Author Information
Manjrekar V*, Parulekar SV**, Fernandes G***, Shaikh S****.
(* Third Year Resident, *** Professor and Head, Department of Pathology, *** Associate Professor, **** Second Year Resident, Department of Pathology, Seth G S Medical College & KEM Hospital, Mumbai, India.)
Abstract
Metaplastic papillary tumor of the fallopian tube is an extremely rare condition. It is a benign condition, without any reports of recurrence or malignancy. But its nuclear atypia and papillary architecture suggest a similarity to serous borderline ovarian tumors. There are only eleven cases reported in the world literature. We report the twelfth case.
Introduction
Metaplastic papillary tumor (MPT) of the fallopian tube is an extremely rare condition. Though its behavior is as of a benign condition in that it does not show recurrence or metastases, it has some features resembling serous borderline ovarian tumors. There are eleven such cases reported so far. We report the twelfth case here, and discuss its etiology and management.
Case Report
Figure 1. Intraoperative findings: Uterus (white arrow), right ovarian cyst (yellow arrow), right fallopian tube (hollow arrows).
Figure 2. Scanner view of cross section of fallopian tube showing an intraluminal polypoidal mass composed of glands embedded in stroma. Also seen is a focus of mucinous metaplasia. (H&E x 50)
Figure 3. High power view of intraluminal fallopian tubal mass highlighting the glandular architecture. (H&E x 100)
Figure 4. High power view showing glands lined by columnar epithelial lining. No cellular atypia seen. (H&E x 400)
Figure 5. High power magnification of the focus showing mucinous metaplasia. (H&E x 100)
Figure 6. Classic chorionic villi & blood clots also seen in the lumen of the fallopian tube. (H&E x 100)
Discussion
References
Manjrekar V, Parulekar SV, Fernandes G, Shaikh S. Metaplastic Papillary Tumor Of The Fallopian Tube. JPGO 2016. Volume 3 Number 6. Available from: http://www.jpgo.org/2016/07/metaplastic-papillary-tumor-of.html
Manjrekar V*, Parulekar SV**, Fernandes G***, Shaikh S****.
(* Third Year Resident, *** Professor and Head, Department of Pathology, *** Associate Professor, **** Second Year Resident, Department of Pathology, Seth G S Medical College & KEM Hospital, Mumbai, India.)
Abstract
Metaplastic papillary tumor of the fallopian tube is an extremely rare condition. It is a benign condition, without any reports of recurrence or malignancy. But its nuclear atypia and papillary architecture suggest a similarity to serous borderline ovarian tumors. There are only eleven cases reported in the world literature. We report the twelfth case.
Introduction
Metaplastic papillary tumor (MPT) of the fallopian tube is an extremely rare condition. Though its behavior is as of a benign condition in that it does not show recurrence or metastases, it has some features resembling serous borderline ovarian tumors. There are eleven such cases reported so far. We report the twelfth case here, and discuss its etiology and management.
Case Report
A 26 year old primigravida was referred to obstetric emergency room from a private hospital in Mumbai with ultrasonography (USG) suggestive of an unruptured right tubal ectopic gestation. Patient was receiving treatment for primary infertility since 3 months, currently on follicular monitoring and planned relations. She was asymptomatic having no complaints of abdominal pain, bleeding per vaginum and syncope. On examination her vital parameters were in normal limits, systemic examination was unremarkable. The abdomen was soft and nontender. On per speculum examination cervix and vagina were healthy. Vaginal examination revealed a 6 weeks size retroverted uterus with right forniceal tenderness and a 2 cm x 1 cm smooth mass felt through the right fornix with no cervical motion tenderness. An USG done at KEMH showed 1.8 x 2.0 cm hypoechoeic structure suggestive of Right adnexal ectopic gestation with a 3x 2 cm right simple ovarian cyst with no free fluid in the pelvis. Her routine blood investigations and serum biochemistry were within normal range. Serum β-HCG was 5296 mIU/ml and 5319 mIU/ml after 48 h. A plan for conservative line of management was made and Methotrexate 50mg/m2 was given intramuscularly. The patient was monitored and serial abdominal girth measurements were done. Patient complained of acute abdominal pain 6 h post methotrexate administration and USG done at that time revealed moderate hemoperitoneum, suggesting rupture of the ectopic gestation. An emergency exploratory laparotomy was performed under general anesthesia. There was a 5 cm x 4 cm right adnexal mass having a smooth surface. It was made from the right fallopian tube, fimbria and ovary. The uterus was of about 6 weeks' size. Left sided fallopian tube and ovary visualized. Left fallopian tube was short, about 4 cm in length. Left ovary was normal. Moderate hemoperitoneum was noted, the source of bleeding being the posterior surface of the right adnexal mass. The adnexal mass was incised over its superior surface to reveal products of conception, right ovary and right fimbria within it. Right fallopian tube was delineated in the wall of the mass and salpingectomy was performed. The ovarian cyst was enucleated and right ovary was reconstructed. Peritoneal wash was given. Haemostasis was confirmed.Post operatively the patient's condition was stable and course was uneventful. She made an uneventful recovery.
Microscopy showed bits of fallopian tubal structure with blood clot in the lumina. Plenty of chorionic villi were seen embedded in the blood clot. One of the fallopian tubal bits showed an intraluminal polypoidal mass composed of glands and papillae embedded in loose stroma. The glands and papillae were lined by columnar non ciliated cells with eosinophilic cytoplasm and round nuclei with bland nuclear features. Focal pseudostratification of the columnar epithelium was seen. A focus of mucinous metaplasia was also seen. No nuclear atypia, mitotic activity or necrosis was seen. A diagnosis of Papillary Metaplastic Tumor of the fallopian tube was made.
Microscopy showed bits of fallopian tubal structure with blood clot in the lumina. Plenty of chorionic villi were seen embedded in the blood clot. One of the fallopian tubal bits showed an intraluminal polypoidal mass composed of glands and papillae embedded in loose stroma. The glands and papillae were lined by columnar non ciliated cells with eosinophilic cytoplasm and round nuclei with bland nuclear features. Focal pseudostratification of the columnar epithelium was seen. A focus of mucinous metaplasia was also seen. No nuclear atypia, mitotic activity or necrosis was seen. A diagnosis of Papillary Metaplastic Tumor of the fallopian tube was made.
Figure 1. Intraoperative findings: Uterus (white arrow), right ovarian cyst (yellow arrow), right fallopian tube (hollow arrows).
Figure 2. Scanner view of cross section of fallopian tube showing an intraluminal polypoidal mass composed of glands embedded in stroma. Also seen is a focus of mucinous metaplasia. (H&E x 50)
Figure 3. High power view of intraluminal fallopian tubal mass highlighting the glandular architecture. (H&E x 100)
Figure 4. High power view showing glands lined by columnar epithelial lining. No cellular atypia seen. (H&E x 400)
Figure 5. High power magnification of the focus showing mucinous metaplasia. (H&E x 100)
Figure 6. Classic chorionic villi & blood clots also seen in the lumen of the fallopian tube. (H&E x 100)
Discussion
MPT may be seen as a small lesion in the lumen of the tube postpartum or with a tubal ectopic gestation. Histopathologically it shows papillae lined by stratified epithelium, with abundant, dense, eosinophilic cytoplasm, and nuclei which are bland or with mild atypia. The origin of MPT is debated. In the 1980s, a group led by Saffos et al first described MPT of the fallopian tube incidentally found in four cases of puerperal tubal ligation.[1] They also noticed a close association with pregnancy as well as a significant similarity with serous borderline ovarian tumors. Pang reported such a tumor in a 52-year-old patient, along with bilateral partially calcified chorionic villi [2] This raised the question whether the tumor was newly developed or was present in quiescent for years. Most authors believe it to be a low-grade borderline tumor, but a few believe that it is a reactive condition.[2,3,4,5,6] The immunoprofiles of MPT are positive for cytokeratin and epithelian membrane antigen, and negative for CEA.[5] Salazar et al. also reported positivity for cyclin D1, and hormone receptors.[7] D'Adda et al presented molecular data on MPT showing that it resembles atypical proliferative serous tumors, which are a subtype of borderline ovarian tumors.[8] Some workers have suggested that MPT might represent Arias-Stella reaction.[1,4] They believe it to be due to simultaneous action of estrogen causing proliferative and ciliogenic activity and progesterone causing secretory activity. Changes like variations in proportion and height of cells, stratification, papillary tuft formation, hyperplasia and metaplasia are known to occur in the epithelium of the fallopian tube in conditions like salpingitis, endometrial carcinoma, exposure to endo- or exogenous estrogen, or even without any cause.[1,3,4,5,6,9] Salazar et al. Suggest that since neoplastic condition has not been irrefutably demonstrated in MPT, it should be called fallopian metaplastic papillary polyp instead of MPT.[7]
The differential diagnoses of MPT are papillary tubal hyperplasia, papilloma, serous borderline tumor of the fallopian tube or spread of such a tumor from an ovarian tumor. A papillary tubal hyperplasia differs from MPT in that it shows papillary tufting and small round clusters of bland epithelium often with psammona bodies.[10] A papilloma differs from MPT in that it maintains normal endosalpingeal cell types. A serous borderline tumor is very rare. It shows complex papillary formation lined by hobnail, ciliated, and mesothelium-like cells in stratification. Mitotic activity is uncommon, but focal nuclear atypia is seen.[6,11,12] In our case, an association with tubal ectopic pregnancy was seen. Curiously, the patient also showed features of old pelvic inflammatory disease, which had resulted in the formation of a tuboovarian mass. The fimbriae had been free, and permitted entry of ovum into the fallopian tube, which resulted in the ectopic pregnancy. It cannot be stated with certainty if the MPT was associated with the tubal ectopic gestation, or was present from the time of the chronic salpingitis.
Conclusion
MPT is a benign condition and its prognosis is good. Hence drastic surgical excisions should not be performed. Since it is a very rare condition, there are not enough cases to study and draw conclusions from. Hence all new cases should be published, so that molecular studies can be performed to determine the pathogenesis of the consition, and long term follow-up can be done to study the behavior of the condition.
References
- Saffos RO, Rhatigan RM, Scully RE. Metaplastic papillary tumor of the Fallopian tube: a distinctive lesion of pregnancy. Am J Clin Pathol. 1980;74:232–6.
- Pang LC. Hydrosalpinx due to asymptomatic bilateral tubal pregnancies associated with metaplastic papillary tumor of the Fallopian tube. South Med J. 1999;92:725–7.
- Starr AJ, Ruffolo EH, Shenoy BV, Marston BR. Primary carcinoma of the Fallopian tube: a surprise finding in a postpartum tubal ligation. Am J Obstet Gynecol. 1978;132:344–5.
- Keeney GL, Thrasher TV. Metaplastic papillary tumor of the Fallopian tube: a case report with ultrastructure. Int J Gynecol Pathol. 1988;7:86–92.
- Bartnik J, Powell WS, Moriber-Katz S, Amenta PS. Metaplastic papillary tumor of the Fallopian tube. Case report, immunohistochemical features, and review of the literature. Arch Pathol Lab Med.1989;113:545–7.
- Vang R, Wheeler JE. Diseases of the Fallopian tube and paratubal region. In: Kurman RJ, Ellenson LH, Ronnett BM, editors. Blaustein´s pathology of the female genital tract. 6th ed. New York: Springer; 2011. pp. 529–78.
- Salazar MF, Moscoso IE, Vázquez LT, García NLL, Abril PAE. Fallopian Metaplastic Papillary Tumour: An Atypical Transdifferentiation of the Tubal Epithelium? Journal ListJ Pathol Transl Medv.2015 Mar 49(2); PMC4367111. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4367111/
- D'Adda T, Pizzi S, Bottarelli L, Azzoni C, Manni S, Giordano G. Metaplastic papillary tumor of the salpinx: report of a case using microsatellite analysis. Int J Gynecol Pathol. 2011 Nov;30(6):532-5.
- Solomon AC, Chen PJ, LiVolsi VA. Pathologic quiz case: an incidental finding in the Fallopian tube. Fallopian tube, left, tubal ligation: metaplastic papillary tumor of Fallopian tube. Arch Pathol Lab Med. 2003;127:e363–4.
- Feeley L, Quinn CM. Columnar cell lesions of the breast. Histopathology. 2008;52:11–9.
- Walker RA, Hanby A, Pinder SE, Thomas J, Ellis IO, National Coordinating Committee for Breast Pathology Research Subgroup Current issues in diagnostic breast pathology. J Clin Pathol. 2012;65:771–85.
- DeLellis RA, Shin SJ, Treaba DO. Immunohistology of endocrine tumors. In: Dabbs DJ, editor. Diagnostic Immunohistochemistry. Theranostic and Genomic Applications. 3rd ed. Philadelphia: Saunders Elsevier; 2010. pp. 291–339.
Manjrekar V, Parulekar SV, Fernandes G, Shaikh S. Metaplastic Papillary Tumor Of The Fallopian Tube. JPGO 2016. Volume 3 Number 6. Available from: http://www.jpgo.org/2016/07/metaplastic-papillary-tumor-of.html