Clinically occult primary fallopian tube carcinoma presenting as a malignant pleural effusion

Our plain-English summary of Clinically occult primary fallopian tube carcinoma presenting as a malignant pleural effusion, by R. Hiensch, K. Meinhof, A. Leytin, et al (The Clinical Respiratory Journal, 2017).

The study

• Authors: R. Hiensch, K. Meinhof, A. Leytin, G. Hagopian, E. Szemraj, O. Epelbaum
• Journal: The Clinical Respiratory Journal
• Published: 2017;11(6):1086-1090
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

We report the first known case of malignant pleural effusion (MPE) as the sole presenting feature of clinically occult primary fallopian tube carcinoma (PFTC). A 57-year-old healthy woman was admitted with dyspnea. Evaluation demonstrated a right pleural effusion, fluid of which was malignant. The immunohistochemical profile, including negative calretinin, favored metastatic adenocarcinoma over mesothelioma but could not identify the primary tumour site. Pleural biopsy was not pursued as it would not have helped localize the primary. Chest, abdomen and pelvic computed tomography (CT) demonstrated only borderline lymphadenopathy in the left para-aortic lymph node chain that was hypermetabolic on positron emission tomography. Ultrasound and CT showed normal adnexal anatomy. These findings, coupled with an elevated serum CA-125, prompted empiric neoadjuvant chemotherapy targeting epithelial ovarian carcinoma (EOC) followed by surgery, which revealed a tiny left PFTC with negative peritoneal washings. Sampled left para-aortic lymph nodes were positive. The pleural effusion resolved after chemotherapy. Malignant pleural disease without peritoneal involvement is more characteristic of PFTC than of EOC, in which MPE is common but almost always accompanies peritoneal carcinomatosis. The extensive lymphatic supply of the fallopian tube promotes distant metastasis of small, seemingly localized tumours. This case is a reminder that the clinician should not be dissuaded from considering carcinoma of Müllerian origin, especially PFTC, as the cause of a MPE even in the face of normal gynecologic imaging. Appropriately broad immunohistochemical staining and careful attention to even minimal lymphadenopathy can be invaluable in pinpointing the primary tumour site in such patients.

© 2015 John Wiley & Sons Ltd.

In plain English

This article is a case report about one patient. She was a 57-year-old woman with high blood pressure who had two weeks of shortness of breath on exertion. Fluid around her right lung (a pleural effusion) contained adenocarcinoma cells. Staining tests, including a negative result for calretinin, did not point to where the cancer had started. Her pelvic examination and ultrasound were normal. CT scanning found no mass but showed enlarged lymph nodes beside the aorta, up to 1.5 cm. A blood marker, CA-125, was raised. She received three rounds of carboplatin and docetaxel chemotherapy and then surgery. The surgery found a mass of about 1 cm at the end of the left fallopian tube, a serous adenocarcinoma, and cancer in the lymph nodes. The omentum and abdominal washings were negative. The effusion had cleared on an X-ray one month after surgery. Cancer returned in lymph nodes six months after surgery. The authors concluded that fallopian tube cancer should be considered even when gynecologic imaging is normal. Asbestos is not discussed.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case report of a single patient
• Who was studied: One 57-year-old woman with a history of hypertension who had immigrated to the United States from Poland 3 years earlier. The authors are at Elmhurst Hospital Center and Icahn School of Medicine at Mount Sinai, New York. No dates of care are given.
• Exposure: No asbestos or other environmental exposure is reported. The article does not discuss asbestos. The patient's occupation was childcare.
• Main results:
  • Pleural fluid cytology was positive for moderately well-differentiated adenocarcinoma.
  • Immunohistochemical stains, with calretinin negative among them, were judged not specific for any particular primary site.
  • CT of the chest, abdomen and pelvis showed no discrete mass, but showed left para-aortic lymphadenopathy measuring up to 1.5 cm.
  • Pelvic examination and transvaginal ultrasound were normal.
  • Serum CA-125 was elevated. The article prints the value as 433 mg/dL, with normal under 35.
  • After three rounds of carboplatin and docetaxel, surgery found matted left para-aortic lymph nodes positive for adenocarcinoma and an approximately 1 cm mass at the distal end of the left fallopian tube.
  • The omentum and peritoneal washings were negative for malignancy. The patient was staged T3N1M1, FIGO stage IVA.
  • A chest X-ray 1 month after surgery showed the malignant pleural effusion had resolved. A PET scan 6 months after surgery showed recurrence in pelvic and retroperitoneal lymph nodes.
• The authors' conclusion: The authors concluded that, in a malignant pleural effusion of adenocarcinoma type with no clear primary site, clinicians should watch for seemingly isolated lymphadenopathy that could signal an occult primary fallopian tube carcinoma, even when adnexal imaging is normal.
• Limitations the authors state:
  • The authors note that the para-aortic lymph nodes were not sampled before surgery, and that sampling them could have established the primary site earlier.
  • The authors note that PAX8 staining was not performed. In their view it would likely have identified the primary site early.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Carcinoma, Pleural Effusion, Dyspnea, Calretinin, Adenocarcinoma, Mesothelioma, Pleural Biopsy, Lymphadenopathy.

Related studies

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• Development patterns in "adenomatoid lesions" of the fallopian tube — C.J. Pauerstein, J.D. Woodruff, et al. (1968)
• Fallopian Tube Neoplasia and Mimics — D.L. Kolin, M.R. Nucci (2019)
• Correlation of asbestos fiber burdens in fallopian tubes and ovarian tissue — D.S. Heller, R.E. Gordon, et al. (1999)
• Pleural small cell carcinoma with massive pleural effusion: A case report — J.G. Jang, M.H. Jang, et al. (2019)
• Wilms tumor 1/cytokeratin dual-color immunostaining reveals distinctive staining patterns in metastatic melanoma, metastatic carcinoma, and mesothelial cells in pleural fluids: an effective first-line test for the workup of malignant effusions — J.R. Conner, E.S. Cibas, et al. (2014)

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