age of diagnosis of BRCA mutation carriers was 57 years compared with 65 years among sporadic cases (P = .09). Patients with BRCA-associated fallopian tube cancer had a median survival time of 68 months compared with 37 months when compared with sporadic cases (P = .14). Both groups had predominantly advanced stage, high grade, serous fallopian tube cancers. No patient had exclusively proximal disease. Occult fallopian tube cancer diagnosed at prophylactic surgery in BRCA mutation carriers was exclusively distal. "Skip" areas of high-grade dysplasia were only seen in 2 patients, both of whom were BRCA mutation carriers. There were no differences in the immunohistochemical staining for p53, ki67, estrogen receptor or progesterone receptor in carcinomas and dysplastic or benign epithelia of patients with or without BRCA mutations. Overexpression of p53 was commonly seen in fallopian tube cancers and dysplastic epithelium, but rarely noted in benign epithelium.

CONCLUSION

Fallopian tube cancer is part of the BRCA mutation phenotype and seems to share many clinical features with sporadic fallopian tube cancers, including no exclusively proximal disease. The presentation of BRCA-associated fallopian tube cancers may, however, occur at a younger age and have an improved survival.

Advances in the recognition of tubal intraepithelial carcinoma: applications to cancer screening and the pathogenesis of ovarian cancer

Prophylactic salpingo-oophorectomies from women with BRCA mutations (BRCA+) have identified the tube as a frequent site of early pelvic serous carcinoma (tubal intraepithelial carcinoma [TIC]). These observations have implications for both the early recognition of pelvic serous carcinoma in susceptible women and determining the ultimate site of origin for pelvic serous carcinomas. Moreover, the unique pathology of TIC has shifted attention from the more exuberant proliferations mentioned in prior studies to a spectrum of neoplastic atypias that can be morphologically subtle. This review addresses a multitude of epithelial changes; benign, malignant, and an intriguing third group, which we term "p53 signatures," is found in benign, nonciliated epithelium and stain intensely positive for p53. Understanding all 3 is important for the proper management of women undergoing prophylactic salpingo-oophorectomy and possibly formulating an integrated model for the pathogenesis of serous carcinoma in the reproductive tract. A protocol for sectioning and extensively examining the fimbriated end (SEE-FIM), and its rationale, is described.

Atypical epithelial proliferation in fallopian tubes in prophylactic salpingo-oophorectomy specimens from BRCA1 and BRCA2 germline mutation carriers

Although growing numbers of tubal carcinomas in carriers of BRCA1 and BRCA2 germline mutations have been reported, very little is known about the nature and frequency of their possible precursor lesions. The aim of this study is to investigate the occurrence of atypical proliferative tubal lesions in grossly normal fallopian tubes from 26 women with BRCA1 and BRCA2 germline mutations who underwent prophylactic salpingo-oophorectomy and whose ovaries were histologically negative for carcinoma. Fallopian tubes from 49 women who had undergone hysterectomy with salpingo-oophorectomy for uterine leiomyoma served as controls. In the 22 BRCA1-mutated women, there were two in situ carcinomas and two atypical hyperplasias of the tubal epithelium. The tubes of the BRCA2-mutated women and of the 49 control women did not show any atypical proliferation. The frequency of proliferative lesions of the tubal epithelium, including in situ carcinoma, appears to be increased in BRCA1 mutation carriers. Removal and thorough examination of the fallopian tubes at the time of surgical prophylaxis for ovarian cancer is therefore recommended.

Fallopian tube malignancies: experience of Social Security Agency Aegean Maternity Hospital

The aim of the study was to determine the clinical characteristics and management of fallopian tube malignancies together with the results there unto that had been diagnosed and treated in our oncology department retrospectively. Twelve cases of fallopian tube malignancies, of a total of 2155 gynecologic malignancies (0.55%), that had been diagnosed in or referred to our hospital between January 1986 and December 2001 were evaluated retrospectively. Eight of 12 cases were diagnosed after surgical intervention in our department. Staging laparotomies were applied to all of the eight cases. Complementary surgeries of other four cases who were referred to our department were done according to the same principles of cytoreductive surgery. Staging of the cases was done according to Federation of International Gynecologists and Obstetricians (FIGO). Adjuvant chemotherapy was applied to all of the cases except two (10 cases, 83.3%). Second-look laparotomy (SLL) was applied to two of the cases. Mean age of the cases was 54.2 (range 35-72) years. Histopathology of the cases was as follows: serous adenocarcinoma in 10 cases (83.3%), endometrioid adenocarcinoma in one case (8.3%), and undifferentiated carcinoma in one case (8.3%). Adjuvant chemotherapy (PAC regimen to eight of the cases and PP regimen to two cases) was applied to 10 of the cases (83.3%). SLL was applied to two cases. Another case had died because of local recurrence at the 27th month of the follow-up. Mean follow-up period of the cases was 37.8 months (range 1-144 months). Fallopian tube malignancies are very rare malignancies. Diagnosis can be made generally peri- or postoperatively. More extensive clinical research must be performed in order to have definite etiologic, diagnostic, management modalities, and prognostic markers.

Challenges in the early diagnosis and staging of Fallopian-tube carcinomas associated with BRCA mutations

The histopathologic diagnosis of fallopian-tube carcinoma has been traditionally made at an advanced stage. More recently, predictive genetic BRCA testing is leading to the recognition in prophylactic oophorectomy specimens of clinically occult tubal carcinomas that are frequently in situ or small early-stage invasive carcinomas. These early lesions present a challenge in diagnosis and staging because the available criteria for the histopathologic diagnosis and staging of tubal carcinoma were derived from the clinicopathologic experience derived from the usual high-stage tubal carcinomas. The detection of early-stage tubal carcinomas requires that all tubal tissue be submitted for histologic examination. The diagnostic criteria for tubal in situ carcinoma have been defined, although the natural history of this lesion is unclear. Similarly defined criteria for a diagnosis of tubal dysplasia are lacking. Any early, invasive tubal carcinoma should be staged using a refined staging system suitable for early stage and fimbrial carcinomas. The adoption of these methods should increase our knowledge of early-stage tubal carcinoma and may add to our understanding of the development of ovarian-epithelial neoplasia.

Salpingitis, salpingoliths, and serous tumors of the ovaries: is there a connection?

We have observed luminal and mucosal calcifications frequently surrounded by a mantle of bland epithelium in the fallopian tubes ("salpingoliths") of women with serous tumors of the ovaries. These lesions resemble noninvasive peritoneal "implants" in women with advanced stage atypical proliferative serous tumors (APSTs) and micropapillary serous carcinomas (MPSCs). The presence of salpingitis and salpingoliths was prospectively evaluated in 358 women with a variety of nonneoplastic and neoplastic ovarian conditions and compared with 87 previously reported women with APSTs/MPSCs in an effort to determine whether these lesions were specifically associated with serous tumors. The frequency of chronic salpingitis among women without ovarian pathology was 27%, and the frequency of salpingoliths was 4%. Serous epithelial tumors (cystadenomas, APST/MPSC, and carcinomas) were significantly more often associated with chronic salpingitis (53%) and salpingoliths (32%) than all other cases with or without ovarian neoplasms (p<0.01). APSTs/MPSCs were associated with salpingoliths significantly more frequently than all other groups (p<0.001). For patients with APSTs/MPSCs, salpingoliths were found significantly more often in advanced stage (FIGO II and III) patients (51%) than stage I patients (24%) (p<0.01), but salpingitis, present in 60% of these patients, was not stage-dependent (p>0.05). Chronic salpingitis was identified in 66% of women with endometriosis, which was significantly more frequent than those with normal ovaries (27%) (p<0.001). In conclusion, fallopian tube abnormalities may be related to both the high frequency of infertility and the noninvasive peritoneal implants in women with APSTs/MPSCs. Whether the fallopian tubes with salpingoliths are the source of the peritoneal "implants," the recipient of implants, or are independent is unknown. In addition, the high frequency of salpingitis in women with endometriosis may be related to the mechanism of endometriosis-associated infertility.

Unexpected gynecologic neoplasms in patients with proven or suspected BRCA-1 or -2 mutations: implications for gross examination, cytology, and clinical follow-up

Identification of inheritable mutations associated with the development of malignancy has led to prophylactic surgeries to remove tissues at risk. We report seven unrelated patients with family histories of breast and/or ovarian cancer, five of whom underwent prophylactic salpingo-oophorectomy with hysterectomy. Four had proven BRCA-1 or -2 mutations. Malignant cells were found unexpectedly in the peritoneal washings of two patients, leading to the discovery of early-stage fallopian tube carcinoma. After changing the sampling technique at our institution, two more cases of unexpected fallopian tube carcinoma in situ were discovered. Another patient had a significant family history and underwent hysterectomy for uterine fibroids, leading to the discovery of fallopian tube carcinoma. Another patient with BRCA-1 mutation had unexpected widespread primary peritoneal papillary serous adenocarcinoma. The final patient had a borderline malignant clear cell adenofibroma. These cases underscore the importance of peritoneal cytology and thorough sampling in the management of patients undergoing hysterectomy with a family history of breast/ovarian cancer and/or known BRCA-1/BRCA-2 mutations. As prophylactic surgeries are becoming more common secondary to advances in molecular diagnostics, pathologists need to be aware that surgical specimens from these patients may require more rigorous examination to uncover early neoplastic changes.

Clues to the pathogenesis of fallopian tube carcinoma: a morphological and immunohistochemical case control study

The purpose of this study was to identify histopathological fallopian tube changes that might be related to the development of fallopian tube carcinoma (FTCA). Each of 14 unilateral cases of the latter was matched with 2 controls for age, hospital, and year of diagnosis. The uninvolved fallopian tube from patients with FTCA, all of which were of serous type, was compared to fallopian tubes from the same side in 28 matched controls. The features evaluated included plical bridging, trapped gland-like structures, inflammation, epithelial stratification, tufting, nuclear atypia, plical atrophy, luminal dilatation, and presence or absence of in situ carcinoma. The significant changes (p < 0.05) in the contralateral tubes of patients with FTCA were luminal dilatation (p = 0.0004), plical atrophy (p = 0.0015), and chronic inflammation (p = 0.0089). FTCA may therefore develop in tubes demonstrating histologic features of chronic healed salpingitis, findings that reflect bilateral tubal disease which apparently antedates the development of the FTCA. p53 stains were strongly positive in 9 of 14 FTCAs and in 5 of 6 foci of in situ carcinoma found in the tubes with unilateral FTCA. No p53 staining was found in any of the contralateral tubes. Serous FTCAs may be etiologically related to antecedent bilateral healed chronic salpingitis and arise from in situ carcinoma in a background of atrophy.