Fallopian tube tumour presenting as supraclavicular lymph node metastasis
- 1 Departamento da Mulher e da Medicina Reprodutiva, Centro Materno Infantil do Norte Dr Albino Aroso - Centro Hospitalar Universitário do Porto, Porto, Portugal
- 2 Clínica de Ginecologia, Instituto Português de Oncologia do Porto Francisco Gentil EPE, Porto, Portugal
- Correspondence to Dr Maria Lúcia Moleiro; lucia.moleiro@gmail.com
Abstract
A 72-year-old woman noted a lump in her left supraclavicular fossa with no other symptoms or other signs on physical exam. A cervical biopsy indicated metastatic carcinoma. On the diagnostic workup: thoracic–abdominal–pelvic CT revealed augmented lymph nodes (LNs) in the retroperitoneum; Positron Emission Tomography–CT showed uptake in the LNs described and in two small areas in the pelvis; blood tests showed elevated CA125 and CA72.4. Another biopsy, considering a para-aortic LN, proved to be metastasis of a high-grade serous carcinoma (HGSC). Gynaecological exam and pelvic imaging were innocent. Diagnostic laparoscopy, including hysterectomy and bilateral adnexectomy, was performed and anatomopathological examination confirmed a HGSC in the fallopian tube (FT), in a tiny focus of 1.5 mm. The patient continued treatment with adjuvant chemotherapy. Literature review indicates that supraclavicular LN as first manifestation of FT carcinoma is not usual, and widespread lymphadenopathies with no macroscopic pelvic disease at diagnosis are even rarer.
Background
Fallopian tube (FT) tumours are rare, but they are associated with high mortality rate as diagnosis occurs mainly at late stages.1 2 They may cause few or even no symptoms until widespread disease. Usually, presenting symptoms include abdominal pain (or just a vague discomfort) or mild digestive disturbances, and their severity does not necessarily correlate with disease stage.1 2
Moreover, FT carcinoma spreads early through haematogenous, lymphatic and peritoneal routes, besides direct extension in the pelvic cavity, namely, to the homolateral ovary.2–4 The early spreading is notorious as complete lymphadenectomy often reveals positive pelvic and/or para-aortic lymph nodes (LNs), even with no pelvic visible disease.2 3 Nevertheless, extrapelvic metastases, namely, supraclavicular LNs, are very uncommon in this kind of carcinoma, especially at presentation as first symptom.5
Case presentation
A 72-year-old female patient was referred to an oncological centre because of a swollen left supraclavicular LN noted 2 months before. Initially mentioned as a small lump with 1 cm, it has increased to 3 cm until the first medical consultation. Despite mild odynophagia, she denied any other symptoms. Her medical history comprised pulmonary tuberculosis at 47 years old (medically treated), Hürthle cell adenoma of the thyroid gland at 67 years old (treated with total thyroidectomy), hypertension, dyslipidaemia and depression. No allergies were known. Smoking, alcohol or other drug consumption was denied.
Regarding gynaecological record: menarche at 13 years old, contraceptive pill usage for a few years; two pregnancies/two eutocic deliveries (first one at 30 years old, breast feeding during around 5 months in each); and menopause at 50 years old (no hormone replacement treatment).
Familial history included a brother deceased with pulmonary cancer and another brother alive, 87 years old, with pulmonary cancer and urothelial cancer.
She had an Eastern Cooperative Oncology Group (ECOG) performance status of 0. In her first medical examination, a 3 cm well-defined lump, which was mobile and with elastic consistency, was described in her left supraclavicular fossa. Otorhinolaryngology examination was carried and was uneventful. By the time of first contact in our oncological centre, the general physical exam was also uneventful with no other palpable LNs.
Investigations
Since the presentation, the patient had performed several exams. Cervical CT showed augmented left supraclavicular LNs (the biggest with 3 cm) (figure 1); thoracic–abdominal–pelvic CT revealed retroperitoneal LNs (in renal and splenic hila, para-aortic and in the left external iliac chain), the bigger ones with 6 cm (figure 2). A cervical biopsy was performed, and histological exam was compatible with a carcinoma metastasis. Positron Emission Tomography (PET)–CT showed uptake in the LNs previously described and in two small areas in the pelvic region: one on the left (maximum standardized uptake value (SUVmax): 4.5) suggestive of pelvic adenopathy, and the other one, posterior and lateral to the right rectus muscle (SUVmax:2.1), which was unspecific. Blood tests showed an elevated lactate dehydrogenase, with carcinoembryonic antigen, cancer antigen 19–9 and squamous cell carcinoma negative.
PET–CT images at initial diagnostic workup. Top image: transverse plane identifying high ((18)F)-fluorodeoxyglucose (18F-FDG) uptake in the left supraclavicular nodes. Bottom image: coronal plane at the same region where left clavicular node 18F-FDG uptake is notorious.
PET–CT images at initial diagnostic workup. Top image: transverse plane revealing high 18F-FDG-uptake in the retroperitoneal region. Bottom image: coronal plane showing high 18F-FDG-uptake in splenic and hepatic hila and in the retroperitoneal region until the aorta bifurcation level. A, anterior; R, right; RP, right/posterior.
Some studies carried a few months before included cervical–vaginal cytology negative for intraepithelial lesion or malignancy; normal colonoscopy and upper digestive endoscopy study; breast exams with a BIRADS (Breast Imaging Reporting and Data System)-2 classification.
Since no primary location was suspected at that moment, another LN biopsy was carried in our centre, this time on a para-aortic LN, under CT guidance. Tumour markers requested at that time revealed an elevated CA 125 and CA 72.4 (898 and 152 U/mL, respectively), which motivated the repetition of the digestive endoscopy study: it was normal. On the other hand, anatomopathological and immunohistochemistry examination of the LN biopsy was compatible with a high-grade serous carcinoma (HGSC). Gynaecological evaluation was requested: gynaecological physical exam with thorough evaluation for augmented LNs, cervical–vaginal cytology repetition (with high-risk human papilloma virus test) and image control with pelvic MRI was executed. All these exams reported no alterations and the patient remained asymptomatic.
The case was discussed in a gynaecology/oncology multidisciplinary meeting and diagnostic laparoscopy was decided. During the operative procedure, a small quantity of yellowish ascitic fluid and a left fallopian tube (FT) slightly enlarged were noted; uterus had normal dimensions and a pericentimetric posterior subserous myoma; no peritoneal implants were identified. Ascitic fluid was collected for cytological analysis; laparoscopic hysterectomy with bilateral salpingo-ooforectomy was performed, and the left adnexa was examined during the procedure: no tumour was identified on extemporaneous histological report. The surgery was uneventful, and the patient recovered well, being discharged 2 days after surgery.
Cytological and immunocytochemical analyses of ascitic fluid reported no malignant cells. Definite histological exam of uterus and adnexa found an invasive carcinoma of 1.5 mm in the fimbria stroma of the left tube; no other alterations were noticed. Bearing in mind previous investigations, the tumour was classified as an HGSC of the FT and was staged according to TNM staging system (American Joint Committee on Cancer (AJCC), Eighth Edition)6 as pT1aN1bM1b, and according International Federation of Gynecology and Obstetrics (FIGO) (2014)7 classification as IVB (hepatic and/or splenic parenchymal metastasis, metastasis to extraabdominal organs - including inguinal lymph nodes and lymph nodes outside of the abdominal cavity).
Treatment
As the tumour included positive LNs in the retroperitoneum and outside the abdominal cavity, which were not accessed during surgery, systemic chemotherapy was initiated. The intravenous combination of carboplatin/paclitaxel was the chosen scheme, and seven cycles were completed with acceptable tolerance (dose reduction in cycle 6 was needed due to peripheral neuropathy). CA 125 level was 114 U/mL by that time.
Outcome and follow-up
Partial response was obtained after four cycles (figure 3), but disease progressed after the seventh cycle—rising in CA 125 was noted (769 U/mL) and PET–CT revealed higher uptake in previously known lesions and new ones.
Positron emission tomography–CT images. transverse (top) and coronal (bottom) planes after 4 cycles of chemotherapy revealing partial metabolic response. A, anterior; R, right; RP, right/posterior.
Genetic analysis of the tumour revealed no pathogenic mutations in BRCA1, BRCA2, BRIP1, RAD51C, RAD51D, MLH1, MSH2, MSH6, PLAB2 and PMS2 genes. The patient’s peripheral blood was also examined for pathogenic mutations in BRCA1 and BRCA2 genes—none was identified.
Palliative chemotherapy was proposed, and the patient initiated pegylated liposomal doxorubicin in monotherapy every 4 weeks. After the first cycle, the patient presented an ECOG performance status of 1. Her main complaint was peripheral neuropathy that persisted after first-line chemotherapy, despite medical treatment with pregabalin (previously duloxetine was used but not tolerated, given nausea and vomits). On physical exam, a left supraclavicular LN was palpable but not painful, and no other LNs were noticed; march limitation was obvious due to peripheral neuropathy. Cardiological evaluation and blood tests were unremarkable, except for haemoglobin (1.11 g/L), neutrophils (1830 /L), lactate dehydrogenase (273 UI/L) and CA 125 (1417 U/mL).
Currently, the patient had completed two cycles with good tolerance. Image and analytical re-evaluation were planned after the fourth cycle—8 months after surgery and 14 months after the first appointment due to a supraclavicular LN appearance.
Discussion
FT tumours are rare among gynaecological malignancies, but recent data suggest that many ovarian cancers may have been mistakenly classified and were originally tube tumours with direct extension to homolateral ovary.1 8 Despite direct extension, peritoneal dissemination is one of the great remarks of this kind of cancer, and many patients have extensive peritoneal disease at the time of diagnosis. In this scenario, optimal cytoreductive surgery is not feasible in many patients who will benefit from neoadjuvant chemotherapy, and interval surgery, with more chances of total tumorous resection with less morbidity.1 2
Extra-abdominal disease, including inguinal LNs, and other LNs outside the abdominal cavity are classified as stage IVB (according to FIGO 2014 classification).7 Distant disease may occur through lymphatic and haematogenous dissemination, and it is not uncommon at presentation or at recurrence. Nevertheless, its occurrence as the only initial sign of disease is relatively rare.3 9 10
Left supraclavicular LN (Virchow node or Troisier’s sign) is well known as a ‘marker’ of gastrointestinal cancer metastisation, but its occurrence is not pathognomonic.11 Ovarian cancer is also reported as a cause of enlarged left clavicular LN, but few cases describe this as the first complaint, as in our case.5 11–15 Most of these cases, during diagnostic investigation, have found a pelvic mass that leads to ovary/FT as the main primary cancer suspect (table 1).
Review of case reports and series of case reports presenting ovarian/FT/peritoneal cancer, which presented supraclavicular LNs as one of the first referred symptoms
| Report | Year | Primary cancer | LN as the only presentation symptom | Pelvic and para-aortic LNs | CA-125 | Pelvic mass on diagnostic workup | Histology | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CA-125, cancer antigen 125; FT, fallopian tube; LN, lymph node; NR, not referred. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Scholz et al18 | 2000 | FT | Yes | NR | NR | NR | ‘Papillary serous carcinoma of the fallopian tube’ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Euscher et al19 | 2004 | Ovary/FT/peritoneum | Variable | Variable | NR | Variable | ‘Serous carcinoma of the ovary, fallopian tube or peritoneum’ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Mayadevi et al20 | 2005 | Ovary | Yes | No | 900 | No | ‘High-grade serous cystadenocarcinoma confined to the right ovary’ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Verbruggen et al14 | 2006 | Ovary | No | Variable | High/NR | Variable | ‘Serous borderline ovarian tumour’ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Cebesoy et al21 | 2008 | Ovary | Yes | NR | NR | NR | ‘Serous ovarian carcinoma’ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sakurai et al22 | 2010 | FT | Yes | Yes | 982 | No | ‘Primary fallopian tube adenocarcinoma’ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Wu et al15 | 2011 | Ovary | Yes | Yes | High | Yes | ‘Papillary serous cystoadenocarcinoma of the ovaries’ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Rahman et al12 | 2012 | Ovary | No | Yes | 387 | Yes | ‘High-grade serous ovarian carcinoma’ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| He et al23 | 2013 | Ovary | Yes | No | 1028 | Yes | ‘Ovarian low-grade serous carcinoma’ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Kemal et al13 | 2015 | Ovary | Yes | Yes | 614 | Yes | ‘Serous adenocarcinoma of the right ovary’ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Hong et al5 | 2018 | Ovary | Yes | Yes | 290.4 | Yes | ‘Poorly differentiated serous carcinoma’ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Footnotes
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Contributors MLM: concept, writing, literature review and data collection. HV and RDB: data collection, literature review and critical review. AG: concept, supervision, critical review and final approval.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
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