Fallopian tubes

Connected to broad ligament by mesovarium (double fold of peritoneum), to uterine cornu by utero-ovarian ligament, to lateral pelvic sidewall by infundibulopelvic (suspensory) ligament

Extends from posterior superior uterine fundus laterally and anterior to ovary

Lymphatic drainage to para-aortic, internal iliac, external iliac, common iliac and inguinal nodes

Segments: intramural (within wall of uterus), isthmus (thick walled), ampulla (thin walled), infundibulum (trumpet shaped end lined by fimbriae, attaches to ovary)

Plica: delicate folds of mucosa on inner aspect of tube; contain ciliated columnar cells, secretory cells (non-ciliated) and intercalated (peg) cells which may be inactive secretory cells; plica merge with fimbriae

Epithelium secretes amylase, Archives 1982;106:17

Normally contains neutrophils at menstruation and post-partum (don’t call salpingitis)

Muscle usually has 2 smooth muscle layers, 3 in isthmus near cornua

Covered by surface epithelium (a modified mesothelium aka coelomic or germinal), closely related to mullerian duct lining epithelium

Stroma resembles fibroblasts, in whorled / storiform pattern, surrounded by dense reticulin network; positive for actin and desmin

Stroma also contains luteinized stromal cells, decidual cells, smooth muscle, fat, neuroendocrine cells, endometrial stroma-like cells

Intramuscular edema associated with postpartum period; intramuscular mast cells common, Archives 2002;126:951

Embryology

Germ cells arise from yolk sac at 4 weeks, migrate to urogenital ridge at 5-6 weeks, then mesothelium of urogenital ridge proliferates to form epithelium and stroma of gonad, incorporating the germ cells

At 6 weeks, lateral mullerian ducts (paramesonephric ducts) form from fusion of coelomic lining epithelium, proximal portion forms fallopian tubes, caudal portion fuses to form uterus, upper vagina

Urogenital sinus forms lower vagina and vestibule, fuses with mullerian ducts

Note: mucosa of uterus, tubes & ovaries is derived from coelomic epithelium

In male fetus, testes produce mullerian inhibitory substance, which causes regression of mullerian ducts and persistence of paired wolffian (mesonephric) ducts, which form epididymis and vas deferens

In female fetus (or male without functioning testis), mullerian structures persist and mesonephric duct regresses; vestiges may persist as epithelial inclusions; in cervix/vagina, are Gartner duct cysts

Development affected by clomiphene, tamoxifen and to a lesser extent DES, Hum Path 1987;18:1132, Hum Path 1982;13:190

Salpingitis

Acute salpingitis (see suppurative salpingitis below)

Bacterial infection common; may cause infertility

Causes: sexual transmission (Neisseria gonorrheae, Chlamydia, Mycoplasma) most common; also post instrumentation, post-IUD, post-pregnancy or abortion

N. gonorrhea isolation decreases with increasing episodes of salpingitis

Coliforms commonly recovered from tubo-ovarian abscesses

Gross: pyosalpinx (pus), hematosalpinx; enlarged, erythematous, edematous; may have fibrinous exudate; tubo-ovarian abscess common

Micro: marked neutrophilic infiltrate, congestion and edema; mucosal ulceration; reactive epithelial changes

DD: ecic pregnancy, hydrosalpinx (transudate, follows purulent salpingitis), menstruation / pregnancy (neutrophils common, but usually don’t invade muscularis, no necrosis, no ulceration, no chronic inflammatory infiltrate)

Chronic salpingitis

Gross: enlarged distorted tube adherent to ovary; may be associated with hydrosalpinx or pyosalpinx that transforms to a tubo-ovarian cyst

Micro: blunted, shortened, fibrotic plica contain chronic inflammatory cells; fused plica may produce a pseudoglandular pattern (chronic follicular salpingitis) that resembles malignancy

Cysticercosis

Case report of focally calcified larva in 50 year old woman, Hum Path 1982;13:665

Foreign body salpingitis

Causes: lubricant jelly, mineral oil, radiographic contrast media, starch, talc

Note: lipoid granulomas may occur with gonococcal or TB salpingitis

Gross: yellow or chocolate brown resembling endometriosis

Micro: foamy histiocytes (if due to lipid), foreign body giant cell reaction extending to serosa

Granulomatous salpingitis

Causes: Actinomyces, Crohn’s disease, endometriosis, Enterobius, foreign bodies (see above), giant cell arteritis, malakoplakia, Mycobacterium tuberculosis or bovis, post-diathermy, post-radiation, sarcoidosis, Schistosomiasis, xanthogranulomatous salpingitis

Actinomyces

Associated with intrauterine devices; bilateral in 50%; ovaries often involved

Gross: changes of acute and chronic salpingitis plus small yellow “sulfur granules” within luminal exudate; may have fistulous tract with bowel, bladder, skin

Micro: clusters of gram positive filamentous bacteria surrounded by a purulent exudate

Enterobius vermicularis

Aka pinworm

Often migrates from lower female genital tract

Gross: nodular thickening of tubal wall, tubercle-like nodules in peritoneum

Micro: worms / ova and necrotic debris are surrounded by granulomatous inflammation with eosinophils, giant cells, fibrous tissue, granulation tissue

Fungi

Rare; blastomycosis and coccidiomyosis most common in US

Peritoneal surfaces may have tubercle-like nodules

Often tubo-ovarian mass or abscess

Schistosomiasis

Common throughout world, usually S. haematobium; rare in US

Gross: fibrosis related scarring and nodularity

Micro: ova with granulomatous reaction

Tuberculous salpingitis

Usually bilateral; hematogenous spread

Associated with young infertile patients with endometrial involvement, rare in US

Micro: caseating granulomas within mucosa, extreme adenomatous proliferation may resemble carcinoma; chronic inflammation and fibrosis in muscularis; Schaumann bodies often present

DD: leprous salpingitis

Xanthogranulomatous salpingitis

Rare, <20 cases reported

Diffuse infiltration of mucosa by histiocytes

May represent hemorrhage in endometriotic foci; may have infectious etiology

May simultaneously affect ovary

Symptoms: lower abdominal or suprapubic pain, fever, menorrhagia, vaginal bleeding, with adnexal tenderness and pelvic mass

Micro: lipid-containing macrophages, lymphocytes, plasma cells, neutrophils; variable multinucleated giant cells

DD: malakoplakia (Michaelis-Gutmann bodies)

Reference: Archives 2001;125:260

Ligneous salpingitis

Ligneous: resembles wood or marble

Rare, may cause infertility

Associated with involvement of female genital tract and conjunctiva

Micro: amorphous hyaline eosinophilic material

Pelvic inflammatory disease

Generic term for pelvic inflammation centered on fallopian tubes

Pseudoxanthomatous salpingiosis

Localized deposition of lipofuscin-laden macrophages in lamina propria of fallopian tube

Associated with chronic endometriosis in 2 cases, Mod Path 1993;6:53

Suppurative salpingitis (see acute salpingitis above)

60% due to gonorrhea, also chlamydia (lymphoid follicles), peptostreptococci, peptococci, Bacteroides fragilis, case report of S. pneumoniae (Hum Path 1990;21:1288)

Benign or non-neoplastic conditions

Amyloidosis

Case report of beta 2 microglobulin amyloidosis in renal dialysis patient presenting as bilateral ovarian masses with involvement of fallopian tubes, AJSP 2002;26:130

Arias-Stella reaction

Present in 16% with ecic tubal pregnancy

Rarely associated with intrauterine pregnancy

Micro: large epithelioid cells with atypical nuclei; rarely clear cylasm

Decidual reaction

Common at time of cesarean section (with accompanying tubal ligation) or after hormonal therapy, Hum Path 1980;11(5 Suppl):583

Serosal decidua formation common finding (5.5%) after tubal ligation, AJSP 1987;11:526

Micro: small nodules of decidual cells covered by flattened or inflamed epithelium; affects stromal cells of lamina propria

Ecic tissue

Encapsulated adrenal cortical tissue in 23%

Case report of ecic pancreatic tissue

Gross: adrenal cortical tissue-small yellow nodules in infundibulopelvic ligament

Micro: all 3 layers of adrenal cortex, but no medullary cells

Ecic / tubal pregnancy

Aka eccyesis; due to chronic salpingitis that destroys the lining folds and traps the ovum

Also due to congenital abnormalities, functional tubal disturbances, salpingitis isthmica nodosa, endometriosis, small tumor

Often a history of infertility

Should sample intratubal blood clot generously to identify products of gestation

Note: use hCG, HPL or keratin stains to find trophoblastic elements if necessary

Note: death of embryo or fetus may cause expulsion of endometrial decidual cast, regeneration of epithelium and normal appearing endometrium; thus presence of cycling endometrium does not rule out a tubal pregnancy if adnexal mass present

Often rupture of maternal vessels (week 8) into gestational sac

Case report of term tubal pregnancy with fetal death, Archives 1986;110:250

Treatment: salpingectomy; usually can conserve ovary

Gross: distension of ampullary segment of tube with thin or ruptured wall, dusky red serosa and hematosalpinx

Micro: intraluminal chorionic villi and extravillous trophoblast (may be degenerated); variable fetal parts; decidual change in lamina propria in 1/3; mesothelial reactive proliferation with papillary formation and psammoma bodies

Uterus - gestational hyperplasia with Arias-Stella reaction, no enlarged, hyalinized spiral arteries, no fibrinoid matrix

DD: missed / incomplete abortion (no fetal parts, no chorionic villi, no trophoblastic cells)

Endometriosis

Nodules in wall or serosa of tube; may focally replace tubal mucosa

Muscularis is usually not involved

Endometriosis is usually present elsewhere in the pelvis

May represent extension of endometrium from uterine cornu (10% of women have extension to isthmus)

Associated with intratubal polyps, causing infertility or ecic pregnancy

Also occurs in 20-50% of tubes after ligation, particularly if short stumps, electrocautery, long interval since ligation

Endosalpingiosis

Tubal epithelium outside the tube, analogous to endometriosis

Usually on ovarian surface close to fimbriae; may follow surgery or be associated with salpingitis, AJSP 1982;6:109

Also represents a peritoneal process with proliferation of mesothelium forming small cystic structures of tubal form, associated with ovarian serous tumors

May present as a tumor mass, AJSP 1999;23:166

Epithelial hyperplasia

Present in women with estrogen producing ovarian tumors

May also be associated with ovarian serous borderline tumors

Often an incidental microscopic finding

Ages 17-40 (patients with pseudocarcinomatous hyperplasia)

May be associated with severe inflammation and scarring and resemble adenocarcinoma

Micro: papillary, gland-like or cribriform patterns, lined by epithelial cells with mild to moderate nuclear pleomorphism, loss of polarity, stratification, crowding, hyperchromatism and mitotic figures; changes may be transmural; may be accompanied by atypical mesothelial proliferation with cuboidal cells lined up in rows with mild nuclear atypia; no invasion

DD: carcinoma (grossly evident, older age, solid epithelial proliferation, brisk mitotic activity, severe atypia)

Reference: AJSP 1994;18:1125

Extratubal secondary trophoblastic implants

Rare complication of conservative laparoscopic procedures for tubal ecic pregnancies

Patients have persistent elevated beta-hCG titers poseratively

Probably due to disruption of ecic pregnancy at salpingostomy or morcellation of fallopian tube at salpingectomy

Gross: may have extensive omental implants, 0.3 cm red-black nodules

Micro: nodules are degenerating chorionic villi associated with implantation changes in the surrounding tissue

Reference: Hum Path 1998;29:184

Heat artifact

Marked pseudostratification and dark nuclear staining

Due to cautery or heating of specimen after removal

Hilar cells

Present in 0.5% of fallopian tubes or paratubal tissue, usually in fimbriae

Mesonephric remnants

In broad ligament

Micro: small tubules lined by low columnar to cuboidal cells without cilia; surrounded by prominent smooth muscle; may be cystic

Metaplastic changes

Mucinous metaplasia associated with mucinous tumors of cervix or ovary and Peutz-Jeghers syndrome

Positive stains: serotonin and somatostatin

Transitional and squamous metaplasias are rare

Metaplastic papillary tumor

Rare, incidental finding usually in pregnant and post-partum women

May be metaplastic and not neoplastic

Benign behavior

Gross: microscopic size; involves only part of circumference of mucosa

Micro: papillae with small rounded cysts; composed of large, stratified, epithelial cells with abundant eosinophilic cylasm, may contain mucin and large vesicular nuclei; no / rare mitotic figures

DD: primary tubal carcinoma (larger, invasive, atypia)

Reference: Archives 1989;113:545

Paratubal cysts

Common incidental findings

Called hydatids of Morgani if large and near fimbriae or broad ligament

Gross: attached to fimbriated end of tube by a pedicle, thin walled, clear content

Micro: usually tubal-type lining, may have plica

Pigmentosis tubae

Presence of hemosiderin-laden macrophages within plical stroma

Associated with surgery for sterilization, chronic pain or benign masses, Archives 2002;126:951

Placental site nodule

Benign lesion of intermediate trophoblast; remnant of placental implantation site

Rarely in fallopian tube

Positive stains: cytokeratin, placental alkaline phosphatase, human placental lactogen, focal human chorionic gonadotropin, EMA

Reference: Hum Path 1996;27:1243

Post-tubal ligation

Dilation of proximal tube, attenuation of plica with pseudopolyp formation and chronic inflammation, plical thickening in distal tube

Prolapse

80% associated with vaginal hysterectomy

Case report of prolapse into urinary bladder, resembling carcinoma, Archives 1983;107:613

Gross: resembles granulation tissue, visible at vaginal apex

Salpingitis isthmica nodosa

Young women, mean 26 years

85% bilateral

Pathogenesis is analogous to uterine adenomyosis

Associated with infertility in 50%; may lead to ecic pregnancy

Also associated with glandular inclusions in lymph nodes, AJSP 1981;5:353

Gross: well-delimited yellow-white nodular enlargement of isthmus

Micro: regularly spaced, cystically dilated glands surrounded by hypertrophied muscle (actually diverticula that communicate with tubal lumen); no stromal response, but may be accompanied by salpingitis; occasional glands surrounded by endometrial-type stroma; no atypia

DD: carcinoma (irregular distribution of glands, atypia, stromal response)

Torsion

Usually due to inflammation or tumor, occasionally no known abnormality

Often accompanies torsion of adjacent ovary with moderate sized cyst

Occurs in women of all ages

May resolve or tube may become necrotic and calcified with autoamputation of tube and ovary

2/3 involve right tube

Gross: swollen, dusky

Walthard cell nests

May represent mesothelial hyperplasia

Gross: white/yellow nodules or cysts up to 2 mm, resemble granulomas

Micro: well-circumscribed, small, glistening, round collections of flat/cuboidal cells, resembling urothelium, on tubal serosa; minimal atypia, no/rare mitotic figures; cells have prominent nuclear groove, 1-2 small nucleoli; may see inspissated eosinophilic secretion or mucin within lumina

DD: serosal tumor implants

Tumors

Adenomatoid tumor

Most common benign tumor of fallopian tube, aka benign mesothelioma

Similar to paratesticular tumor

Gross: usually incidental tumor of myosalpinx (muscle layer), 2 cm or less; circumscribed, gray-white-yellow, firm; usually unilateral

Micro: tubular / glandular spaces of various sizes composed of flattened cells resembling endothelium or large cells with eosinophilic cylasm; may have vacuoles; may have mucinous secretions or infiltrative-like margins; often smooth muscle hyperplasia; cells also in clusters or small cords; rare mitotic figures; minimal atypia; often lymphocytic follicles

Negative stains: CEA

DD: lymphangioma, adenomyoma (more prominent smooth muscle), carcinoma (not circumscribed, invasive, atypia, mitotic activity)

Borderline tumor

Rare cases, mostly mucinous tumors, which may represent spread of appendiceal mucinous cystic tumor

Case report of borderline papillary serous tumor in 31 year old woman, AJSP 1996;20:30

Carcinoma

Rare, 0.3 to 1.0% of genital tract malignancies

Mean age 57 years, rarely teenagers; usually incorrect preoperative diagnosis

High stage with pelvic extension or positive peritoneal cytology

To call primary in fallopian tube, should arise from mucosa (endosalpinx), have tubal histologic pattern, involve the lumen, uterus and ovaries must be normal or have foci of malignancy that resemble metastases or independent primaries; if tubal wall is involved, should detect a transition between benign and malignant tubal epithelium

5 year survival: Stage 1 - 77%, Stage 3 - 20%; usually recur intra-abdominally

Associated with BRCA1 and BRCA2 mutations; for patients with known mutation or family history of breast or ovarian cancer, should submit entire fallopian tube and ovary for microscopic examination, AJSP 2002;26:171, AJSP 2001;25:1283

50% serous, 25% endometrioid, 20% transitional or undifferentiated

Symptoms: vaginal bleeding or discharge (2/3), pain, adnexal mass (triad in 50%); endometrial smear positive in 10%

Gross: enlarged tube, with solid or papillary tumor filling the lumen; tumors occasionally are primary in the fimbriae; 80-97% unilateral; hemorrhage, necrosis and cysts common

Micro: invasive papillary adenocarcinoma; may resemble ovarian serous adenocarcinoma with complex papillary architecture

Endometrioid tumors may be non-invasive, have squamous metaplasia, be associated with endometriosis, contain spindled epithelial cells; may have small, closely packed cells with numerous glandular spaces of varying sizes, containing PAS+ dense colloid-like secretion, resembling female adnexal tumor of probably wolffian origin (but usually intraluminal, typical endometrioid carcinoma elsewhere, more mitotic activity and atypia, mucin present)

Carcinoma in situ

Rare without invasive carcinoma

Micro: flat or minimally papillary lesions, not grossly noted, cells have obvious malignant nuclear features

DD: metastases to fallopian tube

Endometrioid polyp

Common

Female adnexal tumor of probable wolffian origin

Rare, ~ 40 cases reported

Mean age 47, range 15 to 72 years

Nonspecific symptoms or incidental mass

Usually benign, no known features predictive of malignancy

Malignant case in 81 year old woman, Archives 1994;118:310

Gross: solid tumor within or hanging from broad ligament or fallopian tube by a pedicle; mean 8 cm, rounded with bosselated external surface; solid or cystic cut surface; gray-white, tan or yellow, firm to rubbery; hemorrhage or necrosis is rare

Micro: diffuse, trabecular, tubular or sieve like patterns; cells are cuboidal to columnar with minimal cylasm; rarely abundant pale cylasm; nuclei small, round/oval, pale; may have prominent hyalinized stroma or fibrous bands that creates lobular appearance; sheets of tumor cells may have a spindly appearance

Positive stains: AE1/AE3

Negative stains: EMA, CEA, S100, B72.3

EM: thick peritubular basal lamina, no/minimal cilia; Golgi apparatus, secretory granules and glycogen favor Wolffian origin

Lymphoma

Tubes often affected by disseminated lymphoma, although less common than ovarian involvement

No cases of primary tubal lymphoma reported

Malignant mixed mullerian tumor

Rare, < 70 cases reported

Similar age and clinical presentation as primary tubal carcinoma

p53 positive in one study of two tumors, Mod Path 1994;7:619

Gross: large, polypoid mass protruding into lumen

Micro: similar to MMMT of uterus; homologous and heterologous stromal component may be present

DD: endometrioid carcinoma with spindle cells, immature teratoma

Reference: Archives 1987;111:386

Metastases / secondary tumors

Tubal involvement often by ovarian borderline tumors and carcinomas, cervical and endometrial carcinoma (invasive or in-situ) and pseudomyxoma peritonei

Metastases from extra-genital site are rare

Mucinous lesions

Rare, associated with mucinous lesions elsewhere in female genital tract and Peutz-Jeghers syndrome

Mucinous metaplasia and neoplasia of fallopian tube may indicate multifocal mucinous neoplasia, AJSP 1994;18:1205

Papillary cystadenoma of mesosalpinx

Associated with von Hippel Lindau disease

Serous adenofibroma

Similar to ovarian counterpart

Teratoma

Rare, ~ 50 cases reported, almost all benign and cystic

Case report of struma salpingis associated with struma ovarii, AJSP 1993;17:1187

Gross: usually attached by a pedicle to tubal mucosa; 0.7 to 2.0 cm

Micro: usually cystic and mature

Staging

Widespread intra-abdominal disease is common, so multiple biopsies of commonly involved sites are required for staging

Primary tumor (T)

TX: primary tumor cannot be assessed

T0: no evidence of primary tumor

Tis (FIGO 0): carcinoma in situ (limited to tubal mucosa)

T1 (FIGO I): tumor limited to fallopian tube(s)

T1a (FIGO IA): tumor limited to one tube, without penetrating the serosal surface; no ascites

T1b (FIGO IB): tumor limited to both tubes, without penetrating the serosal surface; no ascites

T1c (FIGO IC): tumor limited to one or both tubes, with extension onto or through the tubal serosa, or with malignant cells in ascites or peritoneal washings

T2 (FIGO II): tumor involves one or both fallopian tubes with pelvic extension

T2a (FIGO IIA): extension or metastasis to the uterus or ovaries

T2b (FIGO IIB): extension to other pelvic structures

T2c (FIGO IIC): pelvic extension with malignant cells in ascites or peritoneal washings

T3 (FIGO III): tumor involves one or both fallopian tubes, with peritoneal implants outside the pelvis

T3a (FIGO IIIA): microscopic peritoneal metastasis outside the pelvis

T3b (FIGO IIIB): macroscopic peritoneal metastasis outside the pelvis 2 cm or less in greatest dimension

T3c (FIGO IIIC): peritoneal metastasis more than 2 cm in diameter

Note: Liver capsule metastasis is T3/FIGO III; liver parenchymal metastasis is M1/FIGO IV. Pleural effusion must have positive cytology for M1/FIGO IV.

Regional lymph nodes (N)

NX: regional lymph nodes cannot be assessed

N0: no regional lymph node metastasis

N1(FIGO IIIC): regional lymph node metastasis

Distant Metastasis (M)

MX: distant metastasis cannot be assessed

M0: no distant metastasis

M1 (FIGO IV): distant metastasis (excludes metastasis within peritoneal cavity)

Stage grouping

Stage 0: T1s N0 M0

Stage 1: T1 N0 M0

Stage 1A: T1a N0 M0

Stage 1B: T1b N0 M0

Stage 1C: T1c N0 M0

Stage 2: T2 N0 M0

Stage 2A: T2a N0 M0

Stage 2B: T2b N0 M0

Stage 2C: T2c N0 M0

Stage 3: T3 N0 M0

Stage 3A: T3a N0 M0

Stage 3B: T3b N0 M0

Stage 3C: T3c N0 M0 or any T N1 M0

Stage 4: M1

Tumor features to report

Histologic type

Grade

Size

Depth of invasion (i.e. layers of tube involved)

Location in segment of tube

Extension to adjacent tissue

Angiolymphatic invasion

Resection margins

Pathologic findings for other tissue submitted

Additional findings (salpingitis, endometriosis)

Reference: Archives 1999;123:33

Broad ligament tumors

Ependymoma

3 cases reported, ages 13, 45, 47 years, sizes 1.0, 9.5, 13 cm

Resemble ependymoma of central nervous system

Positive stains: GFAP

Leiomyoma

Most common soft tissue tumor of broad ligament

Leiomyosarcoma

Most common sarcoma of broad ligament

Papillary cystadenoma

Associated with von Hippel-Lindau disease

Tumors often bilateral

Serous tumors

Mean age 33 years

Gross: unilateral, unilocular cysts up to 13 cm

Micro: resemble ovarian counterparts, with ovarian-type stroma; no ova, no ovarian follicles

Fallopian Tubes

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