{"paper_id":"01f20bad-2e5c-4831-9052-955f974f4370","body_text":"Submit Manuscript | http://medcraveonline.com\nAbbreviations: B/L, Bilateral; TAH, Total Abdominal \nHysterectomy; BSO, Bilateral salpingo-oopherectomy\nIntroduction\nMalignant tumors of fallopian tube are very rare. The most common \nhistological type is adenocarcinoma. Sarcomas occur infrequently \nand carcinosarcomas or Malignant mixed mullerian tumors (MMMT) \nare very rare. These highly aggressive tumors are composed of both \nmalignant epithelial and stromal elements and usually have poor \nprognosis. Most patients of MMMT fallopian tube present with non- \nspecific symptoms like abdominal pain or distension or abnormal \nvaginal bleeding. In a great majority of cases the diagnosis is not \nmade until the time of surgery or histological evaluation. Data are \nlimited, but primary cytoreductive surgery followed by platinum \nbased chemotherapy seems to be effective.\nCase presentation\nWe present the case of 49 year old perimenopausal female, \nP2L2, who came to our institute in November 2014 with the chief \ncomplaints of irregular and heavy bleeding for the past 3 months. \nOn examination the general condition of patient was stable with a \npulse rate of 88/minute and blood pressure of 128/78 mm Hg. On \nper-abdomen examination, a mass was palpable in the lower abdomen \narising from the pelvis and the same mass was palpable on the per-\nvaginal examination. Her CA125 level was 136 U/ml while her CA19-\n9 and CEA levels were normal. Her CBC was normal, Hb-9.9 g/dl, \nTLC-9000/mm3, Platelet count-2.3 lakh/mm3. MRI suggested a right \nadenexal mass of 9.3 x 5.4 x 6.6 cm adherent to the adjacent rectal \nwall with no other evidence of disease. Endometrial biopsy revealed \nsecretory endometrium with no evidence of malignancy. Cervical \ncytology was also normal. A pre-operative diagnosis of malignant \novarian tumor was made.\nShe underwent exploratory laparotomy. Per-operatively the \nupper abdomen was normal. About 50 ml of haemorrhagic fluid \nwas present in the pelvis. Left fallopian tube was dilated to about \n10 x 5 cm with smooth outer surface. Bilateral ovaries, uterus and \nright tube was apparently normal while the bladder peritoneum \nappeared suspicious. She underwent total abdominal hysterectomy \nwith bilateral salpingo-oopherectomy (TAH with BSO), which was \nmalignant on frozen section and this was followed by B/L pelvic nodal \ndissection, retroperitoneal lymph node sampling, total omentectomy, \nappendicectomy, bladder peritonectomy, multiple peritoneal biopsies \nand fluid for cytology.\nHistopathological findings           \nGross description- Right fallopian tube was enlarged and expanded \nto 9 x 5 x 5 cm. The serosal surface was smooth with no breach. \nThe luminal surface showed a friable, polypoidal, yellowish white \nhaemorrhagic tumor8.3 x 4.8 x 4.7 cm.\nHistological description: The tumor was composed of \nmalignant epithelial as well as mesenchymal component. The \nepithelial component was in the form of high grade endometrioid \nadenocarcinoma. The mesenchymal component was composed of \nhigh grade spindle cells with marked pleomorphism, brisk mitosis \nand extensive areas of necrosis (Figure 1). The tumor was infiltrating \ninto the wall of fallopian tube, however serosal breach was not \nidentified. Lymphovascular invasion was not seen. B/L ovaries, \nleft fallopian tube, uterus, omentum, appendix, peritoneal biopsies, \nbladder peritoneum, pelvic and retroperitoneal lymph nodes were free \nof tumor. Peritoneal fluid was negative for malignant cells. So a final \ndiagnosis of MMMT (carcinosarcomas) of fallopian tube, stage IA \n(FIGO 2014) was made. The patient received 6 cycles of cisplatin, \nifosfamide and paclitaxel (TIP) based chemotherapy and presently the \npatient is alive with no evidence of disease with a follow up period of \nabout 28 months.\nDiscussion\nPrimary MMMT of fallopian tube are rare (less than 4% of all \ngynaecological carcinosarcomas), which most frequently occur in \nthe endometrium, vagina, cervix and ovary in descending order of \nObstet Gynecol Int J. 2017;7(6):349‒350. 349\n©2017 Jain et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which \npermits unrestrited use, distribution, and build upon your work non-commercially.\nMalignant Mixed Mullerian T umor of Fallopian T ube: \nA Case Report\nVolume 7 Issue 6 - 2017\nVandana Jain,  Rupinder Sekhon, Shveta Giri, \nSudhir Rawal\nDepartment of Uro-Gynae Oncology, Rajiv Gandhi Cancer \nInstitute and Research Centre, India\nCorrespondence: Vandana Jain, Fellow Gynecologic Oncology, \nRajiv Gandhi Cancer Institute and Research Centre, Sector \n5, Rohini, New Delhi, India, T el 919910700788, Fax 91-11-\n27051037, Email \nReceived: April 18, 2017 | Published: August 15, 2017\nAbstract\nWe report a case of malignant mixed mullerian tumor (MMMT) of fallopian tube in a 49 \nyear old female who presented to our institute in November 2014 with the chief complaints \nof irregular and excessive bleeding per vaginum for 3 months. MRI of the patient revealed a \nright adenexal complex mass of 9 x 5 x 7 cm. Her CA125 level was 136 U/ml, whileCA19-9 \nand CEA levels were normal. Her cervical cytology was normal and preoperative \nendometrial curetting revealed secretory endometrium. A malignant ovarian tumor was \nsuspected and the patient was taken up for staging surgery. On final histopathology it was \nMMMT of right fallopian tube, stage IA. She received 6 cycles of cisplatin, ifosfamide and \npaclitaxel (TIP) based chemotherapy. Presently she is alive with no evidence of disease \nwith a follow up period of 28 months. This case report suggests that prognosis of early stage \nMMMT is good, especially if there is no deep infiltration of the muscle layer of fallopian \ntube and the peritoneal cytology is negative. Chemotherapy using a platinum drug after \nsurgery seems to be the most effective treatment in this disease.\nKeywords: MMMT of fallopian tube, Platinum based chemotherapy, Staging surgery\nObstetrics & Gynecology International Journal\nCase Report\n Open Access\n\n\nMalignant Mixed Mullerian Tumor of Fallopian Tube: A Case Report\n350\nCopyright:\n©2017 Jain et al.\nCitation: Jain V, Sekhon R, Giri S, et al. Malignant Mixed Mullerian T umor of Fallopian T ube: A Case Report. Obstet Gynecol Int J. 2017;7(6):349‒350. \nDOI: 10.15406/ogij.2017.07.00268\nfrequency.1,2 In our study the age of the patient was 49 yrs. In a review \nmost patients were in the fifth or sixth decade of life, with a mean age \nof 57.5 years. 1 Most of the patients with MMMT of fallopian tube \npresent with nonspecific symptoms. In a review, frequent symptoms \nwere abdominal pain or distension (47.9%) followed by atypical \ngenital bleeding (34.2%). 3 It has been noted that postmenopausal \nbleeding or spotting with negative cervical cytology and endometrial \ncuretting should raise the suspicion of tubal malignancy, 4 as was the \ncase in our patient. The diagnosis is usually not made until the time of \nsurgery, with the most common pre-operative diagnosis being ovarian \nmalignancy.1 Our patient was also diagnosed as malignant ovarian \ntumor prior to surgery.\nSurgical procedures at laparotomy should include collection \nof washings for cytology, a thorough exploration of all peritoneal \nsurfaces, omentectomy, pelvic and retroperitoneal lymph node \nsampling and peritoneal biopsies in addition to TAH with BSO. \nA maximal effort at tumor cytoreduction is emphasized similar to \novarian cancer and adenocarcinoma of fallopian tube.5\nThe prognosis of patients with MMMT of fallopian tube is \nusually poor. Extra tubal spread is the most important prognostic \nfactor which is same as primary adenocarcinoma of fallopian tube.  \nMMMT of fallopian tube is usually diagnosed at an advanced stage. \nIn a recent review only about 32.3% patients were stage I. The 3 year \nsurvival was 62.7% for stage I/II patients and 39.8% for stage III/IV \npatients.3 There is increasing evidence that adjuvant platinum based \nchemotherapy used alone or in combination with radiotherapymay \nimprove the survival in cases of tubal MMMT.2,3,6 In a recent review, \nIfosfamide based chemotherapy (IEP) appeared to be a promising \nregiment for this disease. 3 GOG has also reported a high level of \nbenefit for ifosfamide and cisplatin in uterine carcinosarcomas. 7 In \nthe present case report the patient was stage I MMMT of fallopian \ntube and received platinum based chemotherapy (TIP) after staging \nsurgery. The patient is alive with no evidence of disease after 28 \nmonths of follow up.\nConclusion\nIn conclusion, MMMT of fallopian tube is associated with poor \nprognosis, although in early stage the prognosis is not that bad, \nespecially if there is no deep infiltration of the wall of fallopian tube. \nPrimary cytoreductive surgery followed by adjuvant platinum based \nchemotherapy is the most effective treatment available at present.\nAcknowledgements\nWe would like to say special thanks to Dr. Anila Sharma and Dr. \nParul Tanwar for providing the histopathology pictures to us.\nConflicts of Interest\nNo financial interest or conflicts of interest exist.\nReferences\n1. Imachi M, Tsukamoto N, Shigematsu T, et al. Malignant mixed mullerian \ntumor of the fallopian tube: report of two cases and review of literature. \nGynecol Oncol. 1992;47(1):114–124.\n2. Horn LC, Werschnik C, Bilek K, et al. Diagnosis and clinical \nmanagement in malignant mixed mullerian tumors of the fallopian tube. \nArch Gynaecol Obstet. 1996;258(1):47–53.\n3. Yokoyama Y , Yokota M, Futagami M, et al. Carcinosarcoma of the \nfallopian tube: Report of four cases and review of literature. Asia Pac J \nClin Oncol. 2012;8(3):303–311.\n4. Kinoshita M, Asano S, Yamashita M, et al. Mesodermal mixed tumor \nprimary in the fallopian tube. Gynecol Oncol. 1989;32(3):331–335.\n5. Shen YM, Xie YP, Xu L, et al. Malignant mixed mullerian tumor of the \nfallopian tube: report of two cases and review of literature. Arch Gynecol \nObstet. 2010;281(6):1023–1028.\n6. Weber AM, Hewett WF, Gajewski WH, et al. Malignant mixed mullerian \ntumors of the fallopian tube. Gynecol Oncol. 1993;50(2):239–243.\n7. Sutton G, Brunetto VL, Kilgore L, et al. A phase III trial of ifosfamide \nwith or without cisplatin in carcinosarcoma of the uterus: a Gynecologic \nOncology Group Study. 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