Recurrent Serous Carcinoma of the Right Fallopian Tube Involving the Dome of Cecum and Rectum

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Introduction. Ovarian cancer (OC), fallopian tube and primary peritoneal cancer are a group of malignant tumors originating from the epithelium of the corresponding organs. Cancer of the fallopian tube (RMT) is a rare pathology that occurs in approximately 0.11–1.18% of cases among other oncogynecological diseases [1, 2]. According to a presentation made by Doran at a meeting of the Manchester Pathological Society in 1896, RMT was first described by Ranmond in 1847. This observation was recorded in an unpublished manuscript held in the library of the Royal College of Surgeons in London [3]. In 1888 E.G. Ortmann was the first to publish his own data concerning the registered observation of primary carcinoma of the fallopian tube [4]. Since then, more than 2000 cases have been reported in the literature [5].
It is believed that RMT is diagnosed 150 times less often than ovarian cancer [3]. In 10% of patients with ovarian cancer, BMT, the development of the disease is associated with the presence of known hereditary syndromes. The most common is the syndrome of inherited breast and ovarian cancer associated with mutations in the BRCA genes [6].
In the structure of cancer among the female population of Russia, RMT ranks 9th, which corresponded to 4.2% in 2018. The "rough" incidence rate of RMT in Russia in 2018 was 18.19 per 100 thousand female population, which in absolute terms, there were 14,318 new cases. The average age of women at the time of diagnosis is 59.3 years. The age-standardized incidence rate of RMT and OC was 11.14 cases per 100,000 female population. The increase in the incidence rate of OC over the previous 10 years (since 2008) was 4.66% [7].
The rarity of the pathology makes it difficult to verify and standardize the tactics of treating tubal carcinoma. Preoperative diagnosis of RMT is extremely poorly informative (only 10%) [3].
RMT is often preoperatively misdiagnosed as ovarian cancer. Accurate diagnosis and differentiation of BMT from lesions that extend from the ipsilateral ovary directly or from the contralateral ovary via the transcavitary route are important for monitoring morbidity trends, for better prognostic characteristics, and possibly for improved management. The criteria for establishing the diagnosis of primary BCI were first proposed by C.Y. Hu et al. in 1950 [8], later modified by A. Sedlis in 1978 [9]. RMT is diagnosed if: the main tumor is in the fallopian tube and arises from the endosalpinx; the histological picture reproduces the epithelium of the mucous membrane of the fallopian tubes; a transition from benign to malignant tubal epithelium must be demonstrated, and the ovaries and endometrium are either normal or have significantly less tumor volume than the tubal volume.
The recent increase in the number of published observations of BMT is explained not only by oncological alertness, but also by an increase in the level of knowledge of symptomatology, the expansion of diagnostic methods and their capabilities, as well as the introduction of immunohistochemical research methods [10]. Therefore, the study of the characteristics of rare tumors of the female reproductive system is relevant for expanding the clinical experience of a surgeon and doctor of any specialty.
Clinical observation.
In July 2015, at the Department of Liver and Pancreas Surgery, N.N. A.V. Vishnevsky, a 65-year-old patient came to complain of diarrhea after 15 minutes. after meals, up to 5-6 times a day, frequent urination mixed with mucus, discharge of clear fluid from the vagina.
Anamnesis. Extirpation of the uterus with appendages, resection of the greater omentum 12/01/2014 (Vladimir Regional Oncology Center). According to the results of histological examination: poorly differentiated adenocarcinoma of the right fallopian tube T4N1M0.
Colonoscopy on an outpatient basis (06/20/2015): tumor of the rectosigmoid part of the colon (by 20-22 cm), no changes were found in the proximal parts of the intestine. According to the results of histological examination: poorly differentiated adenocarcinoma of the colon.
For further examination and surgical treatment, the patient was referred to the N.N. A.V. Vishnevsky.
Multispiral computed tomography of the abdominal and pelvic organs.
No fluid was detected in the pleural cavities and abdominal cavity. The liver is not enlarged in size (20x12x14 cm), the contours of the liver are clear. The average indicators of the density of the liver parenchyma are 58 units. H, the vascular pattern is differentiated. The intrahepatic ducts are not dilated. The common bile duct is not dilated, it can be traced to the level of the large duodenal papilla. The gallbladder was removed. There is no liquid in the bubble bed.
The pancreas is not enlarged: head - 32 mm, body - 16 mm, tail - 19 mm. The GPP is not expanded. When contrasting, the density of the parenchyma increases evenly. Parapancreatic fiber is not changed. Parapancreatic lymph nodes are not enlarged. The portal vein is 12 mm in diameter, the left branch is 10 mm, the right branch is 8 mm, the inferior vena cava (D = 30 mm) and hepatic veins are usually contrasted. The splenic vein is 7 mm in diameter. The right hepatic artery departs from the superior mesenteric artery.
The spleen is not enlarged, it is determined by the size of 9x3.8x7 cm. The average densitometric parameters of the spleen are 43 units. N.
The position, shape and size of the adrenal glands are not changed. Right adrenal gland: lateral peduncle - 3 mm, medial - 2 mm, body - 4 mm. Left adrenal gland: medial pedicle - 2 mm, lateral - 3 mm, body - 4 mm. Volumetric formations in the projection of the adrenal glands are not determined.
The kidneys are usually located. The shape and size of the kidneys are not changed, the density indicators are within normal limits. When contrasting, the density is evenly increased, the crustal layer can be traced throughout. The pelvis is not enlarged, the excretory function is timely on both sides. No calculi were found. The perirenal cell is not changed.
In the small pelvis, in the projection of the sigmoid colon with partial extension to the river-sigmoid junction, a large multinodular formation, 13x8 cm in size, is determined. The structure of the formation contains liquid cavities with the presence of air (Fig. 1). When contrasting, the formation increases the density unevenly. A small amount of liquid is determined along the formation contour. The lower pole of the formation is at the level of the bladder, the upper pole is at the level of the upper sacral vertebrae. Fiber around the formation of tyazhist with the presence of enlarged up to 19 mm lymph nodes. The subiliac vessels are intact. The uterus is removed, the ovaries are not defined. The bladder collapsed, the contents are homogeneous. The ureters are intact.
No pathological foci on the part of the bones of the skeleton were revealed.

Figure: 1. MSCT image of the formation of the sigmoid colon (indicated by labels). A small amount of fluid in the pelvis.

Performed surgical intervention (07.16.2015): Combined anterior rectal resection with resection of the sigmoid colon, right-sided hemicolectomy, resection of the posterior vaginal wall, imposition of ileotransverse anastomosis, end sigmostomy.
The ascending, transverse and descending colon are not changed. There is no big sal-nick. Uterus and uterine appendages are absent (history: extirpation of the uterus with appendages). The parietal peritoneum is clean, without signs of metastasis.
In the area of ​​the distal third of the sigmoid colon, the rectosigmoid junction, a tumor conglomerate is determined, which spreads and fills the aperture of the small pelvis, measuring 15x9 cm. The tumor conglomerate is tightly attached to the anterior wall of the bladder. The medial wall of the cecum is involved in the tumor conglomerate for up to 8 cm, which causes the formation of an internal sigmolene-intestinal fistula, probably due to the disintegration of the tumor.
The iliac vessels of the left and left ureter, the tumor conglomerate does not grow, below the level of the promontorium from behind we separate from the sacral fascia.
Ligation and transection of the right colonic and ilio-colonic arteries were performed at the orifice. The blind, ascending and right third of the transverse colon was mobilized and skeletonized (in the amount of right-sided hemicolectomy) with the preservation of the middle colonic vessels. The ileum was transected 15 cm from the ileocecal angle, and the transverse colon was transected at the border of its middle and right thirds using the GIA-50 apparatus. The right ureter was visualized up to the tumor conglomerate, to which the cecum was tightly fixed.
The inferior mesenteric artery at the ostium was tied and transected. The inner layer of the parietal peritoneum of the mesentery was dissected and the sigmoid colon was skeletonized. On the clamps, the mesentery of the sigmoid colon was transected and tied with ligation of the sigmoid arteries. In an acute way, the tumor conglomerate is separated from top to bottom and back from the sacral fascia. Mobilization was continued in the distal direction with rectal skeletonization. Produced mobilization of the upper and lower ampullar part of the rectum. It was revealed that the tumor infiltrates the anterior and right walls of the upper ampullar part of the rectum. When mobilizing a tumor conglomerate, a part of the posterior wall of the vagina, up to 4x3 cm in size, which is germinated by the tumor, was excised from the front.
Mobilization of the rectum was supplemented by transection and ligation of its lateral ligaments and excision of the mesorectum to the level of the intended intersection.
The rectal stump was sutured in an open manner with a two-row continuous suture (1 row - through all layers, 2 row - with a seromuscular suture) (vicryl 3/0). The defect in the posterior wall of the vagina was sutured with a two-row continuous suture (vicryl 3/0).
A number of mechanical sutures on the stump of the transverse colon were peritonized with a continuous suture (ty-crown 3/0). Formed ileotransverzoanastomosis "end-to-side" with a 2-row continuous suture (1st row - vicryl 3/0, 2nd row - ti-crown 3/0), the width of the anasto-mosaic is 2 cm.
The skin in the left iliac region (up to 3 cm in diameter) was excised with a rounded incision. The peritoneum was fixed to the skin along the perimeter of the incision with interrupted sutures (vicryl 3/0). The proximal end of the transected sigmoid colon is brought out into the wound. With the free ends of the superimposed threads, the sigmoid colon is fixed to the skin along the perimeter.
The duration of the operation was 320 minutes, blood loss was 350 ml. Anesthetic aid was unremarkable.
Histological examination. In the projection of the dome of the cecum and rectum, there is a morphological picture of the recurrence of high-grade serous carcinoma of the right fallopian tube in the form of a node, measuring 10x8 cm, involving the dome of the cecum and rectum (Fig. 2).

Figure: 2. Macrodrug. The removed third of the right transverse colon, the lower third of the sigmoid colon, the caecum, part of the posterior wall of the vagina (the arrow shows a tumor that grows into the sigmoid colon with partial extension to the recto-sigmoid junction, measuring 10x8 cm)

Taking into account the similar histological structure of the primary tumor (when revising the histological preparations of the primary tumor No. 30563/14 and histological specimens of the biopsy from the dome of the cecum No. 38066-68 / 15) (Fig. 3) and the tumor node in the projection of the dome of the cecum and rectum - a morphological picture of recurrent serous carcinoma of high grade of malignancy of the right fallopian tube (Fig. 4) in the form of a 10x8 cm node involving the dome of the cecum and rectum.

Figure: 3. Structures of high-grade serous carcinoma in the wall of the colon. Staining with hematoxylin and eosin. Magnification x100

Figure: 4. In the area of ​​the tumor node, a tumor of a solid structure of relatively monomorphic cells is presented. Staining with hematoxylin and eosin. Magnification x200.

Immunohistochemical study. Tumor cells show expression: Cytokeratin 7 (clone OV-TL 12/30, Cell Marque) - pronounced membrane-cytoplasmic; Wilms' Tumor (clone WT49, Leica Biosystems) - diffuse nuclear; Estrogen receptor (clone SP1, Cell Marque) - diffuse nuclear (Fig. 5); Ki67 (clone SP6, Cell Marque) - nuclear in 75% of tumor cells.
Tumor cells are negative for the Progesterone receptor (clone Y85, Cell Marque);
Synaptophysin (clone MRQ-40, Cell Marque); Chromogranin A (clone DAK-A3, DAKO); CD56 (clone 123C3.D5, Cell Marque); CD45 (clone 2B11 + PD7 / 26, DAKO).
Tumor cells show expression: Cytokeratin 7 (clone OV-TL 12/30, Cell Marque) - pronounced membrane-cytoplasmic (Fig. 6); Estrogen receptor (clone SP1, Cell Marque) - diffuse nuclear; Ki67 (clone SP6, Cell Marque) - nuclear in 75% of tumor cells.
Tumor cells are negative for Wilms' Tumor (clone WT49, Leica Biosystems); Progesterone receptor (clone Y85, Cell Marque); Synaptophysin (clone MRQ-40, Cell Marque); Chromogranin A (clone DAK-A3, DAKO); CD56 (clone 123C3.D5, Cell Marque); CD45 (clone 2B11 + PD7 / 26, DAKO).

Figure: 5. Immunohistochemical study. Nuclear Expression Estrogen
in tumor cells. Magnification x400.

 

Figure: 6. Immunohistochemical study. Cytoplasmic expression
CK7 in tumor cells. Magnification x200.

Conclusion. A similar histological structure and a similar immunophenotype for Cytokeratin 7 and Estrogen receptor of the primary tumor of the fallopian tube and tumors in the tissue in the projection of the dome of the cecum are most consistent with high-grade serous carcinoma.
The postoperative period was complicated by the formation of an incomplete colo-vaginal fistula.
The patient was discharged in satisfactory condition on the 14th day with a functioning drainage, the discharge rate was up to 50 ml / day.
At the place of residence, she received chemotherapy (carboplatin, paclitaxel) for 6 courses.
On September 6, 2016, the patient returned to the N.N. A.V. Vishnevsky with a colostomy in the left lateral region to perform a planned surgical intervention in the volume: reconstructive surgery to restore intestinal continuity with the elimination of the stoma, the formation of an anastomosis.
On September 7, 2016, the following operation was performed: Closure of the sigmoidostomy with hardware end-to-end sigmoidorectal anastomosis, uncoupling of adhesions, hernia repair with plasty with local tissues.
At control multispiral computed tomography of the abdominal organs (12/14/2016): Condition after hemicolectomy. No other changes in the organs of the abdominal cavity and small pelvis were found.
In the spring of 2018, the patient discovered a hernial protrusion in the area of ​​the postoperative scar in the mesogastric region, which gradually increased in size. 11/26/2018 applied to the N.M. A.V. Vishnevsky with a diagnosis of Median postoperative ventral hernia. Marginal necrosis of the postoperative wound.Multispiral computed tomography (08/09/2017). In the area of the postoperative scar, immediately below the navel, a hernial protrusion is determined, the width of the hernia orifice is up to 27 mm, the contents of the hernial sac are a loop of the small intestine (Fig. 7). Data for secondary damage to internal organs, relapse of the process were not obtained.

Figure: 7. MSCT image of a hernial protrusion in the area of ​​the postoperative scar, immediately below the navel (indicated by labels), the contents of the hernial sac - a loop of the small intestine

Surgical intervention was performed (11/28/2018): hernia repair, combined plastic surgery of the anterior abdominal wall. The patient was discharged in a satisfactory condition, without complications.
According to the patient, she refused chemotherapy, she was observed dynamically by the oncologist at the place of residence.
At the moment (February 2020), the period of observation of the patient is 56 months; no data for a relapse of the disease have been identified either clinically or according to multispiral computed tomography data.
Discussion. Both the histological and staging classifications of malignant tumors of the ovaries, fallopian tubes and peritoneum have recently changed. Discussion of the shortcomings of these classifications and their improvement created the prerequisites for a deeper understanding of the disease in accordance with the data on tumor biology obtained at the modern stage, which, of course, led to an improvement in the quality of treatment for such patients. The World Health Organization (WHO) sponsored the review and reclassification of ovarian, tubal, and peritoneal cancer pathology and published these updates in 2014 [11, 12]. In parallel, the International Federation of Gynecology and Obstetrics (FIGO) reviewed and updated the surgical staging system applied to all histotypes of ovarian, tubal and peritoneal cancers, also published in 2014 [13, 14].
Classification of tubal cancer
International histological classification (WHO classification, 4th edition, 2014) [12]:
1.serous carcinoma:
a) low grade of malignancy (low grade);
b) high grade of malignancy (high grade);
2. endometrioid carcinoma;
3. mucinous carcinoma;
4. clear cell carcinoma;
5. Brenner's malignant tumor;
6. serous-mucinous carcinoma;
7. undifferentiated carcinoma;
8.mixed epithelial carcinoma
Table
TNM (8th edition, 2017) and FIGO (7th edition, 2014) staging system for ovarian cancer [14]

TNM FIGO Staging
TX _ TX insufficient data to assess the primary tumor
T0 _ Primary tumor is not detected
T1 I Tumor confined to the ovaries
T1a IA The tumor is limited to one ovary, the capsule is intact, there are no tumor growths on the surface of the ovary, there are no malignant cells in the ascitic fluid or washings from the abdominal cavity
T1b IB The tumor is limited to two ovaries, their capsules are not damaged, non-tumor growths on the surface of the ovaries, there are no malignant cells in the ascitic fluid or washes from the abdominal cavity
T1c IC Tumor is confined to one or two ovaries and is associated with any of the following factors: capsule rupture, presence of tumor growths on the ovarian surface, presence of malignant cells in ascitic fluid or abdominal washings
T2 II The tumor affects one or two ovaries with spread to the pelvis
T2a IIA Invasion and / or metastasis to the uterus and / or one or both fallopian tubes, no malignant cells in ascitic fluid or abdominal washings
T2b IIB Spread to other pelvic tissues, no malignant cells in ascitic fluid or abdominal washings
T2c IIC Pelvic distribution with malignant cells in ascitic fluid or abdominal washings
T3 and / or
N1 III Tumor affects one or both ovaries with histologically confirmed intraperitoneal metastases outside the pelvis and / or metastases in regional lymph nodes
T3a IIIA Microscopic histologically confirmed intraperitoneal metastases outside the pelvis
T3b IIIB Macroscopic intraperitoneal metastases outside the pelvis ≤20 mm in largest dimension
T3 and / or
N1 IIIC Intraperitoneal metastases outside the pelvis> 20 mm in greatest dimension and / or metastases in regional lymph nodes (internal, external and common iliac, obturator, sacral, lumbar or inguinal)
M1 IV Distant metastases (excluding intraperitoneal metastases)
Note: Liver capsule metastases are classified as stage III, liver parenchymal metastases are classified as M1 / ​​stage IV. When cancer cells are found in the pleural fluid, the process is classified as M1 / ​​stage IV.

The small number of observations complicates the search for etiological and prognostic factors characteristic of fallopian tube cancer. The diagnosis of this tumor is difficult due to the low severity of the clinical picture, and the disease is rarely established at the preoperative stage. Despite the success of postoperative chemotherapy, according to the literature, relapse is detected in 70% of cases [10]. Early diagnosis, accuracy in the diagnosis, polychemotherapy, targeted therapy or hormone therapy and the response to its use, the introduction of cytoreductive operations, all these are the main indicators of survival and quality of life in patients with BMT.

Prognostically significant factors for a tumor are assumed to be the stage of the disease, its histological affiliation, as in this clinical case, the idea of ​​an erroneous stage of the disease (T3N1M1), according to the FIGO classification - there is no stage T4, and when revising the histological preparations of the primary tumor and the removed tumor node - serous carcinoma of a high degree of malignancy (high grade). According to the clinical guidelines for the treatment of RMT in relapses, the treatment method is the use of platinum preparations. A commonly used chemotherapy regimen for tubal carcinosarcomas is SAR, a combination of cyclophosphamide, doxorubicin, and cisplatin [15]. However, the method of choice of treatment for our patient was a radical operation, due to the recurrence of a locally advanced tumor, the absence of distant metastasis, the absence of carcinomatosis and ascites, and the absence of contraindications to surgery.
Of the 53 cases of fallopian tube carcinosarcomas described in the literature, 30 patients underwent hysterectomy and bilateral adnexectomy, in 4 cases - removal of uterine appendages from one or both sides and in 6 cases - removal of the greater omentum, external radiation therapy was performed in 17 patients [16]. In connection with the ability of the tumor to implantation, lymphogenous and hematogenous spread, the 5-year survival rates differ from 30 to 57% depending on the morphological structure [17].
According to the literature, attracted 1 case of successful treatment of a patient with stage IIIC (according to the FIGO classification) of mixed Mueller tumor of the right fallopian tube [18]. At the 1st stage, a 71-year-old patient underwent tumor resection, removal of the right uterine appendages and the greater omentum. Intraoperatively, multiple tumor nodes on the sigmoid colon, ranging in size from 3 to 7 cm, were revealed.Further, the patient underwent 3 courses of chemotherapy in the paclitaxel 175 mg / m2 + carboplatin AUC5 regimen every 21 days, after which a cytoreductive operation was performed in the volume of hysterectomy, left-sided adnexectomy, pelvic and para-aortic lymph node dissection. A partial effect was achieved - the size of tumor nodes on the sigmoid colon after chemotherapy decreased by 60% (from 7.5 to 3.0 cm). The patient is alive for 28 months. without signs of disease recurrence [18].
Conclusion. The presented clinical observation of a rare pathology - recurrence of high-grade serous carcinoma of the right fallopian tube, growing into the dome of the cecum and rectum, has no analogues in the literature, emphasizes the non-specificity of the clinical picture of the disease, the complexity of diagnosing RMT (cancer fallopian tube), as well as the choice of the method of treatment in favor of the surgical one in this patient, and ultimately the survival rate - 62 months
(5 years 2 months).

About the authors

A Iosifovna Yurcovskaya

FSBI NMITs Surgery named after A.V. Vishnevsky "Ministry of Health of Russia

Author for correspondence.
Email: ange.yurckovsckaya2017@yandex.ru
ORCID iD: 0000-0002-6823-9929

ординатор 2 абдоминального отделения НМИЦ хирургии им.А.В.Вишневского

Russian Federation, Moscow, B. Serpukhovskaya st., 27

Yulia Alex Stepanova

FSBI NMITs Surgery named after A.V. Vishnevsky "Ministry of Health of Russia

Email: stepanovaua@mail.ru
ORCID iD: 0000-0002-5793-5160

Doctor of Medical Sciences, Scientific Secretary

Russian Federation, Moscow, B. Serpukhovskaya st., 27

Dmitrii V Kalinin

FSBI NMITs Surgery named after A.V. Vishnevsky "Ministry of Health of Russia

Email: medicvichnya333@yandex.ru
ORCID iD: 0000-0001-6247-9481

Candidate of Medical Sciences, Head of the Pathology and Anatomy Department

Russian Federation, Moscow, st. Bolshaya Serpukhovskaya, 27

Ilia A Kozlov

FSBI NMITs Surgery named after A.V. Vishnevsky "Ministry of Health of Russia

Email: kozlov@ixv.ru
ORCID iD: 0000-0002-3563-4981

доктор медицинский наук, ведущий научный сотрудник

Russian Federation, Moscow, st. Bolshaya Serpukhovskaya, 27

References

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