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Mesodermal mixed tumor primary in the fallopian tube
GYNECOLOGIC
ONCOLOGY
32, 331-335
(1989)
Mesodermal Mixed Tumor Primary in the Fallopian Tube MIKIHISA
KINOSHITA,
M.D.,* Department
SADAMU of Obstetrics
ASANO,
M.D.,
MASANORI
and Gynecology,
Toyo-oka
Received
September
Mullerian mixed tumors, as a group, are uncommon. Only 27 cases of this tumor of the fallopian tube have been reported to date. We report the 28th case of mixed mesodermal tumor, originating in the fallopian tube. A 79-year-old woman had mistaken a bloody vaginal discharge for hematuria. Various examinations showed no evidence of malignancy. However, computerized tomography revealed an intrapelvic tumor. Laparotomy was performed, with a suspicion of tubal malignancy. The iinal pathologic diagnosis was mixed mesodermal tumor, originating in the fallopian tube. Postoperatively, the patient was placed on oral adjuvant chemotherapy for 34 months. At present, she is doing well. Though no definite conclusions regarding the best method of therapy can be reached, an aggressive mode of therapy is recommended. The primary therapy is surgery; however, surgery followed by chemotherapy may have a potential benefit. o 1989 Academic prem, IW. INTRODUCTION Mullerian mixed tumors [ll are uncommon. With the exception of vaginal lesions [21, the tumors are generally
found in older women. They may occur anywhere in the female genital tract from the upper portion of the vagina to the ovary and are infrequently found in extragenital sites [3,4]. The most common site of origin is the endometrium, and the least common site in the genital tract is the uterine tube. To date, there have been only 27 reported cases [5-81. By definition [ 11, mullerian mixed tumors are composed of more than one cell type and may show both homologous (carcinosarcoma) and heterologous components (mesodermal mixed tumor). It is believed that both components originate from the multipotent mesoderm of the mullerian system [2,5,9,101. Some authors theorize that this tumor arises in the mullerian system in proportion to the normal functional activity encountered in the tissue [l 11. This paper reports the 28th case of mesodermal mixed tumor, originating in the fallopian tube, and briefly reviews the literature concerning the diagnosis, prognosis, and therapy of this disease.
YAMASHITA, Public
Hospital,
M.D., Toyo-oka,
AND
TSUTOMU
Hyogo,
MATSUDA,
M.D.
Japan
14, 1987
CASE REPORT
A 79-year-old Japanese female, gravida I, para I (a stillbirth), 27 years beyond menopause, visited the outpatient department of urology, Toyo-oka Public Hospital, on March 10, 1983, with a complaint of hematuria. She experienced no pain or other associated symptoms. Since the urological examinations revealed no abnormalities in the urinary tract, the patient was referred to the gynecologic department for further examinations on March 22, 1983. Past history revealed that the patient had had a left salpingo-oophorectomy because of pyosalpinx at the age of 26. The findings on physical examination were normal. Through pelvic examination, 1 to 2 ml of watery, bloody discharge with no foul smell was found in the vaginal cavity. It was considered that the patient might have mistaken the watery bloody vaginal discharge for hematuria. The uterus was hardly palpable and neither adnexa nor abnormal mass could be palpated. Papanicolaou smears were studied four times, always showing class II results. Laboratory data were not contributory, except for immunosuppressive acidic protein (640 pg/ml) and erythrocyte sedimentation rate (1 hr:55 mm, 2 hr:l 10 mm). Histological study of the cervix, pelvic ultrasound study, hysterosalpingogram, colposcopic study, and hysteroscopy gave no significant information. Curettage of the uterine cervix and corpus yielded no tissues which were adequate for histological study. Computerized tomography demonstrated an irregularly shaped mass, with low homogenous density, which lay dorsal to the atrophic uterus (Fig. 1). Thus, no evidence of malignancy was obtained from the above-mentioned examinations. However, consideration of the clinical symptom, the persistent postmenopausal watery bloody vaginal discharge, suggested the presence of malignant disease of the genital organs, in
331 0090~8258/89 $1 SO Copyright Q 1989 by Academic Press, Inc. All rights of reproduction in any form reserved.
332
KINOSHITA
FIG.
1.
Computerized
ET AL.
tomograph. (6) A mass in the pelvis. (T) Uterus.
particular, the uterine tube. Thus, surgical intervention was indicated. On June 3, 1983, the patient underwent laparotomy, which revealed a tumor of the right fallopian tube. No ascites was present. Total hysterectomy and right salpingooophorectomy were performed. During the operation, cytological examination of the stamp of the tumor content revealed malignant cells. The final pathologic diagnosis was mixed mesodermal tumor, originating in the fallopian tube. The stage was estimated as Ia [12]. Postoperatively, the patient was placed on a combination of tegafur (800 mg/day) and PSK [ 13](3.0 g/day) for 47 days, from June 30, 1983, and a combination of carmofur (300 mgjday) and PSK (3.0 g/day) for 280 days, from August 16, 1983, to May 22, 1984. Because she complained of a loss of appetite, she received only PSK from May 22, 1984, to April, 1986. She has been well and has shown no signs of recurrence.
GROSS PATHOLOGY
The left adnexa had been previously excised for pyosalpinx when the patient was 26 years of age. The Surgical specimen consisted of the uterus and the right adnexa (Fig. 2). The uterus was normal in size, shape, and consistency, and its surface was smooth. Though the isthmus of the tube was not remarkable, its ampulla was swollen to approximately 1.5 cm in thickness, and snaked. The distal end formed a spherical, elastic firm tumor of ap-
proximately 5 cm in diameter. The tumor was loosely adherent to the posterior uterine wall, right pelvic wall, and posterior leaf of the right broad ligament. The surface of the tumor was smooth and grayish white. The loose adhesion around the tumor was carefully dissected, but the tumor capsule was readily ruptured. The tumor was wrapped in gauze to avoid a spill of the contents during the operation. The right ovary was markedly atrophic and appeared to be unrelated to the tumor.
MICROSCOPIC PATHOLOGY
Though the histology of the cervix, endometrium, myometrium, isthmus of the fallopian tube, and ovary revealed no malignancy, sections of the tumor of the tubal ampulla showed both carcinomatous and sarcomatous elements (Fig. 3). The carcinomatous areas, showing papillary growth, resembled a poorly differentiated primary carcinoma of the fallopian tube (Fig. 4). The sarcomatous component was made up of round, elongated or bizarre-shaped mononuclear cells, including occasional multinucleated giant cells (Fig. 3). In the cytoplasm of some of the elongated cells, cross-striation was seen in both hematoxylin and eosin (Fig. 5), and phosphotungstic acidhematoxylin-stained sections. The sarcomatous component resembled endometrial stromal sarcoma. No areas of chondrosarcoma, osteosarcoma, or liposarcoma were present.
MULLERIAN
TUMOR
OF THE UTERINE
TUBE
333
FIG. 2. Posterior view of the removed specimen. The fallopian tube is stretched to clearly show the ovary (a).
DISCUSSION The 27 reported cases of mullerian mixed tumor, originating in the fallopian tube, have commonly occurred in the fifth and sixth decades of life 15-81. The mean age (59.0) seems to be slightly younger than that of patients with mullerian mixed tumors originating in the uterus [14-161.
In the early stages, the tumor might not produce any clinical symptoms [5,10,17,18]. The late manifestations are nonspecific, such as abdominal enlargement, crampy abdominal pain, and vaginal spotting [5-8,191. These symptoms are similar to those of carcinoma of the fallopian tube [10,17,18,20,21]. The diagnosis is usually made on histological examination [5,10,17,18]. It should be noted that postmenopausal bleeding or intermenstrual bleeding
FIG. 3. Carcinomatous (right) and sarcomatous (left) components. HE stain, x 100.
334
KINOSHITA
FIG. 4. Carcinomatous
ET AL.
area showing papillary growth. HE stain, x 100.
with nondiagnostic endometrial and endocervical curettings should heighten the suspicion of tubal neoplasms [ 10,221. The routes of metastasis are similar to those of carcinema of the fallopian tube [5,10,17,18,23]. The most common metastatic sites are the neighboring organs, such as the ovaries, the contralateral fallopian tube, the pa-
raaortic and lumbosacral lymph nodes, the bowel, and the peritoneal surfaces [5]. Distant metastasis is rare [5]. The prognosis is usually poor. Out of the 27 patients reported, only 1 patient has lived longer than 5 years [7], while at least 8 patients have died within 3 years after their surgery [5]. The relationship between the prog-
FIG. 5. High power view of a sarcomatous area. HE stain, x400. (t ) Cross-striation.
MULLERIAN
TUMOR
nosis and the histological type still remains controversial [14,15]. The cause of all deaths was metastasis; thus confinement of the tumor to the tube with a smooth outer surface might lead to a reasonably favorable outcome [7,191. All patients had partial or complete removal of the tumor, including total or subtotal hysterectomy and bilateral salpingo-oophorectomy [5-81. Of these patients, 14 were treated with surgery alone [5,6,10,18,24]. Radiation was used as a therapeutic approach in 10 patients [2,5,7,911,17,19,23]. Mullerian mixed tumors seem to be relatively radioresistant, regardless of the site [5,14,19,25]. Five patients, including the present case, had surgery and postoperative chemotherapy [2,5,7,8]. Our patient is presently doing well, with no signs of recurrence (October, 1987, 51 months after the operation). Recently, Kohorn [14] suggested that some patients with mixed mullerian tumors of the uterus might demonstrate a significant response to chemotherapy, especially to platinum-containing chemotherapeutic regimens. Due to the small number of reported cases of mullerian mixed tumor of the fallopian tube, no definite conclusions regarding the best method of therapy can be reached. As the prognosis is generally poor, an aggressive mode of therapy is recommended. Thus, the primary method of therapy is surgery; however, surgery followed by chemotherapy may have a potential benefit.
1. Paulsen, H. E., Taylor, C. W., and Sobin, L. H. No.
typing
(1973).
on neonatology
13.
14.
15.
16. 17.
19.
Health Organization, Geneva,
p. 69 (1975). 2. McQueeney, A. J., Carswell, B. L., and Sheehan, W. J. Malignant mixed miillerian tumor primary in uterine tube: Review of the literature and report of an additional case, Obstet. Gynecol. 23, 338-343 (1964). 3. Marchevsky, A., Jacobs, A. J., Deppe, G., and Cohen, C. J. Extragenital homologous mixed mullerian tumor, J. Reprod. Med. 27, 110-112 (1982). Chumas, J. C., Thanning, L., and Mann, W. J. Malignant mixed mullerian tumor arising in extragenital endometriosis: Report of a case and review of the literature, Gynecol. Oncot. 23, 227-233 (1986). Hanjani, P., Petersen, R. O., and Bonnell, S. A. Malignant mixed mullerian tumor of the fallopian tube: Report of a case and review of literature, Gynecol. Oncol. 9, 381-393 (1980). Buchino, J. J., and Buchino, J. J. Malignant mixed mullerian tumor of the fallopian tube, Arch. Pathol. Lab. Med. 111, 386-387 (1987). Kahanp%, K. V., Laine, R., and Saksela, E. Malignant mixed
335
11. Williams, T. J., and Woodruff, J. D. Malignant mixed mesenchymal tumor of the uterine tube: Report of a case, Obstet. Gynecol. 21, 618-621 (1963). 12. American College of Obstetricians and Gynecologists’ Committee on Terminology. Obstetric-gynecologic terminology with section
fnternationd
13. Histological
TUBE
mullerian tumor of the fallopian tube: Report of a case with 5-year survival, Gynecol. Oncol. 16, 144-149 (1983). 8. Hoist, N., and Erichsen, A. Mixed mesodermal tumor of the fallopian tube. A case report, Ann. Chir. Gynaecol. 70, 207-209 (1981). 9. De Queiroz, A. C., and Roth, L. M. Malignant mixed miillerian tumor of the fallopian tube: Report of a case, Obstet. Gynecol. 36, 554-557 (1970). 10. Wu, J. P., Tanner, W. S., and Fardal, P. M. Malignant mixed miillerian tumor of the uterine tube, Obstet. Gynecol. 41, 707-712
18.
REFERENCES histological class$cation of tumors: of female genital tract tumors, World
OF THE UTERINE
20.
21.
22. -23.
24. 25.
and glossary
of congenital
anomalies
(E. C. Hughes,
Ed.), Davis, Philadelphia, p. 154 (1972). Tsukagoshi, S., Hashimoto, Y., Fujii, G., Kobayashi, H., Nomoto, K., and Orita, K. Krestin (PSK), Cancer Treat. Rev. 11, 131-155 (1984). Kohorn, E. I., Schwartz, P. E., Chambers, J. T., Peschel, R. E., Kapp, D. S., and Merino, M. Adjuvant therapy in mixed mullerian tumors of the uterus, Gynecol. Oncol. 23, 212-221 (1986). Lotocki, R., Rosenshein, N. B., Grumbine, F., Dillon, M., Parmley, T., and Woodruff, D. Mixed mullerian tumors of the uterus: Clinical and pathologic correlations, Int. J. Gynecol. Obstet. 20, 237-243 (1982). King, M. E., and Kramer, E. E. Malignant mullerian mixed tumors of the uterus: A study of 21 cases, Cancer 45, 188-190 (1980). Acosta, A. A., Kaplan, A. L., and Kaufman, R. H. Mixed miillerian tumors of the oviduct, Obstet. Gynecol. 44, 84-90 (1974). Jain, U. Mixed mesodermal tumor of the fallopian tube: Report of a case and review of literature, Md. State Med. J., November, 43-46 (1977). Manes, J. L., and Taylor, H. B. Carcinosarcoma and mixed miillerian tumors of the fallopian tube: Report of four cases, Cancer 38, 1687-1693 (1976). Podratz, K. C., Podczaski, E. S., GafTey, T. A., O’Brien, P. C., Schray, M. F., and Malkasian, Jr., G. D. Primary carcinoma of the fallopian tube, Amer. J. Obstet. Gynecol. 154, 1319-1326 (1986). McMurray, E. H., Jacobs, A. J., Perez, C. A., Camel, H. A., Kao, M., and Galakatos, A. Carcinoma of the fallopian tube. Management and sites of failure, Cancer 58, 2070-2079 (1986). Israel, S. L., Grisp, W. E., and Adrian, D. C. Preoperative diagnosis of primary carcinoma of the fallopian tube, Amer. J. Obstet. Gynecol. 68, 1589-1593 (1954). Henderson, S. R., Harper, R. C., Salazar, 0. M., and Rudolph, J. H. Primary carcinoma of the fallopian tube: Difficulties of diagnosis and treatment, Gynecol. Oncol. 5, 168-179 (1977). Malnasy, J., and Gaal, M. Primary carcinosarcoma of the fallopian tube, Gynaecologia 154, 203-208 (1963). Kiihn, W., Herberling, D., Hijffken, H., and Rummel, H. H. Morphologie und Klinik der malignen Miillerschen Mischtumoren des Corpus uteri, Geburtshilfe Frauenheilkd. 42, 888-891 (1982).
ONCOLOGY
32, 331-335
(1989)
Mesodermal Mixed Tumor Primary in the Fallopian Tube MIKIHISA
KINOSHITA,
M.D.,* Department
SADAMU of Obstetrics
ASANO,
M.D.,
MASANORI
and Gynecology,
Toyo-oka
Received
September
Mullerian mixed tumors, as a group, are uncommon. Only 27 cases of this tumor of the fallopian tube have been reported to date. We report the 28th case of mixed mesodermal tumor, originating in the fallopian tube. A 79-year-old woman had mistaken a bloody vaginal discharge for hematuria. Various examinations showed no evidence of malignancy. However, computerized tomography revealed an intrapelvic tumor. Laparotomy was performed, with a suspicion of tubal malignancy. The iinal pathologic diagnosis was mixed mesodermal tumor, originating in the fallopian tube. Postoperatively, the patient was placed on oral adjuvant chemotherapy for 34 months. At present, she is doing well. Though no definite conclusions regarding the best method of therapy can be reached, an aggressive mode of therapy is recommended. The primary therapy is surgery; however, surgery followed by chemotherapy may have a potential benefit. o 1989 Academic prem, IW. INTRODUCTION Mullerian mixed tumors [ll are uncommon. With the exception of vaginal lesions [21, the tumors are generally
found in older women. They may occur anywhere in the female genital tract from the upper portion of the vagina to the ovary and are infrequently found in extragenital sites [3,4]. The most common site of origin is the endometrium, and the least common site in the genital tract is the uterine tube. To date, there have been only 27 reported cases [5-81. By definition [ 11, mullerian mixed tumors are composed of more than one cell type and may show both homologous (carcinosarcoma) and heterologous components (mesodermal mixed tumor). It is believed that both components originate from the multipotent mesoderm of the mullerian system [2,5,9,101. Some authors theorize that this tumor arises in the mullerian system in proportion to the normal functional activity encountered in the tissue [l 11. This paper reports the 28th case of mesodermal mixed tumor, originating in the fallopian tube, and briefly reviews the literature concerning the diagnosis, prognosis, and therapy of this disease.
YAMASHITA, Public
Hospital,
M.D., Toyo-oka,
AND
TSUTOMU
Hyogo,
MATSUDA,
M.D.
Japan
14, 1987
CASE REPORT
A 79-year-old Japanese female, gravida I, para I (a stillbirth), 27 years beyond menopause, visited the outpatient department of urology, Toyo-oka Public Hospital, on March 10, 1983, with a complaint of hematuria. She experienced no pain or other associated symptoms. Since the urological examinations revealed no abnormalities in the urinary tract, the patient was referred to the gynecologic department for further examinations on March 22, 1983. Past history revealed that the patient had had a left salpingo-oophorectomy because of pyosalpinx at the age of 26. The findings on physical examination were normal. Through pelvic examination, 1 to 2 ml of watery, bloody discharge with no foul smell was found in the vaginal cavity. It was considered that the patient might have mistaken the watery bloody vaginal discharge for hematuria. The uterus was hardly palpable and neither adnexa nor abnormal mass could be palpated. Papanicolaou smears were studied four times, always showing class II results. Laboratory data were not contributory, except for immunosuppressive acidic protein (640 pg/ml) and erythrocyte sedimentation rate (1 hr:55 mm, 2 hr:l 10 mm). Histological study of the cervix, pelvic ultrasound study, hysterosalpingogram, colposcopic study, and hysteroscopy gave no significant information. Curettage of the uterine cervix and corpus yielded no tissues which were adequate for histological study. Computerized tomography demonstrated an irregularly shaped mass, with low homogenous density, which lay dorsal to the atrophic uterus (Fig. 1). Thus, no evidence of malignancy was obtained from the above-mentioned examinations. However, consideration of the clinical symptom, the persistent postmenopausal watery bloody vaginal discharge, suggested the presence of malignant disease of the genital organs, in
331 0090~8258/89 $1 SO Copyright Q 1989 by Academic Press, Inc. All rights of reproduction in any form reserved.
332
KINOSHITA
FIG.
1.
Computerized
ET AL.
tomograph. (6) A mass in the pelvis. (T) Uterus.
particular, the uterine tube. Thus, surgical intervention was indicated. On June 3, 1983, the patient underwent laparotomy, which revealed a tumor of the right fallopian tube. No ascites was present. Total hysterectomy and right salpingooophorectomy were performed. During the operation, cytological examination of the stamp of the tumor content revealed malignant cells. The final pathologic diagnosis was mixed mesodermal tumor, originating in the fallopian tube. The stage was estimated as Ia [12]. Postoperatively, the patient was placed on a combination of tegafur (800 mg/day) and PSK [ 13](3.0 g/day) for 47 days, from June 30, 1983, and a combination of carmofur (300 mgjday) and PSK (3.0 g/day) for 280 days, from August 16, 1983, to May 22, 1984. Because she complained of a loss of appetite, she received only PSK from May 22, 1984, to April, 1986. She has been well and has shown no signs of recurrence.
GROSS PATHOLOGY
The left adnexa had been previously excised for pyosalpinx when the patient was 26 years of age. The Surgical specimen consisted of the uterus and the right adnexa (Fig. 2). The uterus was normal in size, shape, and consistency, and its surface was smooth. Though the isthmus of the tube was not remarkable, its ampulla was swollen to approximately 1.5 cm in thickness, and snaked. The distal end formed a spherical, elastic firm tumor of ap-
proximately 5 cm in diameter. The tumor was loosely adherent to the posterior uterine wall, right pelvic wall, and posterior leaf of the right broad ligament. The surface of the tumor was smooth and grayish white. The loose adhesion around the tumor was carefully dissected, but the tumor capsule was readily ruptured. The tumor was wrapped in gauze to avoid a spill of the contents during the operation. The right ovary was markedly atrophic and appeared to be unrelated to the tumor.
MICROSCOPIC PATHOLOGY
Though the histology of the cervix, endometrium, myometrium, isthmus of the fallopian tube, and ovary revealed no malignancy, sections of the tumor of the tubal ampulla showed both carcinomatous and sarcomatous elements (Fig. 3). The carcinomatous areas, showing papillary growth, resembled a poorly differentiated primary carcinoma of the fallopian tube (Fig. 4). The sarcomatous component was made up of round, elongated or bizarre-shaped mononuclear cells, including occasional multinucleated giant cells (Fig. 3). In the cytoplasm of some of the elongated cells, cross-striation was seen in both hematoxylin and eosin (Fig. 5), and phosphotungstic acidhematoxylin-stained sections. The sarcomatous component resembled endometrial stromal sarcoma. No areas of chondrosarcoma, osteosarcoma, or liposarcoma were present.
MULLERIAN
TUMOR
OF THE UTERINE
TUBE
333
FIG. 2. Posterior view of the removed specimen. The fallopian tube is stretched to clearly show the ovary (a).
DISCUSSION The 27 reported cases of mullerian mixed tumor, originating in the fallopian tube, have commonly occurred in the fifth and sixth decades of life 15-81. The mean age (59.0) seems to be slightly younger than that of patients with mullerian mixed tumors originating in the uterus [14-161.
In the early stages, the tumor might not produce any clinical symptoms [5,10,17,18]. The late manifestations are nonspecific, such as abdominal enlargement, crampy abdominal pain, and vaginal spotting [5-8,191. These symptoms are similar to those of carcinoma of the fallopian tube [10,17,18,20,21]. The diagnosis is usually made on histological examination [5,10,17,18]. It should be noted that postmenopausal bleeding or intermenstrual bleeding
FIG. 3. Carcinomatous (right) and sarcomatous (left) components. HE stain, x 100.
334
KINOSHITA
FIG. 4. Carcinomatous
ET AL.
area showing papillary growth. HE stain, x 100.
with nondiagnostic endometrial and endocervical curettings should heighten the suspicion of tubal neoplasms [ 10,221. The routes of metastasis are similar to those of carcinema of the fallopian tube [5,10,17,18,23]. The most common metastatic sites are the neighboring organs, such as the ovaries, the contralateral fallopian tube, the pa-
raaortic and lumbosacral lymph nodes, the bowel, and the peritoneal surfaces [5]. Distant metastasis is rare [5]. The prognosis is usually poor. Out of the 27 patients reported, only 1 patient has lived longer than 5 years [7], while at least 8 patients have died within 3 years after their surgery [5]. The relationship between the prog-
FIG. 5. High power view of a sarcomatous area. HE stain, x400. (t ) Cross-striation.
MULLERIAN
TUMOR
nosis and the histological type still remains controversial [14,15]. The cause of all deaths was metastasis; thus confinement of the tumor to the tube with a smooth outer surface might lead to a reasonably favorable outcome [7,191. All patients had partial or complete removal of the tumor, including total or subtotal hysterectomy and bilateral salpingo-oophorectomy [5-81. Of these patients, 14 were treated with surgery alone [5,6,10,18,24]. Radiation was used as a therapeutic approach in 10 patients [2,5,7,911,17,19,23]. Mullerian mixed tumors seem to be relatively radioresistant, regardless of the site [5,14,19,25]. Five patients, including the present case, had surgery and postoperative chemotherapy [2,5,7,8]. Our patient is presently doing well, with no signs of recurrence (October, 1987, 51 months after the operation). Recently, Kohorn [14] suggested that some patients with mixed mullerian tumors of the uterus might demonstrate a significant response to chemotherapy, especially to platinum-containing chemotherapeutic regimens. Due to the small number of reported cases of mullerian mixed tumor of the fallopian tube, no definite conclusions regarding the best method of therapy can be reached. As the prognosis is generally poor, an aggressive mode of therapy is recommended. Thus, the primary method of therapy is surgery; however, surgery followed by chemotherapy may have a potential benefit.
1. Paulsen, H. E., Taylor, C. W., and Sobin, L. H. No.
typing
(1973).
on neonatology
13.
14.
15.
16. 17.
19.
Health Organization, Geneva,
p. 69 (1975). 2. McQueeney, A. J., Carswell, B. L., and Sheehan, W. J. Malignant mixed miillerian tumor primary in uterine tube: Review of the literature and report of an additional case, Obstet. Gynecol. 23, 338-343 (1964). 3. Marchevsky, A., Jacobs, A. J., Deppe, G., and Cohen, C. J. Extragenital homologous mixed mullerian tumor, J. Reprod. Med. 27, 110-112 (1982). Chumas, J. C., Thanning, L., and Mann, W. J. Malignant mixed mullerian tumor arising in extragenital endometriosis: Report of a case and review of the literature, Gynecol. Oncot. 23, 227-233 (1986). Hanjani, P., Petersen, R. O., and Bonnell, S. A. Malignant mixed mullerian tumor of the fallopian tube: Report of a case and review of literature, Gynecol. Oncol. 9, 381-393 (1980). Buchino, J. J., and Buchino, J. J. Malignant mixed mullerian tumor of the fallopian tube, Arch. Pathol. Lab. Med. 111, 386-387 (1987). Kahanp%, K. V., Laine, R., and Saksela, E. Malignant mixed
335
11. Williams, T. J., and Woodruff, J. D. Malignant mixed mesenchymal tumor of the uterine tube: Report of a case, Obstet. Gynecol. 21, 618-621 (1963). 12. American College of Obstetricians and Gynecologists’ Committee on Terminology. Obstetric-gynecologic terminology with section
fnternationd
13. Histological
TUBE
mullerian tumor of the fallopian tube: Report of a case with 5-year survival, Gynecol. Oncol. 16, 144-149 (1983). 8. Hoist, N., and Erichsen, A. Mixed mesodermal tumor of the fallopian tube. A case report, Ann. Chir. Gynaecol. 70, 207-209 (1981). 9. De Queiroz, A. C., and Roth, L. M. Malignant mixed miillerian tumor of the fallopian tube: Report of a case, Obstet. Gynecol. 36, 554-557 (1970). 10. Wu, J. P., Tanner, W. S., and Fardal, P. M. Malignant mixed miillerian tumor of the uterine tube, Obstet. Gynecol. 41, 707-712
18.
REFERENCES histological class$cation of tumors: of female genital tract tumors, World
OF THE UTERINE
20.
21.
22. -23.
24. 25.
and glossary
of congenital
anomalies
(E. C. Hughes,
Ed.), Davis, Philadelphia, p. 154 (1972). Tsukagoshi, S., Hashimoto, Y., Fujii, G., Kobayashi, H., Nomoto, K., and Orita, K. Krestin (PSK), Cancer Treat. Rev. 11, 131-155 (1984). Kohorn, E. I., Schwartz, P. E., Chambers, J. T., Peschel, R. E., Kapp, D. S., and Merino, M. Adjuvant therapy in mixed mullerian tumors of the uterus, Gynecol. Oncol. 23, 212-221 (1986). Lotocki, R., Rosenshein, N. B., Grumbine, F., Dillon, M., Parmley, T., and Woodruff, D. Mixed mullerian tumors of the uterus: Clinical and pathologic correlations, Int. J. Gynecol. Obstet. 20, 237-243 (1982). King, M. E., and Kramer, E. E. Malignant mullerian mixed tumors of the uterus: A study of 21 cases, Cancer 45, 188-190 (1980). Acosta, A. A., Kaplan, A. L., and Kaufman, R. H. Mixed miillerian tumors of the oviduct, Obstet. Gynecol. 44, 84-90 (1974). Jain, U. Mixed mesodermal tumor of the fallopian tube: Report of a case and review of literature, Md. State Med. J., November, 43-46 (1977). Manes, J. L., and Taylor, H. B. Carcinosarcoma and mixed miillerian tumors of the fallopian tube: Report of four cases, Cancer 38, 1687-1693 (1976). Podratz, K. C., Podczaski, E. S., GafTey, T. A., O’Brien, P. C., Schray, M. F., and Malkasian, Jr., G. D. Primary carcinoma of the fallopian tube, Amer. J. Obstet. Gynecol. 154, 1319-1326 (1986). McMurray, E. H., Jacobs, A. J., Perez, C. A., Camel, H. A., Kao, M., and Galakatos, A. Carcinoma of the fallopian tube. Management and sites of failure, Cancer 58, 2070-2079 (1986). Israel, S. L., Grisp, W. E., and Adrian, D. C. Preoperative diagnosis of primary carcinoma of the fallopian tube, Amer. J. Obstet. Gynecol. 68, 1589-1593 (1954). Henderson, S. R., Harper, R. C., Salazar, 0. M., and Rudolph, J. H. Primary carcinoma of the fallopian tube: Difficulties of diagnosis and treatment, Gynecol. Oncol. 5, 168-179 (1977). Malnasy, J., and Gaal, M. Primary carcinosarcoma of the fallopian tube, Gynaecologia 154, 203-208 (1963). Kiihn, W., Herberling, D., Hijffken, H., and Rummel, H. H. Morphologie und Klinik der malignen Miillerschen Mischtumoren des Corpus uteri, Geburtshilfe Frauenheilkd. 42, 888-891 (1982).