
==== Front
Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00990-8
10.1016/j.ijscr.2024.110209
110209
Case Report
Fallopian tube cancer with inguinal lymph node metastasis as the first symptom: A case study and review of the literature
Su Qing a1
Han Shichao b2
Yin Rong a3
Yang Qiyu a4
Pan Zhuo pan99zhuo@163.com
c⁎
a Department of Obstetrics and Gynecology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing 400014, China
b Department of Gynecology, the Second Affiliated Hospital of Dalian Medical University, No. 467, Zhongshan Road, Shahekou District, Dalian City, Liaoning Province, China
c Center for Reproductive Medicine, Chongqing Reproductive Genetics Institute, Chongqing Key Laboratory of Human Embryo Engineering, Chongqing Clinical Research Center for Reproductive Medicine, Women and Children's Hospital of Chongqing Medical University, Chongqing Health Center for Women and Children, No.64 Jintang Street, Yuzhong District, Chongqing 400013, China
⁎ Corresponding author. pan99zhuo@163.com
1 First author.

2 Co-first author.

3 Second author.

4 Third author.

27 8 2024
10 2024
27 8 2024
123 11020922 6 2024
17 8 2024
22 8 2024
© 2024 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Fallopian tube cancer that is characterized only by inguinal lymph node metastasis without intra-abdominal widespread is rare. Here we report a patient with primary Fallopian tube cancer with bilateral inguinal metastases as the first symptom.

Case presentation

A 68-year-old patient with primary Fallopian tube cancer, with painless bilateral inguinal enlargement (7 × 6 cm on the right side, 3 × 2 cm on the left side) as the only manifestation, was confirmed by preoperative biopsy as metastatic high-grade serous denocarcinoma, consider the adnexal or peritoneal source. Pelvic MRI, abdominal CT and PET-CT showed irregular signal foci can be seen in the right adnexal area, with a maximum cross-section of about 7.5 × 7.0 × 4.0 cm, considering malignancy, ovarian cancer may be possible; bilateral pelvic wall, bilateral inguinal, right iliac vessels with hypermetabolic lymph nodes. Serum CA125 level was markedly elevated at 922.40 U/ml and HE4 at 394.50 pmol/L. No abnormality was found in gastrointestinal endoscopy. At exploratory laparotomy, the tumor was confined to the right rear of the uterus, and a solid tumor with a size of about 10 × 6 × 6 cm was seen. The surface was smooth and closely related to the uterus. There was almost no tumor spread in the pelvic abdominal cavity, but there was 50 ml of pale blood-colored peritoneal fluid. The right ovarian capsule was intact. Cytoreductive surgery was performed, postoperative pathology confirmed adenocarcinoma of the right fallopian tube, and the patient received six cycles of paclitaxel plus cisplatin combination chemotherapy were administered, with three 3-weeks intervals between cycles. And subsequent the patient participated in a clinical trial. The work has been reported in line with the SCARE criteria.

Clinical discussion

Literature review indicates that inguinal lymph node as the first manifestation of fallopian tube cancer is not usual, and with no widespread lymphadenopathies and abdominopelvic cavity are even rarer. This case shows that rare cases with only inguinal lymph node metastasis may occur through the underlying lymphatic and/or hematogenous routes.

Conclusion

The diagnosis of tubal cancer is sometimes complicated and delayed. For elderly women without nonspecific symptoms, especially those with obvious masses, detailed examinations, and imaging studies should be carried out in time. The treatment of tubal cancer is multi-modal. Due to the high risk of recurrence of fallopian tube cancer, the possibility of metastasis after the initial diagnosis is large, so it is very important to receive close and regular follow-up for patients with fallopian tube cancer after treatment. We suggest that more tumor centers study the possible mechanisms, metastasis patterns, biological characteristics, etc. of such patients, and at the same time efforts should be made to early differential diagnosis, and ultimately prolong the survival time of such patients.

Keywords

Fallopian tube cancer
Ovarian cancer
Inguinal lymph node
Lymphatic spread
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pmc1 Background

Primary cancer of the fallopian tube is a very unusual gynecologic malignancy that accounts for less than 1 % of all malignancies of the female genitalia. Since diagnosis occurs mainly in late stages, it is associated with a high mortality rate. There are no typical clinical symptoms in the early stage of the disease for detecting, and it is not detected until extensive metastases appear. Common symptoms include abdominal pain or mild digestive disturbance, the severity of which is not necessarily related to disease tumor stage. Moreover, early fallopian tube cancer spread via hematogenous, lymphatic, and peritoneal routs and extends directly into the pelvic is remarkable, lymph node metastasis occurred mainly in the pelvic and aortic region. Nevertheless, metastases outside the pelvis and abdomen are relatively rare, especially inguinal lymph node metastasis as the first symptom, which is very rare in this type of cancer. Below we report a 68-year-old patient with complete clinicopathological data who initially presented with asymptomatic enlarged bilateral inguinal lymph nodes, which was confirmed to be metastatic adenocarcinoma by preoperative biopsy. From this, we explore its mechanism in basic science and potential implications in clinical management.

Primary fallopian tube cancer (PFTC) is rare in gynecological malignancies, but recent data suggest that many ovarian cancers may have been misclassified, initially from fallopian tube cancers directly extending to ipsilateral ovaries [1]. PFTC shares the same diagnostic and management guidelines with epithelial ovarian cancer (EOC), because they have similar pathogenesis. Although direct extension, peritoneal dissemination is a major feature of this type of cancer, and many patients have extensive peritoneal metastasis when diagnosed. In this case, it is not feasible for most patients to perform cytoreductive surgery directly. Many patients will benefit more from neoadjuvant chemotherapy and interval surgery and have a longer survival time [2].

2 Case description

In March 2021, a 68-year-old woman, 20 years of menopause, presented to our hospital with a swollen mass in the right groin for 1 year, which gradually increased. There was no history of weight loss or loss of appetite, and no drug history, family history including any relevant genetic information, and bowel and bladder habits were normal. She was pathologically diagnosed with metastatic adenocarcinoma by fine needle aspiration for the right groin swelling in a local hospital 4 days later, and then went to our hospital for treatment. On gross inspection, the palpable enlarged subcutaneous swellings (7 × 6 cm) were observed with the right groin and the left (3 × 2 cm), others were clinically negative. Gynecologic examination showed 8 cm fixed mass within the right adnexa. Serum CA125 level was markedly elevated at 922.40 U/ml and HE4 at 394.50 pmol/L. Pelvic MRI and abdominal CT showed an irregular mass in the right adnexa, with a maximum cross-section of about 7.0 × 4.0 ∗ 7.5 cm, with clear borders; nodules of different sizes were seen in bilateral inguinal areas, and the larger lesions were about 5.8 ∗ 4.2 cm (Fig. 1). PET-CT results showed a hypermetabolic mass in the right adnexal area, which was considered malignant and possibly ovarian cancer; hypermetabolic lymph nodes on the bilateral pelvic wall, bilateral inguinal, and right iliac vessels were considered for metastasis; there were multiple small hypermetabolic lymph nodes in the retroperitoneum. No abnormal high metabolism was found in the brain, the glands on both sides of the oropharynx are highly metabolized, considering inflammation. Left lobe of the liver low density, cyst may, intra-abdominal multiple intestinal diffuse high metabolism, considering inflammation or physiological uptake may be. Vertebral degeneration, vertebral no abnormal high metabolism, the right shoulder soft tissue is highly metabolized, and non-specific uptake is considered (Fig. 2). Cervical cancer screening, gastroduodenoscopy, and colonoscopy were all negative. Serum tumor markers CA 125 level was markedly elevated at 922.40 U/ml and HE4 at 394.50 pmol/L.Fig. 1 Preoperative pelvic MRI and abdominal CT showed an irregular mass in the right adnexa, with a maximum cross-section of about 7.0cm ∗ 4.0cm ∗ 7.5 cm, with clear borders; nodules of different sizes were seen in bilateral inguinal areas, and the larger lesions were about 5.8 ∗ 4.2 cm

Fig. 1

Fig. 2 PET-CT results showed hypermetabolic mass in the right adnexal area; hypermetabolic lymph nodes on the bilateral pelvic wall, bilateral inguinal, and right iliac vessels were considered for metastasis; there were multiple small hypermetabolic lymph nodes in the retroperitoneum.

Fig. 2

Eight days later Professor Han, with rich experience in gynecologic oncology, performed exploratory laparotomy, the tumor was confined to the right rear of the uterus, and a solid tumor with a size of about 10 × 6 × 6 cm was seen. The surface was smooth and closely related to the uterus. There was almost no tumor spread in the pelvic abdominal cavity, but there was 50 ml of pale blood-colored peritoneal fluid. The right ovarian capsule was intact. No abnormality was found in the exploration of the upper abdomen (intestinal tract, mesentery, greater omentum, liver surface, spleen surface, stomach surface, diaphragm surface, peritoneum, bilateral colon lateral sulcus, etc.). During the surgery, frozen sections of the whole uterus and bilateral adnexa showed poorly differentiated carcinoma of the right fallopian tube umbrella, and the tumor was located outside the muscular layer of the posterior wall of the uterus and the right ligament area; no macroscopic lesions in bilateral ovaries, left fallopian tubes, cervix and endometrium. According to the procedures of cytoreductive surgery for ovarian cancer, total abdominal hysterectomy, bilateral adnexectomy, complete omental resection, the bilateral pelvic enlarged lymph node resection was performed, completed with excision of the enlarged node in the groin. The patient at the end of the operation said they were satisfied with the result of the operation.

The surgical specimens are shown in Fig. 3. The postoperative pathological diagnosis was high-grade serous adenocarcinoma of the right fallopian tube, metastatic carcinoma of the right and left inguinal lymph nodes, a negative expression of pelvic lymph nodes, and negative expression of greater omentum. Immunohistochemical staining showed positive expression of Ki67 in the cytoplasm of cancer tissue, positive expression of CK7, and negative expression of P53 (Fig. 4). Pelvic liquid cytology showed negative. PostAfter operative operation CA125 level was at 98.40 U/ml and HE4 at 123.3 pmol/L. The patient was diagnosed as FIGO stage IVB, followed by adjuvant chemotherapy of paclitaxel (175 mg/m2) and carboplatin (AUC-5), 6 cycles every 28 days. Chemotherapy was completed in September 2021. CA 125 level was 7 U/mL and HE4 83.28 pmol/Lby that time. Then the patient participated in a clinical trial. The patient was regularly reviewed according to the follow-up principle of ovarian cancer after operation. The last review time was March 2024, and there were no obvious abnormalities in tumor markers and imaging examinations.Fig. 3 Surgical specimens: whole uterus + double appendages + greater omentum, left and right inguinal lymph nodes, pelvic lymph nodes.

Fig. 3

Fig. 4 A Postoperative pathologic diagnosis was high-grade serous adenocarcinoma of the right fallopian tube; B Right groin tumor, C left groin tumor, D Postoperative positive immunostaining of Ki67 was detected in primary fallopian tube tumor tissues; E CK7(+);F P53(−).

Fig. 4

3 Discussion

The incidence of inguinal lymph node metastasis in ovarian cancer is about 3–5 % of that reported in the literature [[3], [4], [5], [6]]. However, these studies cannot provide sufficient clinical data and pathological features, and lack conclusions, because these studies ignore the pathological examination of pelvic and paraaortic lymph nodes, as well as detailed information about whether inguinal lymph node metastasis occurs in isolation or coexisting in injunction with other tumor metastasis sites. Reviewing previous -literature we found: Scholz et al. [7] reported for the first time a patient with bilateral ovarian undifferentiated serous adenocarcinoma and right tubal umbrella involvement [7]. The peritoneal lavage fluid was positive, initially showing isolated left inguinal lymph node metastasis, without other lymph node involvement. Manci et al. reported a patient with bilateral inguinal lymph node enlargement [8]. PET-CT examination and after postoperative pathological diagnosis confirmed bilateral poorly differentiated serous papillary adenocarcinoma of the ovary, bilateral inguinal lymph node metastasis, and no intra-abdominal or lymph node diffusion. Ang et al. [9] reported a case of left ovarian adenocarcinoma with isolated metastasis of the right inguinal lymph node and no other involved sites. Yang et al. [10] reported an initial case of right SILN metastasis with no evidence of widespread peritoneal dissemination and retroperitoneal pelvic or para-aortic lymph node metastasis. The disease was confined to the right ovary and the tumor was about 5 cm in diameter. Therefore, those are reported in the existing literature of ovarian cancer with isolated SILN metastasis existing is present [11,12], but in fallopian tube cancer has not been reported. In recent years, although the diagnosis of high-grade serous ovarian cancer in the United States has rapidly shifted from high-grade serous ovarian cancer to fallopian tube cancer, especially in cases with smaller unilateral tumors. So, the possibility of fallopian tube cancer cannot be excluded from previous reports of ovarian cancer. Fallopian tube cancer or ovarian cancer with inguinal lymph nodes as the initial symptom is relatively rare, and its mechanism and prognosis need further research.

Lymph node metastasis is an important metastasis pathway of ovarian malignant tumors, mainly para-aortic and iliac lymph nodes. Inguinal lymph node metastasis is rare. Ovarian lymphatic vessels are usually described as following ovarian vessels. The main reasons: (1) From the ovarian lymph drainage, the drainage way is rarely to inguinal lymph nodes. (2) Clinical doctors pay less attention to inguinal lymph node metastasis of ovarian cancer than cervical cancer, including preoperative examination, intraoperative exploration and removal, and postoperative examination.

There are three pathways for ovarian lymphatic drainage: (1) injecting paraaortic lymph nodes with ovarian vessels; (2) Lymphatic ducts drawn from the ovarian hilum enter the interiliac lymph through the broad ligaments on both sides; (3) There were still accessory branches in the ovary from the intra-uterine ligament lymph nodes to the external iliac end and inguinal lymph nodes [[13], [14], [15]]. Para-aortic lymph nodes and pelvic lymph nodes are common lymphatic metastasis sites in ovarian cancer. In recent years, the 1st and 2nd metastasis pathways have attracted widespread attention, but the reports on inguinal lymph node metastasis of ovarian cancer are rare. The patient's condition we conclude that drainage along the round ligament to inguinal lymph nodes is possible. And the patient's pelvic lymph node is negative, indicating that the main flow to the lumbar lymph node is not likely to be blocked, so the patient can be considered to be spread along this side of the flow. Although the large group report on lymph node metastasis in ovarian cancer describes the rule of lymph node metastasis, inguinal lymph node metastasis is not specifically explained, considering whether some patients with round ligament structures including blood vessels, lymphatic vessels, and most people have variations we need further study. Through the report of this case, because considering inguinal lymph node metastasis may occur simultaneously or individually with pelvic or paraaortic lymph node metastasis, the authors believe that attention should be paid to the occurrence of inguinal lymph node metastasis in ovarian malignant tumors. In the systematic retroperitoneal lymph node dissection, the deep inguinal lymph nodes should be routinely resected along the exoskeleton blood vessels. Deep inguinal lymph node positive cases should pay attention to superficial inguinal lymph node enlargement.

Lymph node metastasis is an important part of ovarian cancer FIGO staging, and lymph node resection is also a part of ovarian cancer staging surgery or tumor cell reduction surgery. Recently, after nearly 30 years of use, the FIGO staging system has been revised [[16], [17], [18]]. According to the revised FIGO (2014) staging system, women with inguinal LN metastasis previously regarded as stage III C are now assigned to stage IV B. Nevertheless, unresolved classification issues remain, particularly for women with stage IV diseases [19]. The prognostic significance of this reclassification remains to be further studied. Dimitrios's study shows that the survival time of patients with stage IV ovarian cancer only due to inguinal lymph node metastasis was similar to that of patients with pelvic or para-aortic lymph node involvement, and the survival time of patients with distant metastasis was improved. The findings do not support the classification of these patients as IVB.

We should recognize that PFTC is not only confined to the abdominal cavity disease, isolated inguinal lymph node metastasis and as the first symptom appeared in the initial stage of tumor origin cases are rare, through the potential lymphatic and/or blood source pathways. On the other hand, attention should be paid to the possibility of ovarian cancer in patients with ovarian cancer or in the differential diagnosis of inguinal masses. In such cases, correct preoperative assessments, including gynecological examinations, CA125 levels, and TVUSG, must be undertaken and more experience accumulated during treatment and follow-up, and mechanisms explored to guide treatment. The exact molecular mechanism and/or risk factors of this special clinical metastasis model are still worth further study. The article is written according to the requirements of the SCARE 2023 paper [20].

Ethical approval

Ethics approval and consent to participate and consent: The case report was approved by the Ethics Committee of the Second Affiliated Hospital of Dalian Medical University and fully informed written consent.

Funding

There is no funding for this research.

Author contribution

Qing Su and Shichao Han handled the case and drafted the manuscript. Rong Yin and Qiyu, Yang assisted in the data review and the article work. All authors read the article, and Dr. Zhuo Pan reviewed and approved the final manuscript.

Guarantor

The Doctor Zhuo Pan is the one who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish

Research registration number

This study is not registered.

Conflict of interest statement

The authors report no conflicts of interest.
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