Primary Mixed Myosarcoma of the Uterine Tube: a Case Report and Review of the Literature ALEXANDER S
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Med. J. 258 CASE REPORT: MYOSAIRCOMAMYOSARCOMA OFUTERINEOF UTERINE TUBE Canad.Feb. 3, 1968, Ass.vol. 98 dans 1'cesophage superieur. Le plus petit malade REFERENCES chez qui une biopsie fut prelevee pesait 13 livres 1. CROSBY, W. H.: Amer. or. Dig. Dis., 8: 2, 1963. 2. CAREY, J. B., JR.: Gastroenterology, 46: 550, 1964. et 6tait age de 9 mois. 3. BECK, L T. et al.: Bull. Gastroint. EBndosc., 11: 15, 1965. We wish to thank 0. H. Kimbell, Ph.D., H. Robidoux- 4. MCDONALD, W. G.: Gastroenterology, 51: 390, 1966. 5. PARTIN, J. C. AND SCHUBERT, W. K: New Eng. J. Poirier, R.N., R.-M. Leblanc, R.N., D. Michaud, R.N., Med., 274: 94, 1966. and Marc Gigu6re, R.B.P., for their co-operation and 6. KUITUNEN, P. AND VISAKORPI, J. K.: Lancet, 1: 1276, active assistance. 1965. Primary Mixed Myosarcoma of the Uterine Tube: A Case Report and Review of the Literature ALEXANDER S. ULLMANN, M.D. and MAERIT B. KALLET, M.D., Detroit, Mich., U.S.A. SINCE primary malignant neoplasms of the uterine tube are so rare that no one indi- vidual or clinic has been able to study a large series of patients, the importance of reporting every case has often been emphasized.2-4 Although over 800 cases of primary carcinoma of the tube have been described in the liter- ature,4 up to 1956 only 30 authentic cases of primary sarcoma had been reported and to this number Abrams added another one.1' 8 Recently we had the opportunity to study a patient with primary sarcoma of the fallopian tube. L.C., a 48-year-old coloured gravida 0, para 0, who had her menopause five years before, was first seen in our clinic on January 9, 1964. She stated that she had had vaginal bleeding two weeks previously and this had lasted for about one week. Fig. 1.-Cross-section of the distended fallopian tube Pelvic examination showed a small amount of bleed- with tumour protruding from the lumen (measure in ing from the cervical os. The uterus was thought centimetres). to be enlarged to the size of a two- or three-month pregnancy and it was palpable in the cul-de-sac. January 20, a dilatation and curettage was per- Her past history revealed that she had been ade- formed. Although the sound was passed to a depth quately treated for syphilis eight years previously. of 5 inches, only a small amount of curettings was Although her VDRL test for syphilis was still posi- obtained, and this consisted of mucous material and tive, it was believed that she was a serological-fast a few small fragments of endometrial glands. During individual and no further treatment was necessary. the following four months she felt generally well, Her hematocrit was 33%, and her white blood count although she complained of occasional uterine 7150 per c.mm.; the urinalysis was negative. On bleeding. On June 4, she experienced a sudden onset of lower abdominal pain which increased in From the Departments of Pathology and Gynecology & severity. Her abdomen became markedly distended. Obstetrics, Metropolitan Hospital, Detroit, Michigan, U.S.A. On pelvic examination, the findings were essentially Reprint requests to: Dr. A. S. Ullmann, Crittenton Hos- the same as before, but now the mass in the cul- pital, 1101 W. University Drive, Rochester, Michigan 48063, U.S.A. de-sac was very tender. The most likely diagnosis Canad. Med. Ass. J. Feb. 3,1968, vol. 98 Case Report: Myosarcoma of Uterine Tube 259 Fig. 2..Wall of fallopian tube. Black arrow indicates the mucosa, white arrow the tumour; in between there is the thickened muscular layer. (Hematoxylin and eosin, X 100.) was considered to be either pelvic inflammatory from the left adnexa but adherent to the cecum disease or degenerating fibroids. She responded and to the terminal ileum on the right side. The initially to penicillin, analgesics and sitz baths, but capsule was smooth, except at one point where it later her abdominal pains recurred. Exploration of had perforated and was adherent to the underly¬ the abdomen was advised. On July 10, a laparotomy ing bowel. The left adnexal area was very much was performed under general anesthesia. A mass stretched and attenuated. The mass was readily was found, measuring 10 cm. in diameter, arising separated with blunt dissection, and bilateral Fig. 3..Leiomyosarcomatous portion of the tumour. Fig. 4..Higher magniflcation of a less well-differenti- Spindle-shaped cells with elongated nuclei show palisad- ated area demonstrates cellular pleomorphism. (H. & E., ing. (H. & E., original magniflcation X 100.) X 230.) 260 Case Report: Myosarcoma of Uterine Tube Canad. Med. Ass. J. Feb. 3,1968, vol. 98 to grow out of the lumen of the left fallopian tube, which was markedly dilated at this point, taking the shape of a funnel. The distal portion of the fallopian tube was no longer recognizable in the tumour mass. The mass was surrounded by a smooth capsule (Fig. 1). On sectioning, the parenchyma was yellowish in colour and soft, almost mushy, in con- sistency. In other areas the tumour was degenerated and liquefied. Several smaller portions of similar yellowish tumour mass were also submitted; the largest one of these measured 6 x 3 x 2.0 cm. Microscopical examination..The tumour was composed mainly of long, spindle-shaped cells arranged in interlacing fascicles. The nuclei were elongated and their ends blunt. Most cells were of fairly uniform size, although less well-differentiated areas contained ovoid and polygonal cells of varying sizes with nuclei and Fig. 5..Area of pleomorphic rhabdomyosarcoma shows hyperchromatic frequent great variety of cells, particularly giant cells. Arrow mitotic figures (Figs. 2, 3 and 4). Other portions of indicates a cell with recognizable cross-striations. (H. & the tumour were E., X 390.) characterized by a high degree of cellular pleomorphism. Here, numerous giant cells of various types were present, often with bizarre, salpingo-oophorectomy and total abdominal hyster- nuclei and vacuolated ectomy were performed. There were no signs of hyperchromatic cytoplasm. metastases. The went into shock the Others were elongated strap-like and ribbon cells, patient during some of which but to 1000 c.c. of blood. Her demonstrated remarkably good cross- procedure responded striations in their 5 postoperative course was uneventful. cytoplasm (Figs. and 6). Large areas of the tumour were degenerated and necrotic. This malignant neoplasm was interpreted as having Pathology been formed by two components, smooth and Gross examination..The main mass measured striated muscle, and was called "mixed myo¬ 12 x 9 x 7 cm. and weighed 330 g. It appeared sarcoma". Fig. 6..High magniflcation of two cells shows good cross-striations. (H. & E., X 1100.) Canad. Med. Ass. J. CASEREPORT: MYOSARCOMA OF UTERINE TUBE 261 Feb. 3, 1968, vol. 98 The uterus with the cervix, the contralateral Most of the neoplasms were diagnosed as fallopian tube and both ovaries showed no abnormal spindle-cell sarcoma (14) or myosarcoma (6); findings on gross and microscopical examination. this latter group includes leiomyosarcoma, leio- myoblastoma and mixed myosarcoma, together Subsequent Course with those not otherwise specified. The types of In August 1964 the patient received cobalt tumour found in the cases reported to date are therapy to the entire pelvis totalling 6000 r. Intes- summarized in Table I. tinal obstruction developed in December 1964. At laparotomy a firm metastatic tumour mass was found TABLE II.-TIMES AT WHICH DEATH OCCURRED IN 14 OF in the cecum. An anastomosis between the ileum 30 PATIENTS OPERATED ON FOR PRIMARY SARCOMA OF and transverse colon was performed. The operation FALLOPIAN TUBE was followed by a stormy postoperative course Death in postoperative period (1 to 3 weeks) .5.... 5 which included peritonitis and an episode of shock. Death within 1 to 2 months . 2 The patient developed multiple fecal fistulas which Death within 3 to 5 months . 0 Death within 6 to 11 months . 2 drained continuously. She died in a nursing home Death within 12 to 18 months . 3 in July 1965, shortly after her last hospitalization. Death within 19 to 24 months . 2 Permission for autopsy was not granted. Total ......................................... 14 DISCUSSION Follow-Up Study (Tables II and III) Since the last review,1 three additional cases There was no follow-up reported on eight of have been described in the European liter- the 30 patients who had been operated upon. ature.5-7 Fourteen patients died within two years, and Of the 35 cases reported-including the one eight were alive and well when last seen (one presented here-only nine were reported in the month to five years postoperatively). United States; six of these were from the Phila- delphia area. The youngest patient was 20 years TABLE III.-RESULTS OF FOLLOW-UP OF EIGHT PATIENTS old and the oldest 70; the average age was 46 ALIVE AND WELL AFTER OPERATION FOR PRIMARY years. Thirty of the tumours were removed at SARCOMA OF FALLOPIAN TUBE operation; four were found at autopsy; and the 1 month later .......... 1 source of one was not stated. Six of the tumours 6 months later .......... 1 1 year later .......... 3* were bilateral; 13 were in the left tube and 11 18 months later .......... 1 were in the right. In five cases the site was not 2 years later .......... 1 mentioned. In 13 of the 30 patients operated 5 years later .......... 1 upon, only salpingectomy or salpingo-oophor- Total .......... 8 ectomy was performed; the remaining 17 pa- *One patient was delivered one year later. tients also had total or subtotal hysterectomy. The authors wish to express their thanks to Dr.