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	Spinal Metastases From a Primary Fallopian Tube Serous Adenocarcinoma: A Case Report

Jonathan P. Eskander, MD1
Eren O. Kuris, MD2
Andrew J. Younhein, BA4
Samuel Landsman AB4
Leonard Japko MD3
Mark S. Eskander, MD3

1Tulane University Hospital
Department of Anesthesiology
New Orleans, Louisiana

2 The University of Kansas School of Medicine � Wichita
Department of Orthopedic Surgery
Wichita, Kansas

3Christiana Spine Center
Newark, Delaware

4Tulane University Hospital
Department of Orthopedics
New Orleans, Louisiana

The authors have no disclosures or conflicts of interest to report.

Correspondence to Dr. Eskander
Christiana Spine Center
4735 Ogletown-Stanton Road, MAP 2, Suite 3302
Newark, DE 19713
Email:  markeskander77@gmail.com
Tel: (302) 623-4144Fax: (302) 623-4147





Abstract:
Objective:  
This case exemplifies the importance of a high index of suspicion when dealing with intractable pain and neurological symptoms in patients with and/or without a history of cancer.
Summary of Background Data:  
Fallopian tube cancer is relatively uncommon in females, accounting for less than 0.2% of all female malignancies. Because of a low index of suspicion, it is often detected at an advanced stage. From an orthopedic perspective, osseous metastases from primary fallopian tube malignancies are rare with only a few documented cases in the medical literature.
Methods:  
This case report documents a 68-year-old woman who developed back pain and leg weakness after undergoing surgical resection with adjuvant therapy of a primary fallopian tube adenocarcinoma. Her hospital course and follow-up are documented.
Results:  
Imaging revealed a compression fracture in the L1 body that when biopsied confirmed a metastatic fallopian tube cancer. More specifically, a soft tissue diagnosis of a high-grade serous papillary adenocarcinoma of fallopian tube origin. The patient underwent a surgical decompression, posterior stabilization, and tumor debulking with postoperative resolution of her symptoms. 
Conclusions:  
This is the first reported case of spine metastases from fallopian tube serous carcinoma in a living patient. This case documents the diagnosis of a pathological vertebral fracture due to metastasis of an atypical cancer. 
Keywords: fallopian tube carcinoma; metastasis; spine; reconstruction; FTC; L1; compression fracture; vertebrae; serous adenocarcinoma; malignant; carcinoma; adenocarcinoma

Introduction:
Osseous metastases from primary fallopian tube malignancies are rare with only a few documented cases in the medical literature. This case report illustrates a 68-year-old female with a compression fracture in the L1 body that when biopsied confirmed our suspicions of a metastatic fallopian tube cancer. 

Case Report:
A 68-year-old African American woman presented to the hospital with intractable back pain and lower extremity weakness. Her back pain began about a year prior but gradually worsened during the weeks prior to her admission. She also developed a progressive left lower extremity weakness a week prior to admission that eventually caused significant disability including leg buckling. She has a history of fallopian tube cancer with positive right axillary lymph nodes diagnosed in 2009 that warranted an exploratory laparotomy, hysterectomy, and bilateral salpingo-oophorectomy with radiation and chemotherapy. Notably, she has a remote 20 pack-year history, and her grandmother and aunt were diagnosed with breast cancer. 
Physical examination demonstrated a distended abdomen and paraspinal tenderness around T12-L1. Her neurological examination revealed left hip flexor strength at 2/5 and left quadriceps strength at 4/5.� Sensation was intact to light touch and pinprick and�reflexes were 1+ and symmetric throughout.� A CT scan of the lumbar spine revealed an L1 pathologic compression fracture with moderate to severe canal narrowing (Figures 1-2). She also underwent an MRI of her lumbar and thoracic spine that demonstrated soft tissue extension of the L1 tumor going into the canal and towards T12 (Figures 3-4).� Also, a large mass was noted in her left retroperitoneal space.
Based on the history, physical, and imaging studies, a recurrence of her fallopian tube cancer was high on the differential and the mass was biopsied. The biopsy revealed a high-grade serous papillary adenocarcinoma of fallopian tube origin, warranting surgical intervention (Figures 5-6). Preoperative embolization was performed to control any feeder and vessels minimize blood loss. We performed a midline posterior procedure, which included a laminectomy from T12-L2 followed by L1 corpectomy and reconstruction with a PEEK expandable cage packed with auto graft followed by posterior instrumented arthrodesis of T9-L4. She was treated with chemotherapy and radiation.
The operative approach involved a laminectomy, facetotomy, and foraminotomy, performed with decompression form T12-L2.  Then a L1 pedicle distraction osteotomy and vertebral column resection were performed along with discectomies at T12-L1 and L1-L2 utilizing the left sided transpedicular approach. This position of the case was unusual and complicated, requiring a modifier 22 due to the tumor removal involving the L1 vertebral body causing adhesions to the spinal cord, aorta and kidney as well as brisk bleeding during the removal of the tumor and vertebral body. Posterior arthrodesis of T9 through L4 followed, as well as posterior segmental instrumentation from T9 through L4 and anterior instrumentation from T12 to L2.
The patient�s symptoms resolved postoperatively with no complications. At her six-month follow-up visit, she is able to ambulate without a cane and maintains 5/5 bilateral lower extremity strength. The following postoperative x-rays demonstrate the spinal reconstruction and fixation at 6 months (Figures 7-8). 

Discussion:
Primary fallopian tube malignancies are rare, representing less than 0.2% of all malignancies diagnosed in women.1 They are usually diagnosed at an advanced stage, with 72% of fallopian tube malignancies being diagnosed at stage III or higher.2 Clinically and histologically, fallopian tube cancer resembles epithelial ovarian cancer and is generally managed in the same manner.1 However, because fallopian tube cancer is less common and has a low index of suspicion, treatment is often delayed.3 Management guidelines suggest surgical removal of the gross disease usually accompanied by adjuvant radiation or chemotherapy.4
Skeletal metastasis from a primary fallopian tube malignancy is an even more infrequent occurrence with only a few documented cases in the medical literature. In a clinicopathologic study of 305 patients with gynecologic carcinomas, 49 patients had evidence of skeletal metastasis, but only one of these cases came from a patient with primary fallopian tube carcinoma. And this one occurrence demonstrated a lesion detected postmortem in the vertebrae of a patient with high-grade stage II papillary serous adenocarcinoma with widespread metastasis.5 Courville et. al reported a case of a 56-year old female with metastasis of a fallopian tube cancer to the right femur and left 8th anterior rib. The patient received a trochanteric intramedullary nail and also underwent chemotherapy and radiation therapy to the right femur and left anterior ribs with a good clinical outcome.6 To our knowledge, this is the only documented case of symptomatic spinal metastasis from a primary fallopian tube carcinoma. Despite the advanced nature of this patient�s disease, this case illustrates that pathologic spinal fractures from metastatic primary cancer can be treated surgically at a late stage with good clinical outcomes.

Conclusion:

In conclusion, this is the first reported case of spine metastases from fallopian tube serous carcinoma in a living patient. This is a rare entity, but this case exemplifies the importance of a high index of suspicion when dealing with intractable pain and neurological symptoms in patients with and without a history of cancer. It also highlights the vital role of clinical, radiological, and histological correlation in the diagnosis of a pathological vertebral fracture due to metastasis of an atypical cancer. 

References:	
1. Healy NA, Hynes SO, Bruzzi J, et al. Asymptomatic primary fallopian tube cancer: An unusual cause of axillary  lymphadenopathy. Case Reports in Obstetrics and Gynecology 2011 Dec 11. doi:  HYPERLINK "http://dx.doi.org/10.1155%2F2011%2F402127" \t "pmc_ext" 10.1155/2011/402127

2. Yokoyama Y et al. Investigation of clinicopathological features of fallopian tube malignancy. Oncol Rep 2013 Apr 30. doi: 10.3892/or.2013.2439. [Epub ahead of print]

3.  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Kimmel%20KD%5BAuthor%5D&cauthor=true&cauthor_uid=3189120" Kimmel KD,� HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Chamberlain%20DH%5BAuthor%5D&cauthor=true&cauthor_uid=3189120" Chamberlain DH,� HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Bostrom%20SG%5BAuthor%5D&cauthor=true&cauthor_uid=3189120" Bostrom SG,� HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Christman%20JE%5BAuthor%5D&cauthor=true&cauthor_uid=3189120" Christman JE. Fallopian tube cancer.  Am Fam Physician 1988;38: 121-124.

4. Harrison CR et al. Carcinoma of the fallopian tube: clinical management. Gynecologic Oncology 1989;32: 357-359.

5. Abdul-Karim FW et al. Bone metastasis from gynecologic carcinomas: A clinicopathologic study.  Gynecologic Oncology 1990;39: 108-114.

6. Courville XF, Cortes Z, Katzman PJ et al. Case report: Bone metastases from fallopian tube carcinoma.�Clinical Orthopaedics and Related Research�2005;434: 278�281.

Figure Legend:

Figure 1. is a preoperative lumbar spine sagittal CT scan demonstrating an L1 compression fracture. 

Figure 2. is a preoperative lumbar spine axial CT scan demonstrating an L1 compression fracture.

Figure 3. is a preoperative lumbar spine sagittal T2-weighted MRI demonstrating an L1 compression fracture and spinal cord impingement.

Figure 4. is a preoperative lumbar spine sagittal T1-weighted MRI with gadolinium enhanced contrast demonstrating an L1 compression fracture with spinal cord impingement.

Figure 5. is a low-power pathologic specimen originating from the patient�s spine demonstrating a metastatic papillary carcinoma (H&E, 40x)

Figure 6. is a high-power pathologic specimen originating from the patient�s spine demonstrating complex papillae with epithelial budding and marked nuclear atypia, consistent with high-grade serous papillary adenocarcinoma (H&E, 200x)

Figure 7. is an anteroposterior x-ray demonstrating fusion at a 6 month follow-up

Figure 8. is a lateral x-ray demonstrating fusion at a 6 month follow-up

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