Running Head: FEMALE CANCERS

Activity 4: Female Cancers

Raymund Fines Idica

Master of Arts in Nursing

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Uterine carcinosarcoma or malignant mixed Mullerian tumours (MMMT) was regarded

as very aggressive type of uterine cancer that contains both carcinomatous and sarcomatous

element that may also arise from other parts such as fallopian tube ovaries or cervix

(McCluggage, W. G., 2001). Uterine carcinosarcoma arises from a 5% of all types of uterine

cancers and is considered a rare cancer (Hembree, Teer et. al, 2016). Carcinosarcoma is

dedifferentiated type of carcinoma that comprises carcinomatous and sarcomatous elements that

arise from a single malignancy, thus, are regarded or classified as very high risk type of

adenocarcinoma because they share more common characteristics in epidemiology and clinical

findings with endometrial carcinoma than with uterine sarcomas (Denschlag, Ulrich, 2018). The

existence and the main cause of this occurrence is still unknown and undisputed by some

authors. According to Dr. Rajendra Singh of Department of Radiation Oncology, Tarini Cancer

Hospital and Research Institute India, carcinosarcoma as mostly of monoclonal origin with the

carcinomatous being the driving force, this type of tumor is broadly divided into two groups,

homologous and heterologous depending on the characteristic of the stroma and mesenchymal

components of endometrial tissue (2014). The homologous-type has a sarcoma composed of

tissues native to the uterus such as endometrium or smooth muscle whereas in the heterologous-

type cartilage, skeletal muscle, or bone is present which is not native to the uterus (Kanthan,

Senger, 2011). It is highly malignant in behavior and generally has poor prognosis, and mostly

occurring to elder women (Singh, 2014). Risk factors of this type of cancer are those commonly

seen in endometrial carcinoma and include nulliparity, advanced age, obesity, exposure to

exogenous estrogens, history of pelvic irradiation, and the long-term use of tamoxifen

(Hembree, Teer et. al, 2016). Unlike with endometrial malignancies, uterine carcinosarcoma has
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the higher chance to metastasize to the lungs and lymph nodes, timely surgical staging of the

disease is the most important prognostic factor, determining the prognosis of the patient with

carcinosarcoma (Singh, 2014).

The term Malignant Mixed Mullerian Tumor (MMMT) was derived from conducted

studies of female genitalia in the embryonic stage, during embryogenesis at sixth week,

Mullerian ducts are formed and eventually leads to the formation of female organs like fallopian

tubes, uterus, cervix and vaginal canal (Kanthan, Senger, 2011). It has been identified that there

is a certain Mullerian-type carcinomas and metaplastic transformation of carcinomas into

sarcoma as the basis of clonality study (Kanthan, Senger, 2011). According to Kanthan and

Senger, for over 150 years, malignant neoplasms arising in the uterus composed of both

epithelial and mesenchymal elements have been a subject of debate. It was also cited in their

work that its origin dates back to 1852, whereas it was originally regarded as a mixed

mesodermal tumor and eventually called enchondroma. Malignant Mixed Mullerian Tumours

was originally thought to be primarily sarcomatous, thus management and clinical trials were

done appropriate to the guidelines in managing sarcomatous type of tumor (Kanthan, Senger,

2011). Further explanation of the tumor etiology cited that there are four main theories regarding

the histogenesis of uterine carcinosarcoma, first is the collision theory, wherein it suggests that

the epithelial and mesenchymal elements have arisen independently and collided to give the

impression of single mixed tumor (Singh, 2014). Secondly is the combination theory wherein

both the components are derived from a single stem cell, third, the conversion theory which

suggests that the sarcomatous element is derived from carcinoma during evolution of the tumor,

and lastly, the composition tumor is an endometrial carcinoma with reactive atypical stroma,
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which can be easily excluded because in these neoplasms, the sarcomatous component shows

malignant histologic features (Singh, 2014).

The clinical features of women with carcinosarcoma may vary from patient to patient

with symptoms that can be comparable to other pelvic malignancies, but typically,

carcinosarcoma is usually presented with uterine infection with bleeding, discharges of water or

blood, pain on the abdomen or pelvic masses among elder or post menopausal women (Kanthan,

Senger, 2011). According to Dr Kanthan and Dr Senger, the “symptom triad indicative of

carcinosarcoma rather than endometrial adenocarcinoma includes pain, severe vaginal bleeding,

the passage of dead tissues through vagina. In the diagnosing uterine neoplasia, the first line

imaging study is pelvic ultrasound, however, this imaging studies cannot differentiate

carcinosarcoma from endometrial adenocarcinoma (Denschlag, Ulrich, 2018). For women with

suspected carcinosarcoma, computed tomography (CT) scan or gadolinium-enhanced magnetic

resonance imaging (MRI) is usually done to appreciate and localize the extent of the disease

(Denschlag, Ulrich, 2018). According to Dr Denschlag and Dr Ulrich of Germany, there are no

typical laboratory abnormalities associated with the diagnosis of carcinosarcoma, however, about

10% of the women with carcinosarcoma are experiencing anemia due to vaginal bleeding. Other

than that, women that are suspected to have carcinosarcoma may be obese, hypertensive,

prolonged history of tamoxifen use, nulliparous and/or diabetic (Kanthan, Senger, 2011).

In the study of Denschlag and Ulrich, differentiating carcinosarcoma with a pronounced

mesenchymal component from the uterine sarcoma can be difficult, highlighting the need and

importance of a proper pathological-anatomical work-up. Uterine Carcinosarcoma is definitely a

histologic diagnosis, thus, it is not possible to diagnose the disease through assessment of

symptoms, laboratory results and imaging studies. Histopathological studies are done to
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determine malignancies, endometrial biopsy thru dilatation and curettage is usually performed

prior to definitive surgery. The primary management and diagnostic regime for carcinosarcoma

is surgery for initial treatment and comprehensive staging. But for women with definite stage IV

carcinosarcoma, palliative care is on top recommendation, though surgical staging may be done

for further assessment of the extent of the disease and to identify patient’s clinical status and

treatment goals.

It was mentioned that surgery is the primary treatment choice for uterine

carcinosarcoma, however, considering the increasing rate of relapses and metastases

postoperatively brought the need for effective adjuvant therapies (Kanthan, Senger, 2011). The

choice of proceeding to adjuvant therapies following resection still depends on how extent

carcinosarcoma affected the body (Denschlag, 2018). In women with carcinosarcoma of early

stages, the need for adjuvant therapies has yet to prove, because there is no significant

improvement in prognosis, however trials in patients with early stage disease (I, II) was

consistently reported improvement in rates of recurrence and progression- free survival, but not

in overall survival (Denschlag, 2018). According to Dr. Matsuo et al., treatment of uterine

carcinosarcoma is multidisciplinary including surgery, radiotherapy, and chemotherapy. Various

chemotherapeutic agents were also evaluated in uterine carcinosarcoma, and carboplatin,

cisplatin, ifosfamide and paclitaxel are considered active agents. Several combinations were also

considered like taxane/platinum based and ifosfamide- based regimens. These regimens were

noted to have significant benefits on patients' survival. Trials using adjuvant radiotherapy was

also conducted, and metastatic behavior of the disease was decreased but no more than a

significant change in overall survival of patients receiving radiotherapy following surgery

(Yilmaz et al., 2019). Although surgery and adjuvant radiotherapy provides excellent
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locoregional control (LRC), distant metastases remains the major cause of death, however, the

use of better systemic therapies could tend to decrease metastasis and increased survival

(Yilmaz, et al., 2019).

The role of nurse in the course of treating the patient with carcinosarcoma or any other

cancer is very vital. The patient diagnosed with the disease should be prepared in any aspects

affecting her wellbeing and perspective in life. Women living with uterine carcinosarcoma are on

their edge to understand how it would ruin their strong femininity. The nurse should establish a

bridge to make the patient aware of her disease, including future consequences. Loss of an organ

can change the patient’s perspective, how they would accept the facts of being incomplete, their

drive to grant their female needs. The key is to educate the patient regarding her disease,

encouraging her to participate in the discussion on several treatment regimens with her attending

specialist. To include in the education regarding possible outcomes that could help her

understand the disease and treatment process, showing her both positive and negative results.

During chemotherapy and radiotherapy, the nurse’s focus is her safety and holistic wellbeing.

The nurse should also consider giving the patient options to maximize wellbeing, spending time

with the closest family and expressing out her thoughts and feelings by attending support groups

could help her increase her self esteem.

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REFERENCES

1. Denschlag, D., Ulrich, U., “Uterine Carcinosarcomas- Diagnosis and Management”,

Oncology Research and Treatment 2018; 41:675-679

2. Hembree, T., Teer, J., et al., “Genetic Investigation of Uterine Carcinosarcoma: Case

Report and Cohort Analysis”, Cancer Control, January 2016; 23:61-65

3. Kanthan, R., Senger, JL., “Uterine Carcinosarcomas (Malignant Mullerian Tumours): A

Review with Special Emphasis on the Controversies in Management”, Obstetric and

Gynecology International, 2011;470795:1-13

4. Matsuo, K., et al., “Significance of histologic pattern of carcinoma and sarcoma

components on survival outcomes of uterine carcinosarcoma”, Annals of Oncology 2016;

27: 1257-1266

5. McCluggage, WG., “Malignant biphasic uterine tumours: Carcinosarcomas or

metaplastic carcinoma?”, J Clin Pathology 2002; 55: 321-325

6. Singh, R., “Review literature on uterine carcinosarcoma”, Journal of Cancer Research

and Therapeutics, July- September 2014, Volume 10, Issue 3

7. Yilmaz U., et al., “Adjuvant radiotherapy for uterine carcinosarcoma: A retrospective

assessment of treatment outcomes”, Journal of Cancer Research and Therapeutics 2019;

15:1377-82