Medicine

Benign diseases of the female sexual organs

Benign diseases of the female sexual organs. Gynecological aspects of mammary gland’ disorders.

preapeared by Korda I.

 

BENIGN AND PRECARCINOUS CERVICAL LESIONS

 

Cervical lesions are the most common among all pathological states of the female genital organs. Cervical cancer for its frequency occupies one of the first places among malignant tumours of the female genital organs, and precursor le­sions of the cervix. Early diagnosis of cervical pathology is important for lo­wering of cervical cancer morbidity, decreasing of advanced stages of cancer and re­newing of patients’ working capacity.

The frequency of cervical cancer in young women has grown for the last years on the background of relative stabilization of cervical cancer morbidity.

This is the result of increasing number of precursor cervical lesions of exo- and endocervix in this category of patients. Such state is a result of migration, and urbanization, changes of sexual conduct of young people (lightminded atti­tude to sexual life: its early begining, plenty of sexual partners and inevitable in such condition infecting of vagina by pathogenic micro­organisms), increasing of abortions’ frequency (mechanical trauma of the cervix and abrupt alteration of hormonal woman’s status after abortion).

Cervical cancer appears  rarely on unaltered epithelium.

Asymptomatic precursor cervical lesions predict cervical carcinoma and neoplasia.

the following states belong to benign cervical lesions:

l true cervical erosion

l false cervical erosion (pseudoerosion, endocervicosis)

l cervical leukoplakia (without atypia, simple one)

l cervical polyps (simple, proliferating, epidermizing polyps); papilloma, con­dy­lomas

l endometriosis

l posttraumatic changes (ectropion, scars)

l exo- and endocervicites

Benign cervical lesions are optional precancerous states, they undergo malig­nization rarely.

Such processes as cervical dysplasia, cervical leukoplakia with atypical neo­pla­sia, erythroplakia, adenomatosis belong to obligatory precancerous lesions. Benign and precancerous states, and their localization are depicted by graphical symbols in the indivi­dual patient’s cards.

Histo-physiological characteristics of the cervix
in different periods of age

The portion of the cervix that projects into vagina is covered with stratified squamous epithelium, which resembles the vagina epithelium. This portion is cal­led exocervix. It is very easy to examine it in a speculum. Exocervix is co­vered by mu­cous membrane of pink colour with smooth shining surface. Endocervical por­tion is situated above vaginal portion of cervix and is called endo­cervix. Cervical canal is covered by single columnar epithelium, which is placed on lamina propria. Epithelium forms the crypts that form cervical glands. Mucous membrane of the cervical canal is bordered from the side of isthmus by histological internal uterine os, and outside by the region of external cervical os.

 

 

 

 

 

The cervix is covered by two genetically different types of epithelium. The squamous epithelium changes to a simple columnar epithelium in the transition zone (fig. 112). in infant squamocolumnar junction is situated on the ectocervix surface. This zone is found at about the level of the external cervical os in the  ju­ve­nile period and puberty. In the majority of them in adolescence it is situated on the level of external os of cervical canal, however, approxi­mately in 30 % of young women the junction zone is found outside the external os. Although, it is found higher from the endocervical canal in menopausal and postmenopausal women. This zone comes to lie upward into the endocervical canal, often out of direct visual contact.

So, presence of the “garland” of columnar epithelium around the external cer­vical os in women before 20-21 years, that is interpreted by some authors as «con­­genital erosion», is not a pathological phenomenon. It does not require treat­ment, especially electrocoagulation.

However, if ectopic epithelium undergoes harmful influences, especially me­chanical traumatization (early begining of sexual life, induced abortions), infection, caused by associations of microorganisms and viruses (which hap­pens at frequent change of sexual partners), the part of exocervical epithelium can be trans­­formed into metaplastic flat one with formation of new junction zone. Metaplastic changes take place in this zone. This region is called transforma­tion zone. In some patients carcinogen exposure may cause the abnormal matu­ration process at the trans­formation zone and begin the process of intraepithelial neoplasia.

BENIGN CERVICAL LESIONS

True cervical erosion

True cervical erosion is a pathological process,which is a result of damage and following exfoliation of original stratified squamous epithelium. Absence of epithelium on cervical vaginal part appears. most frequently endocervicitis and endo­metritis are the causes of true erosions. The area of epithelial defect is exposed to purulent secretions and irritants which are common in endocervicitis and endo­metritis, cause secondary inflammation and exfoliation of epithelium from cervical surface. Harmful examination can cause traumatization of the cervical epithelium.

Clinic. Main clinical signs are chiefly the features of the basic di­sease. Pa­tients com­­plain on purulent discharge which is common after gyneco­logical exa­mination and sexual intercourse (contact bleeding).

Diagnosis is based on data of clinical picture, colposcopy, and cytological examination. Erosion is revealed during speculum examination. The fleshy red­dened tissue area on the posterior (more rarely than on anterior) cervical lip and concomitant bleeding are common. Erosion fundum is swollen by the connective tis­sue with subepithelial vessels. Colposcopic criteria such as inflammatory chan­ges, abnor­mal vascular patterns, vessel dilation, edema, and fibrin precipitation on erosion surface help to identify such areas.

 

 

This disease is referred to the short-term processes, true erosion exists no longer than for 2-3 weeks. There is the epithelium defect owing to neogenic squ­a­mous co­lumnar epithelium. Due to the fact that columnar epithelium has higher regene­rative ability, than the squamous one, predominate part of true erosion is replaced by single columnar epithelium thanks to growing on its surface from the cer­vical canal. The process transforms into the following stage called pseu­do­erosion.

Treatment. Treatment of diseases which cause the formation of true cervical erosion. Doctor determines the pathogenic organism and prescribes treatment directed on its elimination and decreasing of inflammatory reaction in tissues. Optimal conditions for erosion elimination are created. Tampons with cod-liver oil, dog-rose and sea-buckthorn oil should be used. Laser therapy for increasing the regenerative ability of the cervical tissue and improving the organic specificity of neogenic epithelium is indicated. Helium-neon or semi-con­ductor lasers are applied for this purpose. Each region is exposed to rays during 1-2 minutes, general exposition is 6-8 minutes. Treatment course takes 6-8 days.

Cervical pseudoerosion

Cervical pseudoerosion is a benign pathological process, which is characte­rised by presence of original columnar endocervical tissue on exocervical surface. Cervical pseudoerosion is discovered in different periods of life in 35-40 % of women.

The disease is polyetiologic. Hormonal correlation in female organism play role in appearing of cervical pseudoerosion. Autoimmune theory of cervical pathology pathogenesis has proved the connection between local humoral immu­nity with the degree of morphological changes in cervix. It confirms possible effect of immunoglobulins of different classes on appearing and progressing of benign lesions.

Congenital, posttraumatic and dyshormonal ectopia are distinguished. Pseudoerosion is formed from the true one when the columnar epithelium spreads on the devoided of stratified squamous epithelium exocervical surface canal. The reserve cells, which are situated under epithelium of cervical canal and its glands (crypts) are the source of ectopic (placed outside the borders of its usual locali­zation) epithelium. Cervical epithelium regeneration passes from these un­differentiated elements. having biopotential properties reserve cells can trans­form both into columnar and into squamous epithelium. Columnar epithelium pene­trates deep in, forming ramified glandular passages, reminding the glands of mucous membrane of cervical canal. The glands produce mucus that is exuded by excretory ducts. As a result of ducts closing during epidermi­zation process mucus accumulates inside the glands. Retention cysts, so-called Nabo­thian cysts are formed. Their dimensions are different, they shine through cervical epithelium as yellow humps.

Papillary, follicular, glandular and mixed pseudoerosions are distinguished according to morphological signs.

 

 

Clinic. Usually patients have no complaints. There can be complaints on vaginal discharge, pain in lower abdomen, sometimes contact bleeding as a result of presence of concomitant diseases (inflammatory processes of the uterus, adne­xa, vagina). Speculum examination reveals on its back lip a spot of red colour, from 3-5 to 30-50 mm in size with “velvet” surface. in touch it slightly bleeds around external cervical os.

 

Diagnosis is based on the data of speculum cervical examination, simple and broadened colposcopy and biopsy. During the simple colposcopy one can see acinar accu­mulation of scarlet and long papillae. The papillae become more relief, pale and acquire clear appearance, reminding a bunch of grapes, as a result of momen­tary vessels’ constriction and epithelium edema during broadened (after applying on erosion surface 3% solution of acetic acid) colposcopy.

 

 

The erosion has lightly-pink colour during the Shiller’s test (applying on the cervix 3% Lugol’s iodine solution or 5% spirit iodine solution). This test gi­ves a possibility to find the most altered epithelium areas for taking biopsy by scalpel or special instruments.

 

 

 

 

 

The biopsy material is fixed in 5-10% for­malin solution and is sent to laboratory.

Treatment. The underlying concept in the treatment of benign cervical lesions is in excision or removal of the superficial precursor lesion avoiding progression to carcinoma:

l women with congenital epithelial ectopy are subject to supervision till 23 years. They need no treatment

l treatment of erosions begins from the treatment of diseases, such as endocer­vicitis, endometritis, salpingoophoritis, ectropion, vaginitis, endocrine disor­ders. Etiotropic treatment should be prescribed after authentication of the path­o­genic organism. It depends on its species (trichomoniasis, chlamidiosis, gonorrhoea). erosion existence supports inflammatory process in vagina, and presence of vaginitis provides long existence of pseudoerosion and provokes regenerative processes and epithelium differentiation impairment

l stimulation of regenerative process of stratified squamous epithelium by appli­cation tampons, moistened with cod-liver oil, dog-rose and sea-buckthorn oil to the cervix after elimination of inflammatory process in vagina, and laser therapy by Helium-Neon or semiconductor lasers — ANP-2, Lika-3 should be used. Laser therapy is emploged to remove lesions involved during 1-2 min, general exposition is 6-8 min; power density is 15-20 mVt/cm2. Treatment course takes 6-8 days

l medical destruction of pathological substratum by the following remedies such as Sol­­covagyn (Solcogyn), Vagotyle, or electrocoagulation, cryo­de­struction of ero­sive surface should be performed if after concervative therapy erosion doesn’t heel over. The biopsy is recommended before electrocoa­gulation or cryo­destruction

l radical surgical intervention is recommended (cone-biopsy (fig. 123) or cer­vical amputation)

The polyps of mucous membrane of cervical canal

The polyps of mucous membrane of cervical canal are created from the mu­cous of the external os, middle or upper third part of endocervix. They can have a pedicle or wide base . Depending on the dominance in their struc­ture of glandular or connective tissue glandular, glandular-fibrose and adenomatous polyps morphologically are distinguished. Their consistency also depends on the tissue presence (dense in fibrous polyps and soft in glandular ones). A po­lyp colour depends on its blood supply. At sufficient blood supply polyp has pink or pale pink colour. Polyp can be changed from red to cyanotic in such compli­ca­tions as hemorrhage, necrosis and inflammation.

 

 

Clinic. Polyps are common in 40 aged women. The uncomplicated polyps have no symptoms, they are found mostly during monitoring. Mucous or in­significant bloody discharge from vagina can appear in some women.

Diagnosis. During speculum examination the rounded formation, that is situated in the cervical canal is visualized. The colposcopy should be per­formed for specification of diagnosis. If polyp is covered with columnar epithe­lium, then during the broadened colposcopy it has a typical papillary surface; if polyp is covered by stratified squamous epithelium (epidermal polyp) then its sur­face is smooth with divaricated vessels. The polyps, originating from mucous mem­brane of endocervix aren’t tinctured by Lugol’s iodine solution.

Treatment. The polyp is removed by screwing it off with the following coagu­lation of its pedicle, if its base is visible. If polyp pedicle’s base is situated in­side the cervical canal, endocervical curettage with the following histolo­gical examination is performed. Cryodestruction of polyp’s base is indicated. Patients need con­sultation of oncogynecologist in the case of polyp’s recurrence.

Endometriosis

Endometriosis also belongs to benign cervical lesions. Its clinic, diagnosis and treatment is described in the separate chapter.

 

 

Cervical papilloma

This disease is caused by human papillomavirus (HPV). There are 18 types of papillomavirus, but only some of them are able to cause lesion of female se­xual organs. The HPV-infections most frequently occur in young women which are relating to early sexual life and neglecting the rules of personal hygiene.

There are three types of HPV-lesions of the cervix:

l condyloma acuminata (exophytic type)

l condyloma lata

l inverted ones (endophytic type)

There are no clinical signs specific for HPV-infection. It is manifested by signs of vaginitis such as discharge from genital tract and itching. Papillomas are found during pelvic examination or during speculum examination of the cervix. Typical cytolo­gical sign of viral invasion are the phenomena of koilocytosis, that is found as enlightening of the cytoplasm around the nucleus. Growth of stratified squamous epithelium of exocervix together with connective tissue, cells without atypia, phenomena of angiomatosis, secondary inflammatory changes,   decidual changes during pregnancy should be histologically revealed.

Treatment. Papillomatous growth of large sizes requires the biopsy. Laser coagulation by high-intensive laser or cryodestruction by liquid Nitrogen should be performed after this. Small excrescences on the pedicle are treated by means of electro­coagulation of papilloma’s pedicle with the following histological re­search of the tissue taken. Conservative methods include powdering by Resorcin, proces­sing with Po­dophillin, Condylin or Pherisol. Very effective is the contem­porary remedy applica­tion of Solkoderm which is a mixture of organic and inor­ganic acids. It provokes papillomatous excrescences coagulation and the condy­lomas fall off.

Ectropion

The ectropion is an inversion of cervical mucous as a result of badly renewed cervix after labour trauma (fig. 117). These traumas rarely occur after abortion.

A surface, that is formed in the result of rupture, heals over thanks to the columnar epithelium of the cervical canal. So, the ectopic epithelium finds itself outside of endocervix borders in acid vaginal, is infected, leads to chronic endo­cervicitis and the cervical hypertrophy. Cervical barrier function is disturbed, microorganisms get into the uterus, causing endometritis development in subacute or chronic form.

Clinic. In some cases patients have no complaints. At complicated forms of the ectropion patients complain on aching pain in the lower abdomen, discharge from genitals, of menstrual dysfunction in the form of hypermenstrual synd­­rome and menorrhagias.

Diagnosis. Presence of old rupture of the cervix, its deformation, the erosive edges are found during the speculum examination (fig. 118). unlike the erosion the ectropion “disappears” when they draw together the edges of rupture. It can be seen only during breeding of the anterior and posterior lip of the cervix. Colposcopy diag­noses the atypical picture caused by the chronic inflammatory process. Dysplasia may be present frequently in strong deformation coexisting with considerable his­to­logical changes. Complex examination of the patient, except the broadened colposcopy, includes cytological research, cervical biopsy, and endocervical curettage.  the question about the volume of treatment is decided after taking into account the received data.

Treatment. Medical arrangements, directed on the renewing of cervical structure start from vaginal flora normalisation. At small dimensions of the rupture, after elimination of inflammatory process in vagina and cervix, electro­coagu­lation of the eroded surface of the ectropion is performed. growing of con­nective tissue leads to constriction of the external os and formation of the exocervix. Recon­structive-plastic surgeries, specifically Emmet’s operation is performed at con­si­derable defor­ma­tion of the cervix and deep lacerations. Presence of the dysplasia is an indi­cation for more radical treatment — cone- or wedge-shaped amputation of the cervix.

Cervical leukoplakia

Leukoplakias belong to hyperkeratoses. Leukoplakia is a pathological state of epithelium that is characterized by its thickness and cornification. Etiology of this disease is connected with hormonal insufficiency, the involutional changes in the female organism, and vitamin A deficiency.

The term is used to describe white or gray plagues that appeared in the portion vaginalis in the result of keratinization.

Histologically leukoplakia is a thickness of stratified squamous epithelium of its basal and granular layers with phenomena of parakeratosis and cornification (hyperkeratosis). Simple leukoplakia without the signs of atypia (it belongs to benign diseases) and leukoplakia with signs of basal cell hyperactivity and atypia belong to the precancer ones. In 15-75% of patients with this form of leukoplakia a squamous cell keratinous cervical carcinoma has developed.

 

 

Clinic. The disease does not have typical clinical picture. Patients have no complaints. Leukoplakia is found during the medical monitoring or during the gyne­­co­lo­gical examination. In some cases patients complain on the great amount of discharge from the genital tract and contact bleeding (this is a sign of possible malignization).

Diagnosis. Leukoplakia, located on the cervix and vaginal walls, is found in the result of speculum cervical examination. It looks like a white film or plague, sometimes with pearl colour, that can be flat or slightly prominent over the level of cervical epithelium (fig. 119). The film can be removed from the cervix, and the base of leukoplakia in the initial stages of the process becomes visible. In col­po­sco­py it looks like Iodine-negative region with crimson dots, that is re­presented by connective tissue papillae in stratified squamous epithelium with loops of ca­pillary vessels. The fields of leukoplakia during colposcopy look like multiangular areas, divided by threads of capillaries that create the mosaic drawing.

Layers of polygonal keratinized cells with picnotic nucleus of irregular form — dyskeratocytes are presented during cytological research in smears-imprints.

Biopsy is the basic method of diagnostics. It is made under control of colpo­scopy from the most altered areas of the cervix. The regions of squamous metaplasia can be situated also in the cervical canal. That’s why it is necessary to perform the endocervical curettage.

Treatment. It is necessary to normalise the vaginal flora, taking into account the pathogenic organism’s species if leukoplakia is combined with the inflam­matory diseases of vagina and cervix. Application of methods influ­encing on tissue exchange and regeneration (dog-rose and sea-buckthorn oil, aloe, etc.) is not reco­mmended because of stimulation of the proliferative pro­cesses of these medecines. It causes dysplastic changes in the cervix.

Solkovagyn deserves special attention from group of the chemical coagulants. This remedy is a mixture of organic and inorganic acids and has coagulative action on columnar epithelium. It penetrates into the tissue on 2,5 mm, that is suf­ficient for destruction of pathologically altered epithelium, and does not cause rough scar changes.

Surgical diathermy should be applied in leucoplakia treatment, but nu­merous disadvantages of this method (implantative endometriosis, bleeding during scab exfoliating, rough changes in the cervix at extremely deep coagulation) can occur. They limit the usage of this method.

 

 

Electroexcision should be performed in the limited areas of leukoplakia. Progesterone in tampons is also used. Such methods as cryodestruction and high-intensive action of Carbon laser have higher effecti­veness. There are the methods of combination of cryo­des­truction with the follo­wing irradiation by low-intensive semiconductor laser. Maxi­mum organo-specificy of the renewed after cryodestruction tissue, decreasing of re­lapses is reached.

PRECANCERous
CERVICAL DISEASES

All precancerous cervical lesions are termed as “dysplasia” by decision of WHO (1973) Experts Committee. Leukoplakia with atypia of cellular elements, erythroplakia and adenomatosis also belong to this group. There are many syno­nyms of dysplasia such as: atypia, atypic hyperplasia, basal cell hyperplasia, cervical intraepithelial neoplasia (CIN) and others. Risk factors of dysplasia, and cervical cancer are: early beginning of sexual life, multiple sexual partners, posttraumatic cervical changes in the result of abortions and deliveries, infecting by HPV and VHS-2 viruses, change of hormonal balance (hyperestrogeny), harm­ful working conditions and ecology. The disease most frequently is found into women after 30 years. According to the localization dysplastic changes in young patients appear in exocervix area and in women of climacteric age — in the cervical canal, that is connected with the transitional zone migration.

Dysplasia

According to the degree of epithelium stinging, cultural atypia and saving of epithelial layer architectonics three degrees of dysplasia have been distingui­shed. There are:

l mild (CIN I)

l moderate (CIN II)

l severe (CIN III )

Hyperplasia and basal cell atypia occupies 1/3 of epithelium layer at CIN 1, at CIN II the changes take about the half of mucous layer, and at CIN III all the epithelium or not less than 2/3 of its layer is altered (fig. 120). The expressed atypia of the superficial layers is considered to be the severe dysplasia.

 

 

The following types of epithelium changes are distinguished at colpo­scopy.They are:

l areas of dysplasia:

a) areas of stratified squamous epithelium

b) areas of columnar epithelium metaplasia

l papillary zone of dysplasia:

a) papillary zone of stratified squamous epithelium hyperplasia

b) papillary zone of columnar epithelium metaplasia

c) precancer transformation zone

Diagnosis. Cytological research of smears allows to find the cells of basal and parabasal layers with signs of dyskariosis.

Histochemical research in patients with dysplasia show a drastic lowering of glycogen in cells up to full its absence and changes of tissue enzymes activity.

Cytogenetic researches testify that under this pathology the cells with tetraploid and pentaploid number of chromosomes appeared.

Various morphological changes were found by means of electronic micro­scopy. Cervical relief is more uneven, one can see a great deal of exfoliated cells, however the epithelium surface appearance still remains close to norm in case of mild and moderate dysplasia. Considerable knottiness of the relief, intensive exfo­liating, absence of micro-rollers and clear borders of the cells are characteristic features of severe dysplasia. All the surface is covered by indiges­tedly placed fibres, in many cells it is also “bald” in this type of dysplasia.

For diagnosis verification it is necessary to perform biopsy with the following  histological research (fig. 121, 122).

Transition of dysplasia into cancer in situ is observed in 40-60 % of patients. CIN 1 precedes the invasive carcinoma by approximatelly 5-6 years and CIN 3 — about one year.

Leukoplakia with atypia

Clinically it does not differ from the simple leukoplakia. The processes of keratinization of the cells in this disease are mistologicaly marked to be reinforced as compared with leukoplakia. Cytological re­search of the stratified squamous epi­thelium reveals cells without nucleus at simple leuko­plakia. Basal and parabasal cells without nucleoses are also present in the patients with leukoplakia and atypia.

Erythroplakia

It is a prettily heterogeneous form of dyskeratoses. The changes of cervical mucous membrane are in thinning and keratinizing of epithelium. It looks like scarlet area in the result of translucence of the basal membrane cells through thinned epithelial layer. It easily bleeds at contact. The seats are single or plural with transition on fornices and vaginal walls. Thinning of epithelial layer  to 1-2 layers with nuclear atypia and cellular polymorphism is revealed during the histo­logical research.

Glandular hyperplasia with atypia

Local hyperplasy of the glands that looks like a clew, similar to endometrial glands at histological research are found. The glands which have different form and size are covered by epithelium, that is unlike the cervical one. It frequently occurs in the first trimester of pregnancy, and disappears after delivery. The adeno­matosis frequently transforms into cancer in situ outside the pregnancy.

Treatment of precancer lesions is made by diathermic excision, cryosurgical and laser destruction. The most radical and less traumatic method is laser coagu­lation. it is bloodless, painless, and can be performed without anaesthesia in out­patient conditions.

Patients who are treated for benign cervical lesions need to be followed more frequently than the patients presenting for annual health examination.

The patients with benign cervical lesions after 2 months of appropriate treat­ment should be encouraged to avail themselves of annual health care checkups to include the Pap smear.

The patients with precancerous lesions after radical therapy usually receive repeates Pap smear and colposcopic assessment at 1, 5, 6 and 12 months. If Pap smears and colposcopic findings remain normal, patients may resume having annual Pap smear assessments at the beginning of the third year.

 

 

 

 

 

 

 

Benign and malignant
ovarian tumors

Ovarian tumors are very common among all gynecologic diseases. The mor­tality rate is high because no effective screening devices are avai­lable for early detection.

According to pathogenic theory of ovarian tumors, gonadotropic ovarian hy­perstimulation is the leading factor in the development of ovarian tumors. This theory should be recommended for pathogenetical explainatum of malignant ovarian tumors diagnosis and treatment.

The risk factors associated with ovarian carcinoma are:

l women with impairment of ovarian function

l women with postmenopausal bleeding

l women that have been monitored for a long period of time with the diagnosis of uterine fibromyoma, chronic inflammatory processes of uterine adnexa, benign ovarian tumors

l women that have had surgical intervention in pre- or postmenopause with keeping ovaries (or their resection)

 All ovarian tumors should be divided into two main groups:

l blastomatic unproliferative tumors (ovarian cysts)

l blastomatic proliferative tumors (ovarian cystadenomas)

Clinical manifestations of ovarian tumors are various and usually uncertain. It de­pends on tumor’s type and character, and also on the spread of the process in the case of mali­gnant tumor.

Ovarian tumors classification

Only histologic signs can give a possibility to distinguish benign and malig­nant ovarian tumor. From the prognostic or survival standpoint, however tumor grade remains the most important factor for all the ovarian tumors.

 

Histologic classification of ovarian tumors is presented below.

I. Epithelial tumors:

A. Serous

B. Mucinous

C. Endometriod

D. Clear cell

E. Brenner

F. Mixed epithelial

G. Undifferentiated

H. Unclassified.

There are benign and malignant tumors in each of these groups of neoplasms.

II. Sex cord stromal tumors:

A. Granulosastromal cell

B. Androblastoma

C. Gynandroblastoma

D. Unclassified

III. Lipid cell tumors

IV. Germ cell tumors:

A. Dysgerminoma

B. Endodermal sinus tumor

C. Embryonal carcinoma

D. Polyembryoma

E. Choriocarcinoma

F. Teratoma

G. Mixed forms

V. Gonadoblastoma:

A. Only blastoma (without any forms);

B. Mixed with disgerminoma and other forms of germ cell tumors.

VI. Soft tissue tumors not specific to the ovary.

VII. Unclassified tumors.

VIII. Secondary (metabolic) tumors.

VIII. Tumor-like conditions:

A. Pregnancy luteoma

B. Ovarian stroma hyperplasia and hyperkeratosis

C. Considerable ovarian edema

D. Functional follicle cyst and luteal cyst

E. Multiple luteal follicle cysts and (or) luteal cysts

F. Endometriosis

G. Superficial epithelial cysts-inclusions

H. Simple cysts

I. Inflammatory processes

J. Paraovarian cysts

Unblastomatic unproliferative
ovarian tumors

(ovarian cysts)

Ovarian cyst is the cavity of mature or atretic follicle that become distended with pale, straw-colored fluid as a result of its retention and excessive secretion. They are usually localized in ovaries (corpus luteum cyst, follicle cyst, theca luteal cyst, dermoid cyst) and in its adnexa (paraovarian cyst).

Follicle cyst

Follicle ovarian cyst is a single tumor with a thin membrane of mobile consis­tency with a straw-colored fluid. Its formation is a result of fluid retention in atre­tic follicles. Follicle cyst may be found in women of any age more often after inflammatory processes. True ovarian blastomatic process is absent in such tumor. Cyst mem­brane is not a new created tissue, it’s a result of the excessive extension of folli­cle membrane. Although these cysts may attain a size from 8 to 10 cm in dia­meter, spontaneous resolution usually occurs within the weeks. It has been growing in­side of abdominal cavity.

 

 

Clinic. The main symptom is the low abdominal pain, rarely menstrual cycle impairment or uterine bleeding as a result of hyperstimulation from exo­genous gonadotropins is observed. Signs of acute abdomen are present in the case of ovarian cyst torsion. Bimanual examination reveals ovarian enlargement up to 10 cm. it is mo­bile, cystic, unilateral mass. Sometimes inflammatory processes in uterine ad­nexa are present. Follicle cysts rarely produce any symptoms and diagnosis is often made during monitoring.

Treatment. Observation for 2-3 menstrual cycles is necessary. If a spon­taneous resolution doesn’t occur, surgical intervention — ovarian resection or oophorectomy — should be recommended. It is very necessary because before surgical intervention it is difficult to make a differential diagnosis of ovarian cyst and serous cystadenoma. Total hysterectomy should be performed in climacteric and postmenopausal women.

Additional therapy is not recommended after operation.

Corpus luteum cyst

The evidence of corpus luteum cyst is 2-5% among all the ovarian tumors.

Corpus luteum cyst is an unilateral cystic enlargement which exceeds 8 cm in dia­meter. Grossly, the cyst protrudes from the contour of the ovary and the wall appears convoluted and thick. The cyst is filled with yellow fluid or blood. It may be found at the age from 16 to 55 years old.

Clinic. Symptoms are related to large size or complications of torsion, rupture or hemorrhage. The main complaint of the patient is abdominal pain as a result of con­comitant inflammatory processes of uterine adnexa. Special clinical signs are absent. Bimanual examination reveals unilateral ovarian enlargement with tuber­­culosis uneven consistency. During pregnancy the corpus luteum becomes truly cystic with growth and continued function. At the absence of pregnancy, the corpus luteum normally collapses and is eventually replaced by hyaline con­nective tissue.

Treatment. More commonly luteum cysts produce no symptoms and undergo absorption or regression. It is necessary to make observation for 2-3 reproductive cycles. Surgical intervention should be recommended in the case if corpus luteum cyst regression doesn’t occur.

Theca lutein cysts belong to retential ovarian cysts. These cysts are almost bilateral and the enlargement may exceed up to 15 cm. They should be present during pregnancy, hydatidiform mole or choriocarcinoma. They are growing very quickly. They can dissolve after the main disease treatment — hydatidiform mole or choriocarcinoma.

Parovarian cyst

Parovarian cyst is formed as a result of fluid retention in ovarian adnexa which has been situated in the broad ligament. It arises at the age of 20-40 years old because only in reproductive period ovarian epo­ephoron is well developed and it undergoes atrophic changes in climacteric wo­men. Children can have parovarion cyst very rarely. Intraligamentous cysts may be small or may reach 8-10 cm or more in diameter. They are thin-walled and unilocular with solid consistency, they have smooth surface with vessels which are situated outside, it is filled with fluid.

 

 

Clinic. Pain in the lower abdomen and sacral region may be present. Symp­toms of adjacent organs compression are present if the tumor reaches large sizes. Symptoms of acute abdomen are common in the case of parovarian pedicle cyst torsion. At bimanual examination pelvic mass with smooth surface and elastic consistency which is palpated near uterus is found. It is painless and immobile.

Treatment. Surgical removal of parovarian cyst. It is very necessary to store the ovarian function. Puncture of the cyst should be indicated in some cases.

Thus, retential cysts are more often found in young women. After exception of true ovarian tumor such diagnosis is made in climacteric women. Ultra­sono­graphy and laparoscopy should be prescribed for diagnostics.

Patients with ovarian cysts should undergo careful monitoring. Retential cysts of small sizes may undergo spontaneous regression under the effects of anti-inflammatory drugs. Thus, they may be treated within 4-6 weeks. One should remember that interm diagnosis and treatment of retential cysts is the prevention to ovarian cancer. True ovarian tumor is revealed in one out of four wo­men with the diagnosis of retential cyst. That’s why, these patients require interm surgical intervention.

Blastomatic proliferative ovarian tumors (ovarian cystadenomas)

Serous cystadenoma

Serous cystadenoma is unilocular unilateral benign cystic neo­plasm derived from the surface epithelium of the ovary and lined by epithelium that resembles the mucosa of the oviduct. It contains clear yellow fluid. The benign serous cystadenoma is usually between 5-15 cm in diameter. occa­sionally it fills the entire abdomen. Tumor growing may lead to the enlarge­ment of abdomen, adjacent organs function impairment. No symptoms are specific for this tumor. Rarely, patient may complain on dull abdominal pain. Reproductive cycle is normal. The symptoms of peritoneal irritation are present in the case of pedicle torsion. These tumors are revealed during monitoring.

 

 

Pelvic examination reveals mobile, painless and unilateral tumor with smooth external surface. Ultrasonography and laparoscopy may confirm the diagnosis.

 

 

Treatment is surgical because of the relatively high rate of malignancy. In the patients after the childbearing age (after 40 years old) treatment should consist of bilateral salpingoophorectomy and hysterectomy not only because of chance of future malignancy, but because of the increased risk of similar occurrence in the contralateral ovary. In the younger patients with smaller tumors an attempt can be made to perform an ovarian cystectomy to try to minimize the amount of ovarian tissue removed. For large, unilateral serous tumors in young patients, unilateral oophorectomy with preservation of the contralateral ovary is indicated to maintain fertility.

Papillary serous cystadenomas

The papillary projections of ovarian cystadenomas may grow inside and outside of the tumor capsule. There are also mixed tumors when these projections are placed into internal and external surfaces of the tumor. Papillary projections may involve peritoneum in the case of malignant degeneration. These tumors are multilocular, they rarely reach large sizes, have a short pedicle. They may be situ­ated intraligamentously. The tumor contains serous or sometimes serous-hemorrhaged fluid. Tumor may coexist with ascites.

No characteristic symptoms are specific for this tumor. Frequently, it is revealed during monitoring. The diagnosis is based on the results of bimanual examination, ultrasonography and laparoscopy.

Bimanual examination reveals immobile painless lobulated tumor which is situated near uterus. Frequently it resembles the subserosal uterine fibroid. These tumors have high frequency of malignant change.

Treatment is surgical and it is the same as in case of serous cystadenomas.

Mucinous cystadenoma

Mucinous cystadenoma is a benign epithelial tumor which may be present in women of different age. It may reach large sizes, sometimes it is multilo­cular, with round or oval form. The cut surface shows the individual cysts or lobules of various si­zes that contain sticky slimy or viscid material of yellow or brown color

 

Clinic. No symptoms are specific for this tumor even in case of large sizes. Pain in the lower part of the abdomen and back region may be present in case of intraligamentous location. Symptoms of adjacent organs compression are present if a tumor is huge. Ascites is rare. Bimanual research reveals elastic tumor with lobular surface in the adnexal region. Laparoscopy and ultrasono­graphy can be used for diagnostics.

 

 

The usual treatment for the obviously benign mucinous cystadenoma is unilateral oophorectomy. In older women after 45 bilateral oophorectomy and hysterectomy are preferable. Total hysterectomy with bilateral salpingo­opho­rectomy are indicated in case of coexisting cervical pathology.

Pseudomyxoma

Pseudomyxoma is one of the kinds of mucinous cystadenoma. The incidence of these tumors is low. The tumor is multilocular and has a thin wall. It can be rup­tured spontaneously or during the pelvic exam. Pseudomyxoma peritoneal is the compli­cation that may result if the contents of mucinous cyst is spilled into the pe­ri­to­neal cavity by rupture, extension or at surgery. Sticky slimy material which is spilled into the peritoneal cavity doesn’t absorb. Diffuse implants develop into all the peritoneal surfaces with tremendous accumulation of mucinous material within the peritoneal cavity. It supports the chronic inflammatory process in the pelvis, thus chronic pelvic pain is a true result of this. Diffuse implants de­velop on all the peritoneal surfaces with the tremendous accumulation of mu­cinous material within the peritoneal cavity.

Clinic. Pain is the main characteristic sign of pseudomyxoma. The clinical course is usually progressive malnutrition and emaciation. The palpation of the abdomen is painful.

Pelvic exam reveals elastic tumor, frequently of large sizes which is situated near uterus. The diagnosis is proved during operation.

Treatment is surgical. The fluid is difficult to remove because of its viscosity. Repeated chemotherapy may be required in postoperative period.

Cystadenofibroma

Cystadenofibroma is a benign tumor which is developed from ovarian stroma. It has round or oval form, it is firm and unilateral and may reach the sizes of fetal head. The age distribution is 40-50 years old. It has asymptomatic duration or sometimes it is accompanied by ascitis. hydro­­thorax and anemia may be present in rare cases (Meigs Syndrome).

The treatment is surgical — removal of the tumor.

Special forms of ovarian tumors

Androblastoma
(arrhenoblastoma)

Androblastoma which is usually masculinizing tumor is reported to produce masculinization. It occurs very rarely and its duration is also malignant. Andro­blastoma is unilateral tumor with smooth or lobular surface. It has small sizes and pedicle and it is mobile.

Clinic. Breast, uterine and female external genitalia atrophy are the charac­teristic signs. Uterine and ovarian hyporplasia, endometrial atrophy are common. Amenorrhea and all masculinizing features are present. The combination of mas­culinizing and feminizing symptoms is possible.

Diagnosis. Ultrasonography, laparoscopy and ovarian biopsy play an important role at confirmation of diagnosis.

Treatment is surgical — removal of the tumor.

In the majority of cases prognosis is favorable.

Thecoma
(Theca cell tumor
)

Thecoma belongs to the feminizing tumors. It occurs at all ages but is com­mon after 40 years old and later. The evidence indicates that thecomas arise from the ovarian cortical stroma. Theca cell tumors are unilateral and in most cases they are not malignant. Their sizes may vary from small to those of fetal head. The external surface is firm, ovoid or round, smooth, and gray, occasionally streaked with yellow. Symptoms are related to estrogen production. When the granulosa cell tumor occurs in the pediatric age group, it may contribute to signs and symptoms of precocious puberty and vaginal bleeding. In women of reproduc­tive age group such symptoms as impairment of menstrual function, infertility and pregnancy loss are common. Menopause bleeding, enlarged sizes of uterus and breasts, increasing libido are present in these patients. Ascites may be present in favorable and unfavorable duration of disease. Malignant degeneration of tumor is frequen­tly common in young patient.

Diagnosis is based on clinic, bimanual research, ultrasonography, laparo­scopy and hysteroscopy.

Treatment is surgical.

Prognosis is good in favorable duration and it is unfavorable during the malignant course.

Folliculoma

Folliculoma is a hormonal active tumor which produces estrogenic compo­nents and may be manifested in patients through feminizing characteristics. It va­ries from microscopic inclusions to 40-50 cm in diameters, they are yellow-colored. Folliculoma may have good as well as malignant potential. It is always uni­lateral with lobular surface. They occur at all ages but are common in women older than 40. Uterine fibromyoma and uterine cancer can coexist with folliculoma.

Clinic. Symptoms depend on the level of hyperestrogenemia and on the women age. The girls have the signs of precocious puberty. In reproductive age group women amenorrhea, acyclic bleeding, and later menopausal uterine blee­ding may be present. Combination of feminizing syndrome with infertility and menstrual function impairment testifies the presence of hormonal active tumor.

Diagnosis is based on the ultrasonography results, laparoscopy, histologic examination of tissue.

Treatment is surgical. In malignant duration of the disease total hysterectomy with omentum major incision should be performed. Chemotherapy is prescribed in III-IV stages of cancer.

Benign cystic teratoma (Dermoid cyst)

Dermoid cysts are almost always ovarian tumors. The tumors may occur at any age. Dermoids are bilateral and have 5-10 cm in diameter. At operation, the tumors are found to be round with smooth, glistening, grey surface. At body tem­perature, they have the consistency of other tensely cystic tumors. Outside the body, they have a soft pultaceous consistency. On sectioning, they are usually unilocular and filled with thick sebaceous material and tangled masses of hair  .In 30% to 50% of cases cysts contain the formed teeth. Slow growing, without any symptoms, as a rule, is a characteristic feature of the tumor. Moreover, a dermoid cyst often has a long cruz. At pelvic examination it allows to palpate the cyst in the abdomen or anterior to the uterus.

 

 

 

 

Clinic. No symptoms are common for small sizes tumors. Pain is present in case of large tumors. Ultrasonography, laparoscopy are used for diagnosis.

Treatment is surgical. It consists of excision of the cyst, conserving the re­maining portion of the ovary.

Prognosis is favorable. In 0,4-1, 7% of patients malignant degeneration of tumor is present.

Brenner tumor

The Brenner tumor is a fibroepithelial tumor with gross characteristics similar to those of fibroma. It constitutes approximately 1%–2% of all the ovarian tumors and is rarely malignant. Brenner tumors have been reported in patients older than 50. Frequently a tumor is unilateral, its shape, sizes and consis­tency are similar to fibroma (fig. 170). According to the most widely accepted theory of histogenesis, Brenner tumors arise from the Walthard cell rests which are
a mo­dification and inclusion of the surface or germinal epithelium of the ovary (fig.171).

Clinic. A few Brenner tumors are associated with postmenopausal bleeding, and it is suggested that some may contain hormonally active stroma. Bimanual examination, ultrasonography and laparoscopy are diagnostics.

Treatment consists in simple excision or oophorectopmy.

Diagnosis of benign ovarian tumors.

General and pelvic examination should be performed. Differential diagnosis should be made with uterine fibromyoma (fig. 172), endometriosis, inflammatory tubo­ovarian tumors and moving kidney.

Additional methods of investigation such as uterine prob­bing, culdoscopy, cystoscopy, urography, X-ray examination, ultrasono­graphy and laparoscopy should be performed.

Thus, benign ovarian tumors have some common­ pecu­liarities of clinical course, such as:

l for a long period of time they are asymptomatic, they are growing into direction of abdominal cavity. Pain is a common symptom in case when the tumor is growing intraligamentously (fig. 173)

l in the majority of cases cysts and cystadenomas are mobile as a result of pedicle presence. The anatomical and surgical pedicles are distin­guished. The anatomical pedicle is composed of the infundibulopelvic liga­ment, the ovarian ligament and mesoovarium. Surgical ligament composes of all of these structures and fallopian tube with its nerves vessels. During tumor removal the clamps should be put on the surgical pedicle below the place of torsion

l the signs of adjacent organs compression are present during tumor’ growing

l the tumors are palpated as a rule in the lateral sides of the uterus

Ovarian cysts and cystadenomas’ complications

Malignant degeneration. It is most commonly found in serous and papillary cysta­denomas, frequently — in mucinous cystadenomas and very rare in dermoid ovarian cysts. It is very difficult to reveal the moment of tumor’ malignant degeneration, that’s why it is very important to remove the tumor at early stages.

Torsion. If the torsion is incomplete, the result is congression and enlar­gement of the neoplasm and thrombosis of the vessels. If the torsion is complete and ob­structs the arterial blood supply, a gangrenous necrosis can appear as a result. The symptoms may be gradual pain and tenderness in the region of the tumor or the abrupt onset of pain typical of an acute abdominal condition. Immediate surgery is necessary to remove the compromised tissue.

 

 

Purulention. High temperature, symptoms of peritoneal irritation, abdominal pain are common. Immediate surgery is recommended.

Rupture. In the result of hemorrhage or torsion ovarian cyst may rupture and spill its contents into the abdominal cavity resulting in intensification of the symptoms. Rupture of suspected neoplasm should initiate immediate laparotomy for a prudent removal of the neoplasm

All ovarian tumors warrant surgical removal because of their potential for malignancy, but it is very difficult to reveal this tumor at early stages.

 

 

DYSHORMONAL DISEASES OF BREASTS

Diseases of breasts out of pregnancy and lactation are called dyshormonal dysplasia or mastopathy.

Breasts are the part of women’s reproductive system and thus the target organ for hormones of ovaries and prolactin. that’s why glandular tissue of breasts undergoes cyclic changes during menstrual cycle, according to its phases. Excessive rate or lack of sexual hormones disturbs regulation of glandular epithe­lium activity of breasts and can cause pathological processes in them.

Determination: Mastopathy is a fibrous-cystic disease which is characterised by a spectrum of proliferate and regressive changes of glandular tissue with abnormal index of epithelial and connective tissue components.

Mastopathy is one of the most widespread diseases. its frequency rate is 30-45%, and among women with gynaecological pathology it is 50-60%. Most frequently the women aged 40-50 suffer from this disease. Then mastopathy fre­quency decreases, but morbidity on breast cancer increases.

Forms of mastopathy:

I — diffusive fibrous-cystic mastopathy:

1) with dominance of glandular component

2) with dominance of fibrous component

3) with dominance of cystic component

4) mixed form.

II — nodular fibrous-cystic mastopathy

Fibrous-cystic mastopathy with dominance of glandular component cli­nically is manifested by pain, swelling, diffusive infiltration of the whole gland or its part. Symptoms become stronger in premenstrual period. This form more frequently happens in young girls at the end of pubescence period.

Fibrous-cystic mastopathy with dominance of fibrosis. For this disease the changes of connective tissue between lobules of breasts are characteristic. At palpation painful, dense and chord regions are determined. Such processes prevail in wo­men of premenopausa.

Fibrous-cystic mastopathy with dominance of cystic component. Plenty of cystic formations of elastic consistence, well delimited from nearby tissue are generated. Typical sign is pain, that becomes stronger before menses. This form happens in menopausal women.

Cysts’ calcination and presence of bloody content in them is a patho­gno­monic sign of malignant process.

Nodular fibrous-cystic mastopathy is characterized by the similar changes in gland tissue, but they are not diffusive, and localize in the form of one or  several nodes. The nodes do not have distinct borders, enlarge before and become smaller after menses. They are not connected with skin.

Diagnosis is based on subjective signs (patient’s complaints) and physical examination, that includes palpation of breasts in upright and lying position with consecutive examining of each quadrant (fig. 75). Infiltrations, which are found during palpation, in great majority of cases localize in upper-external gland sectors, nearer to arm-pit, where many lobules are situated. Some­times  infiltration  have rough consistence.

 

 

 

At pressing on nipples — transparent, light or dull, with green hue discharge can appear. sometimes it is white like milk.

From special examinations mammography, which is made in the first half of menstrual cycle on special rhentgenological vehicles giving minimum radial loading is used. X-ray film is made in two projections. if it is necessary projection with ducts contrasting is made.

Ultrasonic research is also performed in the 1st cycle phase. sono­graphy shows macrocystic changes and formations especially distinetly.

Punction biopsy with the following cytological examing of aspirated mass is indicated. Exactness of cancer diagnosis of such method is 90-100%.

Women with disorders of menstrual cycle frequently suffer from fibrous-cystic mastopathy, and such patients are in risk group for development of breast cancer. That’s why gynecological examination has to include breasts’ palpation.

The patient in which the infiltration in breast, is found, must be obligatorily directed to oncologists consultation. The treatment is prescribed only in that case when by all diagnostic me­thods we have been persuaded that the patient has no malignant tumor. Fibro­adenoma has to be removed only surgically. Other forms of masto­pathy are treated con­servatively: doctor prescribes hormonal the­rapy — progesterone in the second half of cycle. Vitamin therapy is recommended — vitamins A, В1, В6, E; iodine pre­parations — potassium iodide is used during 6-12 months. Among women who use oral contraception there is a few women suffering from fibrous-cystic mastopathy, that’s why appli­cation of gestagen preparations with insignificant doses of estrogens during 6-12 months is effective.

 

Symptoms

Common symptoms include breast pain, lumps, and a discharge from the nipple. Breast symptoms do not necessarily mean that a woman has breast cancer or another serious disorder. However, if a woman has any of the following symptoms, she should see her doctor:

*                   a lump that feels distinctly different from other breast tissue or that does not go away

*                   swelling that does not go away

*                   puckering or dimpling in the skin of the breast

*                   scaly skin around the nipple

*                   changes in the shape of the breast

*                   changes in the nipple, such as turning inward

*                   discharge from the nipple, especially if it is bloody

Breast Pain: Many women experience breast pain (mastalgia). Breast pain may be related to hormonal changes. For example, it may occur during or just before a menstrual period (as part of the premenstrual syndrome) or early in pregnancy. Women who take oral contraceptives or who take hormone therapy after menopause commonly have this kind of pain. The pain is due to growth of breast tissue. Such pain is usually diffuse, making the breasts tender to touch. Pain related to the menstrual period may come and go for months or years.

 

 

General Information about Breast Cancer and Pregnancy

Keypoints:

Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.

The breast is made up of lobes and ducts. Each breast has 15 to 20 sections called lobes, which have many smaller sections called lobules. The lobes and lobules are connected by thin tubes called ducts. Anatomy of the breast, showing lymph nodes and lymph vessels.

Each breast also contains blood vessels and lymph vessels. The lymph vessels carry an almost colorless fluid called lymph. The lymph vessels lead to small, bean-shaped organs called lymph nodes that help the body fight infection and disease. Lymph nodes are found throughout the body. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest.

Breast cancer is sometimes detected (found) in women who are pregnant or have just given birth.

In women who are pregnant or who have just given birth, breast cancer occurs most often between the ages of 32 and 38. Breast cancer occurs about once in every 3,000 pregnancies.

It may be difficult to detect (find) breast cancer early in pregnant or nursing women, whose breasts are often tender and swollen.

Women who are pregnant, nursing, or have just given birth usually have tender, swollen breasts. This can make small lumps difficult to detect and may lead to delays in diagnosing breast cancer. Because of these delays, cancers are often found at a later stage in these women.

Breast examination should be part of prenatal and postnatal care.

To detect breast cancer, pregnant and nursing women should examine their breasts themselves. Women should also receive clinical breast examinations during their routine prenatal and postnatal examinations.

Tests that examine the breasts are used to detect (find) and diagnose breast cancer.

If an abnormality is found, one or all of the following tests may be used:

  • Ultrasound: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
  • Mammogram: An x-ray of the breast. A mammogram can be performed with little risk to the fetus. Mammograms in pregnant women may appear negative even though cancer is present. Mammography of the right breast.
  • Biopsy: The removal of cells or tissues by a pathologist so they can be viewed under a microscope to check for signs of cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

  • The stage of the cancer (whether it is in the breast only or has spread to other places in the body).
  • The size of the tumor.
  • The type of breast cancer.
  • The age of the fetus.
  • Whether there are symptoms.
  • The patient’s general health.

Survival rates of pregnant women with breast cancer may be lower than for women who are not pregnant.

Pregnant women with breast cancer may be less likely to survive because the diagnosis of their cancer is often delayed and the cancers are more advanced when they are found. Cancers found at later stages are more difficult to treat successfully.

Stages of Breast Cancer

Keypoints:

After breast cancer has been diagnosed, tests are done to find out if cancer cells have spread within the breast or to other parts of the body.

The process used to find out if the cancer has spread within the breast or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. (Refer to the PDQ summary on Breast Cancer Treatment for more information on the stages used for breast cancer.)

Methods used to stage breast cancer can be changed to make them safer for the fetus.

Standard methods for giving imaging scans can be adjusted so that the fetus is exposed to less radiation. Tests to measure the level of hormones in the blood may also be used in the staging process.

Treatment Option Overview

Keypoints:

There are different types of treatment for patients with breast cancer.

Different types of treatment are available for patients with breast cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Treatment options for pregnant women depend on the stage of the disease and the age of the fetus.
Three types of standard treatment are used:

Surgery

Most pregnant women with breast cancer have surgery to remove the breast. Some of the lymph nodes under the arm are usually taken out and looked at under a microscope to see if they contain cancer cells.

Types of surgery to remove the breast include:

  • Simple mastectomy: A surgical procedure to remove the whole breast that contains cancer. Some of the lymph nodes under the arm may also be removed for biopsy. This procedure is also called a total mastectomy. Total mastectomy. Dotted line shows entire breast is removed. Some lymph nodes under the arm may also be removed.
  • Modified radical mastectomy: A surgical procedure to remove the whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles.Modified radical mastectomy. Dotted line shows entire breast and some lymph nodes are removed. Part of the chest wall muscle may also be removed.

Breast-conserving surgery, an operation to remove the cancer but not the breast itself, includes the following:

  • Lumpectomy: A surgical procedure to remove a tumor (lump) and a small amount of normal tissue around it. Most doctors also take out some of the lymph nodes under the arm.
  • Partial mastectomy: A surgical procedure to remove the part of the breast that contains cancer and some normal tissue around it. Some of the lymph nodes under the arm may also be removed for biopsy. This procedure is also called a segmental mastectomy.

Breast-conserving surgery. Dotted lines show area containing the tumor that is removed and some of the lymph nodes that may be removed.

Even if the doctor removes all of the cancer that can be seen at the time of surgery, the patient may be given radiation therapy, chemotherapy, or hormone therapy after surgery to try to kill any cancer cells that may be left. Treatment given after surgery to increase the chances of a cure is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Radiation therapy should not be given to pregnant women with early stage (stage I or II) breast cancer because it can harm the fetus. For women with late stage (stage III or IV) breast cancer, it should not be given during the first 3 months of pregnancy.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Chemotherapy should not be given during the first 3 months of pregnancy. Chemotherapy given after this time does not usually harm the fetus but may cause early labor and low birth weight.

Other types of treatment are being tested in clinical trials. These include the following:

Hormone therapy

Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances produced by glands in the body and circulated in the bloodstream. The presence of some hormones can cause certain cancers to grow. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation therapy are used to reduce the production of hormones or block them from working.

The effectiveness of hormone therapy, alone or combined with chemotherapy, in treating breast cancer in pregnant women is not yet known.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site.

Ending the pregnancy does not seem to improve the mother’s chance of survival and is not usually a treatment option.

If the cancer must be treated with chemotherapy and radiation therapy, which may harm the fetus, ending the pregnancy is sometimes considered. This decision may depend on the stage of cancer, the age of the fetus, and the mother’s chance of survival.

Treatment Options by Stage

cyclophosphamide and methotrexate, may occur in high levels in breast milk and may harm the nursing baby. Women receiving chemotherapy should not breast-feed. Stopping lactation does not improve survival of the mother.

Breast cancer does not appear to harm the fetus.

Breast cancer cells do not seem to pass from the mother to the fetus.

Pregnancy does not seem to affect the survival of women who have had breast cancer in the past.

Some doctors recommend that a woman wait 2 years after treatment for breast cancer before trying to have a baby, so that any early return of the cancer would be detected. This may affect a woman’s decision to become pregnant. The fetus does not seem to be affected if the mother has previously had breast cancer.

Effects of certain cancer treatments on later pregnancies are not known.

The effects of treatment with high-dose chemotherapy and a bone marrow transplant, with or without radiation therapy, on later pregnancies are not known.

Changes to This Summary

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

 

Breast disorders may be noncancerous (benign) or cancerous (malignant). Most are noncancerous and not life threatening. Often, they do not require treatment. In contrast, breast cancer can mean loss of a breast or of life. Thus, for many women, breast cancer is their worst fear. However, potential problems can be detected early when women regularly examine their breasts themselves and have mammograms.

Symptoms

Common symptoms include breast pain, lumps, and a discharge from the nipple. Breast symptoms do not necessarily mean that a woman has breast cancer or another serious disorder. However, if a woman has any of the following symptoms, she should see her doctor:

*                   a lump that feels distinctly different from other breast tissue or that does not go away

*                   swelling that does not go away

*                   puckering or dimpling in the skin of the breast

*                   scaly skin around the nipple

*                   changes in the shape of the breast

*                   changes in the nipple, such as turning inward

*                   discharge from the nipple, especially if it is bloody

 

Inside the Breast

Inside the Breast

The female breast is composed of milk-producing glands (lobules) surrounded by fatty tissue and some connective tissue. Milk secreted by the glands flows through ducts to the nipple. Around the nipple is an area of pigmented skin called the areola.

Breast Pain: Many women experience breast pain (mastalgia). Breast pain may be related to hormonal changes. For example, it may occur during or just before a menstrual period (as part of the premenstrual syndrome) or early in pregnancy. Women who take oral contraceptives or who take hormone therapy after menopause commonly have this kind of pain. The pain is due to growth of breast tissue. Such pain is usually diffuse, making the breasts tender to touch. Pain related to the menstrual period may come and go for months or years.

Other causes of breast pain include breast cysts, infections, and abscesses. In these cases, breast pain is usually felt in a particular place. Fibrocystic breast disease can also cause breast pain. Breast pain is occasionally due to breast cancer, but breast cancer does not usually cause pain. Breast pain that persists for more than 1 month should be evaluated.

Mild breast pain usually disappears eventually, even without treatment. Pain that occurs during menstrual periods can usually be relieved by taking acetaminophenSome Trade Names
TYLENOL
or a nonsteroidal anti-inflammatory drug (NSAID).

For certain types of severe pain, danazolSome Trade Names
DANOCRINE
(a synthetic hormone related to testosteroneSome Trade Names
DELATESTRYL
DEPOTESTOSTERONE
) or tamoxifenSome Trade Names
NOLVADEX
(a drug used to treat breast cancer) may be used. These drugs inhibit the activity of estrogen and progesterone, which affect the breast. Because long-term use of these drugs causes side effects, the drugs are usually given for only a short time. TamoxifenSome Trade Names
NOLVADEX
has fewer side effects than danazolSome Trade Names
DANOCRINE
. TamoxifenSome Trade Names
NOLVADEX
is used mainly for postmenopausal women but may benefit younger women.

If a specific disorder is identified as the cause, the disorder is treated. For example, if a cyst is the cause, draining the fluid from the cyst usually relieves the pain.

Breast Lumps: Lumps in the breasts are relatively common and are usually not cancerous. But because they may be cancerous, they should be evaluated by a doctor without delay. Lumps may be fluid-filled sacs (cysts) or solid masses, which are usually fibroadenomas (see Breast Disorders: Fibroadenomas).

Other solid breast lumps include hardened glandular tissue (sclerosing adenosis) and scar tissue that has replaced injured fatty tissue (fat necrosis). Neither is cancerous. However, these lumps can be diagnosed only by biopsy. They require no treatment.

Nipple Discharge: One or both nipples sometimes discharge a fluid. A nipple discharge occurs normally during milk production (lactation) after childbirth or as a result of mechanical stimulation of the nipple by fondling, suckling, or irritation from clothing. During the last weeks of pregnancy, the breasts may produce a milky discharge (colostrum). A normal nipple discharge is a thin, cloudy, whitish or almost clear fluid that is not sticky. However, during pregnancy or breastfeeding, a slightly bloody discharge sometimes occurs normally.

Several disorders can cause an abnormal discharge. Abnormal discharges vary in appearance depending on the cause. A bloody discharge may be caused by a noncancerous breast tumor (such as a tumor in a milk duct, called an intraductal papilloma) or, less commonly, by breast cancer. Among women who have an abnormal discharge, breast cancer is the cause in fewer than 10%. A greenish discharge is usually due to a fibroadenoma, a noncancerous solid lump. A discharge that contains pus and smells foul may result from a breast infection. A large amount of milky discharge in women who are not breastfeeding may result from galactorrhea (see Pituitary Gland Disorders: Galactorrhea). Tumors of the pituitary gland or brain, encephalitis (a brain infection), and head injuries can also cause a nipple discharge. Taking certain drugs, such as antidepressants and certain antihypertensives, can cause a nipple discharge. Taking oral contraceptives may cause a watery discharge.

A discharge from one breast is likely to be caused by a problem with that breast, such as a noncancerous or cancerous breast tumor. A discharge from both breasts is more likely to be caused by a problem outside the breast, such as a pituitary tumor, or by drugs.

If a nipple discharge persists for more than one menstrual cycle or seems unusual to the woman, she should see a doctor. Postmenopausal women who have a nipple discharge should see a doctor promptly. Doctors examine the breast, looking for abnormalities. Mammography and blood tests to measure hormone levels may be performed. Computed tomography (CT) or magnetic resonance imaging (MRI) of the head may be performed. The woman is asked for a complete list of drugs she is taking. Sometimes a specific cause cannot be identified.

If a disorder is the cause, the disorder is treated. If a noncancerous tumor is causing a discharge from one breast, the duct that the discharge is coming from may be removed.

 

Fibrocystic breast disease

Definition

Fibrocystic breast disease is described as common, benign (non-cancerous) changes in the tissues of the breast. The term "disease" in this case is misleading, and many providers prefer the term "change."

The condition is so commonly found in breasts, it is believed to be a variation of normal. Other related terms include "mammary dysplasia," "benign breast disease," and "diffuse cystic mastopathy."

Alternative Names

Mammary dysplasia; Benign breast disease

Causes

The cause is not completely understood, but the changes are believed to be associated with ovarian hormones since the condition usually subsides with menopause, and may vary in consistency during the menstrual cycle.

The incidence of it is estimated to be over 60% of all women. It is common in women between the ages of 30 and 50, and rare in postmenopausal women. The incidence is lower in women taking birth control pills. The risk factors may include family history and diet (such as excessive dietary fat, and caffeine intake), although these are controversial.

Symptoms

  • A dense, irregular and bumpy "cobblestone" consistency in the breast tissue
  • Usually more marked in the outer upper quadrants
  • Breast discomfort that is persistent, or that occurs off and on (intermittent)
  • Breast(s) feel full
  • Dull, heavy pain and tenderness
  • Premenstrual tenderness and swelling
  • Breast discomfort improves after each menstrual period
  • Nipple sensation changes, itching

Note: Symptoms may range from mild to severe. Symptoms typically peak just before each menstrual period, and improve immediately after the menstrual period.

Exams and Tests

Physical examination reveals the presence of mobile (non-anchored) breast "masses." These masses are usually rounded, with smooth borders, and either rubbery or slightly changeable in shape. Dense tissue may make the breast examination more difficult to interpret.

Treatment

Self care may include restricting dietary fat to approximately 25% of the total daily calorie intake, and eliminating caffeine.

Performing a breast self-examination monthly, and wearing a well-fitting bra to provide good breast support are important.

The effectiveness of Vitamin E, Vitamin B-6, and herbal preparations, such as evening primrose oil are somewhat controversial. Discuss their use with your health care provider.

Oral contraceptives may be prescribed because they often decrease the symptoms. A synthetic androgen may be prescribed by a doctor in severe cases, when the potential benefit is thought to outweigh the potential adverse effects.

Outlook (Prognosis)

If dietary changes decrease the symptoms, and are maintained, the benefit most likely will persist. A combination of treatment and use of medications may be necessary to obtain relief for severe cases.

Possible Complications

Because fibrocystic changes may make breast examination and mammography more difficult to interpret, early cancerous lesions may occasionally be overlooked.

When to Contact a Medical Professional

Call your health care provider if you feel a new, unusual, or "dominant" lump during a breast self-examination.

Call for an appointment with your health care provider if you are a woman, aged 20 or older, who has never been taught, or does not currently know how, to perform breast self-examination. Also call if you are a woman, aged 40 or older, who has not had a screening mammogram.

Prevention

Reduction of dietary fat and caffeine if you have fibrocystic breast changes has been suggested, although recent studies have questioned the role of caffeine and fat in fibrocystic disease.