Cervicovaginal smears in the diagnosis of asymptomatic primary fallopian tube carcinoma

Dear Editor, The diagnosis of primary fallopian tube carcinoma (PFTC) is rarely made preoperatively and positive cervicovaginal smears (CVS) in cases of PFTC usually relate to symptomatic patients with advanced disease. In the literature, there is no report on the utility of CVS for the detection of early tubal adenocarcinomas or on the incidence of PFTC identified in asymptomatic women in a cervicovaginal screening programme (CSP). We retrospectively reviewed records from 201 231 CVS collected from 1993 to 2006 for the CSP of Trento district (Italy), performed according to Walton report, with cytological and histological diagnoses according to the Bethesda System and Hu s citeria, respectively. We identified six extrauterine malignancies with positive Pap smears: four primary ovarian carcinomas, three of which were in symptomatic women, and two PFTC in asymptomatic women. The cytological presentation with positive CVS was similar in the two patients. The smears showed papillary groups of glandular malignant cells without tumour diathesis. The malignant cells often appeared overlapped and were roughly circular or cylindrical in shape with borders generally indistinct (Figure 1a,b). Ultrasound examination did not show significant findings and the endometrial aspiration and hysteroscopy were negative in both patients. The first patient (63 years old, gravida 2 para 2) underwent an explorative laparotomy, with a right salpingo-oophorectomy. The right fallopian tube was 11 cm in length and was expanded by a fimbriated, nodular mass, 2 cm in diameter. Histology showed a moderately differentiated (G2) serous PFTC with extension to the tubal serosa (UICC 2001: pT1c; FIGO: IC) (Figure 1c). An abdominal hysterectomy with contralateral salpingo-oophorectomy and appendicectomy was subsequently performed. A left ovarian serous cystadenoma was found, with no evidence of neoplastic involvement in other organs or anatomic sites. Peritoneal washings were negative. The patient received chemotherapy and is at present free of disease. In the second patient (61 years old, gravida 2 para 2), surgery showed a fimbriated and nodular expansion of the right fallopian tube, 2.2 cm in diameter. Frozen sections showed an invasive tubal carcinoma and an abdominal hysterectomy with left salpingo-oophorectomy and appendicectomy was subsequently performed. A diagnosis of moderately differentiated (G2) serous PFTC with extension to the tubal serosa was made. Microscopic peritoneal metastases beyond the pelvis were found and a few neoplastic cells were seen in the peritoneal washings (UICC 2001: pT3a; FIGO: IIIA). The patient was started on chemotherapy and is at present free of disease. CVS are primarily a screening procedure for cervical neoplasms. When glandular malignant cells are found in CVS and neoplastic changes in the cervix or endometrium cannot be proven after curettage and ⁄ or biopsy, extrauterine neoplasia should be suspected. Primary malignancies of the fallopian tube are extremely uncommon. Recommendations for reporting fallopian tube neoplasms are given in a recent paper, but there are no evidence-based criteria for distinguishing PFTC from primary ovarian or primary endometrial carcinoma in patients with high stage disease. Nevertheless, an early PFTC can be more easily approached and correctly diagnosed histologically on the basis of Hu s criteria. Early cytological diagnosis in cases of silent PFTC is a more difficult issue. CSP can disclose cases of otherwise unsuspected PFTC. The anatomical site of tubal cancer may allow an early diagnosis with CVS, as the malignant cells may exfoliate from the primary tumour, migrate through the fallopian tube and be detected at the time of cytological screening in the Correspondence: Dr S. Licci, Department of Pathology, National Institute for Infectious Diseases – L. Spallanzani IRCCS, Via Portuense, 292 00149 Roma, Italy. Tel. : +39 06 55170277; Fax: +39 06 55170437; E-mail: stefano.licci@hotmail.it