SALPINGITIS ISTHMICA NODOSA, CARCINOMA
The nodular enlargement of the innermost isthmic portion of the tube, called salpingitis isthmica nodosa, once was the subject of lively discussion among gynecologists and pathologists with regard to its origin or pathogenesis. It consists of glandular ramified projections of the mucosa into the thickened tubal wall. Most authors assume that nodular isthmic salpingitis is of inflammatory origin. However, it may be, in some or even in the majority of cases, the result of a noninflammatory endosalpingosis, a condition closely related in its nature to uterine adenomyosis or endometriosis. (Approximately two-thirds of women with adenomyosis have coexistent pelvic pathology, including salpingitis isthmica nodosa.) Some studies indicate that salpingitis isthmica nodosa can be documented histologically in more than 50% of patients with ectopic pregnancies. The diagnosis is best made radiographically at hystero-salpingography, where the characteristic finding consists of multiple nodular diverticular spaces in close approximation to the true tubal lumen. Visualization of nodular thickening of the tubes on laparoscopy also suggests the diagnosis.
Neoplasms of the uterine tubes are much rarer than those of the ovaries or
the uterus. They may be epithe- lial in nature such as papillomas, adenomas, carcinomas,
and chorioepitheliomas, or they may be mesenchymal tumors such as fibromas, myomas,
lipomas, chondromas, osteomas, and angiomas. Mixed tumors may, in rare cases, also
arise from the tubal walls. Endosalpingosis occupies an intermediary position between
inflammatory and neoplastic diseases.
Foci of endometrial tissue are commonly found in the endosalpinx and are particularly
frequent in the interstitial portion of the tube. In the interstitial and the adjoining
isthmic region, they may produce a nodular thickening of the tube similar to that
caused by chronic inflammatory irritation. In both cases, ramified glandular projections
are the most conspicuous constituents of the nodules. However, the presence of cytogenic
stroma characterizes the endometriotic nodules, whereas the absence of cytogenic
stroma and the presence of scar tissue and round cell infiltration indicate the inflammatory
origin of nodular isthmic salpingitis. The most important tubal neoplasms are carcinomas,
which may originate in the tubal mucosa or may be secondary to a primary carcinoma
of the ovary, the uterus, or the gastrointestinal tract. In primary tubal
carcinoma, the tube forms an elastic or firm, sausage- or pear-shaped tumor, which
is usually adherent to its surroundings and filled with papillomatous, cauliflower-like
or villous, friable masses of grayish-red or grayish-white neoplastic tissue. The
tumor secretes a clear or turbid fluid, which may occasionally escape from the
uterus, causing a rather conspicuous watery discharge. The cells of the tumor are
arranged in single or multiple layers, and mitoses are frequent. Squamous cell
carcinoma has, in rare cases, also been found in the tubes.
Extension of the carcinoma takes place via the lymph or bloodstream, along
the peritoneal surface, or by contiguity. The ovaries and the uterus are frequently
involved in the disease, and invasion of the iliac and lumbar lymph nodes is common.
The symptoms are minimal in the initial stage of the disease. Burning or darting
pains in the lower abdomen, hemorrhages, and clear or turbid, serous or serosanguineous
discharge may be present. Approximately 50% of patients with fallopian tube cancer
present with vaginal bleeding. Ascites and progressive emaciation occur only in
very advanced stages. Abnormal cervical cytology is occasionally present, with a
reported range of 10% to 40%.
Owing to a lack of frank symptoms and signs, the diagnosis is difficult and
in most cases is only tentative. Because the disease is rarely recognized at an
early stage, the prognosis is poor, and permanent cures by operation and radiation
are rare exceptions.
Retrospective studies have shown that 17% of women with tubal carcinoma harbor germline BRCA mutations. This suggests that the BRCA1/BRCA2 mutations have a role in fallopian tube tumorigenesis.
