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Year : 2010  |  Volume : 53  |  Issue : 4  |  Page : 886-887
Malignant mixed Müllerian tumor of the uterus associated with tamoxifen therapy for breast cancer


Department of Pathology, Gajara Raja Medical College, Gwalior, Madhya Pradesh, India

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Date of Web Publication27-Oct-2010
 

How to cite this article:
Magnani K K, Dubey S, Rai S. Malignant mixed Müllerian tumor of the uterus associated with tamoxifen therapy for breast cancer. Indian J Pathol Microbiol 2010;53:886-7

How to cite this URL:
Magnani K K, Dubey S, Rai S. Malignant mixed Müllerian tumor of the uterus associated with tamoxifen therapy for breast cancer. Indian J Pathol Microbiol [serial online] 2010 [cited 2014 Oct 25];53:886-7. Available from: http://www.ijpmonline.org/text.asp?2010/53/4/886/72038


Sir,

We would like to report a heterologous malignant mixed Müllerian tumor (MMMT) of uterus in a postmenopausal woman after long-term tamoxifen therapy for breast cancer. The 54-year-old postmenopausal, multiparous female presented with white discharge per vaginum of 2 months duration. She had developed intraductal carcinoma of right breast at 47 years and had undergone modified radical mastectomy, followed by tamoxifen therapy for 5 years. Per vaginal examination and abdominal ultrasonography revealed a bulky uterus. Uterine curettings showed pleomorphic cells against myxomatous background. Subsequently, abdominal hysterectomy with bilateral salpingo-oophorectomy was performed.

Grossly, the uterus measured 8 × 5 × 3 cm, with a 4 × 2.5 × 1.5 cm grayish-white, soft polyp at the fundus, dilating the uterine cavity [Figure 1]. Microscopically, the polyp revealed biphasic appearance with admixture of carcinomatous and sarcomatous components [Figure 2]. The carcinomatous element consisted of glandular structures, mainly of high-grade endometrioid type. The sarcomatous element consisted of pleomorphic spindle cells with large, hyperchromatic nuclei and bizarre tumor giant cells. It was heterologous, composed predominantly of fibrosarcomatous areas [Figure 3]a with chondrosarcomatous [Figure 3]b, myxomatous and undifferentiated areas. There was no invasion of underlying myometrium, adjacent endometrium, endocervix and adnexae.
Figure 1: Cut section showing polypoid fleshy mass at fundus of uterus

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Figure 2: Photomicrograph showing biphasic pattern: Adenocarcinomatous and heterologous sarcomatous elements (H and E, ×100)

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Figure 3: Photomicrograph showing sarcomatous elements (a) heterologous area with predominantly fibrosarcomatous along with chondrosarcomatous components (H and E, ×100) (b) chondrosarcomatous area (H and E, ×400)

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MMMTs are rare, aggressive neoplasms of female genital system, composed of both carcinomatous and sarcomatous components. They are monoclonal, poorly differentiated metaplastic carcinomas, most commonly arising from the endometrium.[1] Almost all reported cases present with postmenopausal bleeding but our patient was diagnosed early, with vaginal discharge only and had no myometrial invasion. Favorable prognostic features include myometrial invasion less than one third, size less than 7 cm and no detectable invasion or metastasis.[2]

Tamoxifen, an estrogen receptor agonist and antagonist, has both therapeutic and preventive role in breast cancer. Its estrogenic action causes increased risk of occurrence of uterine carcinomas, mainly adenocarcinoma, on long-term therapy.[3],[4] Women receiving tamoxifen for breast cancers, who subsequently develop uterine cancers are at risk for high-grade endometrial cancers[5] and for rare, aggressive forms of uterine tumors, notably MMMTs,[3] that have poor prognosis. They are more likely to die of cancer than untreated group.[3],[5] In the study by Curtis et al., the relative risk for MMMTs was substantially higher than for endometrial adenocarcinoma and MMMTs tended to be detected later, indicating that tamoxifen may have delayed effects, as in the present case.[3]

The huge positive impact of tamoxifen in the treatment and prevention of breast cancer outweighs its risk for uterine malignancies.[3],[4],[5] This case strives to draw the attention of professionals to the possible occurrence of endometrial cancers of rare histologic types after long-term tamoxifen therapy for breast cancer, and hence, the need for regular follow-up in such patients.

 
   References Top

1.McCluggage WG. Uterine carcinosarcomas (malignant mixed Mullerian tumors) are metaplastic carcinomas. Int J Gynecol Cancer 2002;12:687-90.  Back to cited text no. 1
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2.Schweizer W, Demopoulos R, Beller U, Dubin N. Prognostic factors for malignant mixed mullerian tumors of the uterus. Int J Gynecol Pathol 1990;9:129-36.  Back to cited text no. 2
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3.Curtis RE, Freedman M, Sherman ME, Fraumeni JF. Risk of malignant mixed mullerian tumors after tamoxifen therapy for breast cancer. J Natl Cancer Inst 2004;96:70-4.  Back to cited text no. 3
    
4.Eftekar Z, Yarandi F, Izadi-Mood N, Rahimi-Moghaddam P. Malignant mixed mullerian tumor of the uterus associated with tamoxifen therapy in a patient with a history of breast cancer. Iranian J Pharmacol Ther 2006;5:81-2.  Back to cited text no. 4
    
5.Magriples U, Naftolin F, Schwartz PE, Carcangiu ML. High-grade endometrial carcinoma in tamoxifen-treated breast cancer patients. J Clin Oncol 1993;11:485-90.  Back to cited text no. 5
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Correspondence Address:
Suparna Dubey
F-192 Harishankarpuram, Lashkar, Gwalior, Madhya Pradesh
India
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DOI: 10.4103/0377-4929.72038

PMID: 21045469

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

This article has been cited by
1 Uterine Carcinosarcomas (Malignant Mixed Müllerian Tumours): A Review with Special Emphasis on the Controversies in Management
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Obstetrics and Gynecology International. 2011; 2011: 1
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