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MINISTRY OF PUBLIC HEALTH OF UKRAINE
NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSYA
CHAIR OF OBSTETRICS AND GYNECOLOGY №1
METHODICAL INSTRUCTIONS
for practical lesson
« Benign diseases of the vulva, vagina, cervix and ovary. Benign disease of the uterus.
Gynecologic aspects of mammary gland diseases»
MODULE 4: Obstetrics and gynecology
TOPIC 13
I. Scientific and methodical grounds of the theme
Early and active diagnosis of benign tumors and precancerous diseases of female
genitalia, their timely and correct treatment are the pledge for solution of cancer
problems.
II. Aim:
A student must know:
1. Classification of uterine myoma.
2. Methods of examination for diagnosis of uterine myoma.
3. Conservative methods of treatment.
4. Methods of myoma surgery.
5. Classification of uterine myoma.
6. What additional methods of investigation are used for confirmation of the
diagnosis?.
A student should be able to:
1. Diagnose benign tumors of uterus.
2. Diagnose precancerous diseases of uterine cervix.
3. Carry out a vaginal speculum-examination, vaginal examination, put up
primary diagnosis.
III. Recommendations to the student
VULVAL CYSTS
The Ovary and Adnexa in Pediatric and Adolescent Gynecology: Cysts,
Tumors, and Torsion
Most ovarian masses in this age group are functional ovarian cysts, and if a tumor
is present is most often a benign teratoma (dermoid). Malignancies can, however,
occur and are most often of germ cell origin, but can also be sex cord tumors such
as a graunulosa cell malignancy.
Physiologic and functional cysts of the ovaries are from gonadotropin stimulation
of the follicles. They may present in the fetus, newborn, infant, at puberty, and in
adolescence. The appropriate management may depend on the age and on the
appearance of the cyst on ultrasound. Cysts of follicular development will be clear
without significant solid components and almost always are less than 7 to 10 cm in
size.
Corpus luteum cysts are often more complex than other follicular cysts.
Management is similar to that in mature reproductive women, and observation is
warranted unless signs of malignancy are present. Consideration should be given to
dermoids and the possibility of germ cell tumors if a mass has both solid and cystic
components. In rare cases of intersex such as mixed gonadal dysgenesis suspicion
of malignancy should be high. A rare presentation of hypothyroidism is pediatric
ovarian cysts.
Prenatal Ovarian Cysts
Obstetric ultrasound of a female fetus occasionally demon-strates a simple
abdominal cyst. Before a diagnosis of an ovarian cyst is made, it is critical to
exclude urinary or gastrointestinal anomalies. Fetal malignancy is quite rare. The
management of fetal ovarian cysts is essentially expectant. Cysts rarely may
undergo torsion in the fetus, producing fetal ascites and rarely distress. This is
extremely uncommon. If torsion does occur, autoinfarction is possible. The end
product is unilateral agenesis of an ovary, and sometimes the tube. Again, this is
rare. Cysts greater than 9 cm should be managed with cesarean section. Cyst
aspiration could avoid the complication of silent ovarian torsion; however, the
risks do not justify the complications, unless the fetus is very immature and in
significant stress from the mass. With expectant management, approximately 90%
will resolve within 3 months after birth.
Torsion may be more common prenatally than postnatally although spontaneous
resolution may also be more common. The relative rarity of congenital absence of
one ovary makes it likely that untwisting occurs. The incidence of congenital
unilateral ovarian agenesis is only 1 in approximately 11,000 females. Ovarian
malignancy is extremely rare in this age group and is not a consideration in the
therapeutic approach.
Neonatal Ovarian Cysts
Simple cystic ovarian masses in newborns and neonates can be followed
expectantly. Parents should be given ovarian torsion warnings, and if the infant
presents with acute vomiting or abdominal pain she should be immediately
evaluated for ovarian torsion. Repeat serial ultrasonography should be performed
approximately monthly until the cyst resolves. Almost all will resolve if they do
not undergo torsion. Malignancy is not a consideration in newborns in the
therapeutic approach. Aspiration is a possibility for large cysts.
Ovarian Cysts in Children and Adolescents
The management of cystic ovarian structures in children and adolescents should
also be expectant unless they are extremely large, in which case the possibility of
functional cysts becomes more unlikely. Many times physiologic and functional
cysts are discovered on an abdominal ultrasound performed for complaints such as
abdominal pain. Often the presence of a cyst is incidental and unrelated to the
complaint. However, in patients with pain the possibility of ovarian torsion should
be enter-tained. Pain from ovarian cysts generally stems from three sources: (1)
expansion of the ovarian cortex (which is typically during the growth phase of
follicles and lasts less than 72 hours), (2) peritoneal bleeding from rupture
(particularly common in bleeding disorders and patients on warfarin [Coumadin]),
and (3) ovarian torsion. Ovarian cysts should be suspected in cases of chronic
pelvic abdominal pain.
Ovarian Tumors in Childhood and Adolescents
Various tumors, both benign and malignant, can be seen in the childhood and
adolescent years. These should always be considered, particularly in patients with
solid ovarian masses or cystic and solid components on ultrasound. The diagnosis
should also be considered in patients with presumed functional ovarian cysts that
do not resolve during serial monitoring.
Germ cell tumors are the most common gynecologic neoplasm in this age group,
and fortunately most are benign ovarian teratomas. The most common malignant
germ cell tumor is the dysgerminoma followed by endodermal sinus tumors. These
tumors are covered in detail in Chapter 33 (Neoplastic Diseases of the Ovary), but
several issues are especially pertinent to children and adolescents.
Bilaterality is seen in 10% to 15% of dysgerminomas, but is rare in all of the other
germ cell tumors of the ovary except for immature teratomas. Sex cord tumors,
such as granulosa and thecal cell tumors, can also be seen in this age group and are
often steroid-producing Rare tumors such as gonado-blastomas, a germ cell and
sex cord tumor, are seen in patients with intersex disorders such as mixed gonadal
dysgenesis.
Recurrent abdominal pain is a frequent complaint of grammar school age children
and this common symptom occasionally is the presenting problem with ovarian
neoplasia. The young child does not differentiate lower abdominal pain from
pelvic pain. Because of the small size of the preadolescent female pelvis, the
ovaries are abdominal organs. Thus, increasing abdominal girth is a frequent
symptom associated with ovarian enlargement. The most common clinical
manifestation of an ovarian tumor is lower abdominal pain or the presence of a
mass. Some ovarian tumors in children produce only vague discomfort, such as
abdominal fullness or bloating. However, adnexal masses in children are more
frequently associated with acute complications, such as torsion, hemorrhage, and
rupture, than are similar tumors in adults.
Ovarian tumors constitute approximately 1% of all neo-plasms in premenarcheal
children. Ultrasound, abdominal computed tomography (CT), or magnetic
resonance imaging (MRI) may be utilized in the evaluation of a possible pelvic
mass or abdominal pain of uncertain origin in children. Abdominal
ultrasonography may be used to establish that the origin of the mass is in the
pelvis, whether the mass is cystic or solid, and the presence of ascites.
Calcifications in an ovarian mass may appear toothlike, indicating a diagnosis of
ovarian teratoma. As part of the preoperative workup, the child may be screened
for elevated serum levels of tumor markers such as CA 125, α-fetoprotein, human
chorionic gonadotropin (HCG), inhibin, carcinoembryonic antigen, lactate
dehydrogenase, estradiol, and testosterone; tumor markers that are associated with
various ovarian neoplasms seen in girls. HCG may be positive for either the α or γ
subunit, so a pregnancy test that only tests for the β subunit is inadequate.
Ovarian tumors in preadolescent females, both benign and malignant, are usually
unilateral. Thus it is imperative to be conservative in managing the opposite ovary
in order to protect potential future fertility. During surgery the opposite ovary
should be carefully inspected and palpated. It is unnecessary and potentially
harmful to perform a biopsy on a normal-appearing contralateral ovary in a
preadolescent female. Appropriate exceptions to this rule include consideration of
performing a wedge biopsy in patients with dysgerminoma or a immature
teratoma—malignancies in which bilaterality is not as rare.
Children with suspected ovarian cancer should be referred to specialists who are up
to date on current data from the Pediatrics Oncology Group or Gynecologic
Oncology Group. First these groups will be skilled in getting their patients proper
staging procedures including lymph node sampling and omentectomy. In addition,
standard of care is for patients with nondysgerminomas, with a few exceptions, to
receive postoperative adju-vant chemotherapy. Use of tumor markers to help
differentiate patients with benign teratoma from malignancies is useful in triaging
appropriate referrals. However, regardless of what the makers show, referral is
prudent.
Approximately 75% to 85% of ovarian neoplasms that necessitate surgery in
premenarcheal females are benign, and approximately 15% to 25% are malignant
neoplasms. The risk is less in young children. In a review of ovarian masses in
children Brown and coworkers reported that the risk of malignancy was only 3%
up to age 8.
In summary, even though ovarian neoplasia is rare in chil-dren, this diagnosis must
be considered in a young girl with abdominal pain and a palpable mass. The
surgical therapy should have two goals: first, and most important, the appropriate
surgical procedure including lymph nodes as necessary, and second preservation of
future fertility. The traditional hysterectomy performed in adults with epithelial
ovarian cancers is not necessary even in rare cases of bilateral childhood or
adolescent ovarian malignancy. The uterus should be retained for fertility, which
may be possible through artificial reproductive technology such as use of donor
eggs.
Ovarian Torsion
Ovarian torsion is covered in more detail in Chapter 18 (Benign Gynecologic
Lesions). Issues unique to children and adolescents are covered in this discussion.
Torsion in prepubertal females may be secondary to a pelvic mass or due to
mechanical factors that occur in the peripubertal interval. In early puberty the
ovaries drop from their prepubertal position at the pelvic brim into the pelvis. This
drop occurs under the influence of gonadotropins that surge at puberty. Some
young women may have longer supportive ligaments, predisposing them to
twisting. Approximately two thirds of the time ovarian torsion occurs on the right
side, increasing the likelihood of the process being confused with appendicitis. The
sigmoid colon in the left lower quadrant helps prevent the left ovary from twisting.
Although both appendicitis and torsion can present with acute pain and rebound,
the gradual progression of appendicitis is quite different from the acute severe pain
of torsion. Nausea and emesis often ensue immediately with torsion, owing to the
severity of the pain. Appendicitis tends to present with anorexia, which gradually
worsens. The young girl with acute onset of pain and simultaneous emesis likely
has ovarian torsion rather than appendicitis.
Approximately a third of ovarian torsion cases in children and adolescents are not
associated with a predisposing ovarian mass such as a dermoid, large functional
cyst, or malignancy. Nevertheless, even in children without an ovarian mass, after
torsion the ovary will become swollen and enlarged as the lymphatic flow is
blocked. In children and adolescents the differentiation between torsion and
appendicitis is a common dilemma. Radiologic evaluation to rule out appendicitis
may reveal a pelvic mass, and the appropriate diagnosis of torsion is defined. The
presence of vascular flow in the ovary does not rule out torsion, and in fact many
cases of surgically proven torsion will have had normal vascular flow on
ultrasound evaluation.
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Sebaceous cysts
Epidermal (or epidermoid) cysts are derived from hair follicle epithelium.
Sebaceous cysts have a similar appearance from blockage of the ducts of
sebaceous glands and are most frequently found in the area between the labia
majora and minora. They contain a characteristic cheesy material, and may become
infected.
Bartholin's duct cyst
A cyst may result from blockage of Bartholin's duct by inflammation or by
inspissated secretion. It can occur as a result of gonococcal infection, although this
cause is now rare.
The cyst appears as a swelling situated on the inner side of the posterior end
of the labium majus. As it grows it bulges across the vaginal introitus, and the
posterior end of the labium minus is stretched over it. Small cysts may not give rise
to symptoms, but large cysts cause discomfort and may become infected, to form
an abscess with surrounding cellulitis.
A Bartholin's cyst is treated by marsupialization; an incision is made into the
cyst and the lining epithelium is stitched to the skin. The opening contracts down
to form a small sinus, and the gland may continue to function.
Recurrent cysts are best excised, along with the gland. Careful dissection is
required and there is always free bleeding from the deep bed left after its removal.
It is important not only to tie every bleeding vessel but also to drain the cavity;
otherwise a very large haematoma may result.
LESIONS OF THE URETHRA
Urethral caruncle
This name is applied to a small, usually bright red swelling, which presents
at the urethral orifice. It is always single and arises from the posterior wall of the
urethra, reaching a size of 0.5 cm. A caruncle consists of granulation tissue, in
which a few glandular structures may be seen; it is covered by thin stratified
epithelium.
Caruncles usually occur in postmenopausal women. Some cause no
symptoms, but most of them are very tender, causing dyspareunia or pain on
micturition. Slight bleeding may occur. They are not neoplastic, but probably result
from chronic infection of the paraurethral glands in the floor of the urethra.
Caruncles are treated by excision or destruction with diathermy.
VAGINAL CYSTS
The vagina is lined with stratified squamous epithelium and does not
normally contain glands. Occasionally, aberrant mucus-secreting glands occur in
the upper vagina (adenosis vaginae).
Vestiges of the Wolffian ducts may give rise cysts on the lateral aspect of
the vagina (Gartner's cysts). In the lower vagina such cysts tend to lie more
towards the midline of the anterior vaginal wall. They are lined with low columnar
epithelium and contain serous fluid. Such cysts do not need treatment unless they
are very large or become infected, when they can be excised or marsupial-ized.
Inclusion cysts lined with stratified epithelium may occur in the lower
vaginal wall after childbirth or surgical procedures.
VAGINAL TUMOURS
Fibromyomata These occasionally arise in the vaginal wall. A
hard, smooth tumour is felt under the epithelium; it can easily be enucleated.
UTERINE MYOMA
Uterine myoma (fibromyoma, leiomyoma) — is a benign tumor which contains
varying amounts of muscle and fibrous elements.
Concerning gynecologic diseases benign tumors are found in 10-25% of all the
cases, although during the last years the tendency of increasing the quantity of
these tumors is observed. The myoma arises seldom in young women. The risk of
disease grows after 35-40 years, at the age which is close to climacterium. Later
beginning of menstrual function, irregular menstrual cycle, high frequency of
induced abortions are present in the past history of the patients. Therefore, 35-40
years women are patients at risk for uterine fibromyoma.
Tumor histogenesis and structure. Uterine myoma belongs to tumors, which are
growing from mesenchyma. It has three consecutive stages in its morphogenesis.
They are:
 active region of growth formation
 growing of tumor without differentiation
 growing of tumor with differentiation and maturation
The areas of growth are formed mainly around the vessels. These regions are
characterized by a high level of metabolism and increased capilary and tissual
permeability which stimulate the tumor growing. Uterine fibroid has in its
development parenchymal-stromal features of that layer, from which it has been
educed, therefore the parenchyma and stroma ratio in a tumor is different.
Leiomyoma is developed at predominance of muscle elements, in the structure of
fibromyoma fibrous tissue is predominant. The consistency of tumor depends on
fibrous and muscle tissue ratio: the more there are muscle fibers, the more the
tumor is mild at palpation.
Myomas are classified according to histologic structure as myoma, fibromyoma,
angiomyoma and adenomyoma. According to the speed of growing there are the
tumors which are growing slowly and quickly. According to histogenesis
peculiarities there are distinguished simple and proliferative myomas. Proliferative
myomas contain much more atypical muscle elements, where is a great number of
plasmatic and lymphoid cells and increased mitotic activity. The incidence of
proliferative myomas happen twice more often in the patients with fast growing
tumors.
Very often uterine fibroids arise in places of complex interlacing of muscle fibers
of uterus — near tubal angles, on uterine center line. The myoma is characterized
by the effusive growing. As compared with cancer fibroids they move apart tissue
without destroying it. Tumor is growing simultaneously with tissue mass
surrounding it. Uterine fibroids have few veins, basic amount of vessels is situated
in pseudo-capsule. Uterine fibroids' lymphatic system is atypical without absorbent
vessels. Uterine fibroids are deprived of nervous terminals, choline and adrenergic
nervous frames.
According to their location in the uterus myomas are classified into:
 subserosal — subperitoneal uterine fibroids, which are growing under the
outer serosal layer of the uterus, may have a wide or thin pedicle.
 interstitial (intramural, intraparietal) — uterine fibroids, which are growing
within the muscular wall of the uterus
 submucosal — uterine fibroids which are growing under the uterine mucous
into the uterine cavity
 atypical forms of uterine fibroids location: retrocervical myoma grows from
the posterior surface of the uterine cervix, it is situated within a retrocervical
fat; paracervical myoma grows from the lateral part of uterine cervix, it is
situated in the paracervical fat; intraligamentary myoma grows from the
uterine body or cervix within the broad ligaments.
The fibromyoma can have one fibroid (nodulosus fibromyoma), many fibroids
(multiple fibromyoma) and diffuse growth (diffuse fibromyoma).
Hormonal status of the patients with fibromyoma. They are considered
hormonally depend tumors because the growth of these tumors is related to estrogen production. In the majority of cases these patients have an hormonal dysfunction of ovaries which is characterised by anovulatory cycles, corpus luteum
insufficiency. It leads to hyperestrogenemia and lowering of progesterone level.
Small cystic changes in ovaries occur due to hormonal disordes. Uterine endometrium and myometrium are under the influence of estrogenic hormones. Their
excessive amount in blood can lead to endometrial hyperplastic processes and
cystic changes in myometrium. Such local hyperhormonemia leads to pathological
hypertrophy of myometrium. Not only sexual hormones synthesis, metabolism and
interaction impairment, but also the state of the myometrial receptors especially
large activity of the estrogen receptors as compared with progesterones receptors,
take part in a pathogenesis of uterine fibromyoma.
Fibromyoma grows slowly without any proliferative changes at presence of small
cystic changes in ovaries with nonsignificant hyperestrogenemia. Fibromyoma
growing depends on its type, location, blood supply and patient's age. Fibromyoma
grows quickly in young patients, particularly during pregnancy, as the
fetoplacental complex synthesizes large amount of estrogenic hormones, which are
tumor stimulating growing factor. Quite often fibromyoma accelerates its growing
in climacterium, when there is a rearrangement of woman's hormonal system.
Ovaries undergo polycystic degeneration at that time.
Clinic. Clinical manifestation of fibromyomas depends on uterine fibroid's
location, size of tumour, rate of its growing, and also presence of complications.
Of the most myomas there are not any symptoms at the initial stages. The main
symptoms are pain, bleeding, sensation of pelvic heaviness in the lower part of the
abdomen, progressive increase in pelvic pressure, infertility, frequent urination,
pressure on the rectum. These symptoms most commonly occur during the
excessive growth of tumor, and sometimes they testify development of secondary
degenerative or inflammatory changes in fibromyoma tissue.
Menstrual function in the patients does not variate in case if tumor is sub-serosal
because attached to the uterus by only a stalk or on a wide basis under a peritoneal
integument and it is practically outside of uterine borders. Another spectrum
presentation includes patients with atypical (subperitoneal) location of uterine
fibroids: the tumors from the anterior wall of the uterus and antecervical location
can press upon urinary bladder and cause dysuric signs; pressure on the ureters (as
they traverse the pelvic brim) leads to hydroureter and sometimes to
hydronephrosis. Retrocervical location of uterine fibroid due to intensive growing
can spread in all small pelvic, compressing rectum and provoking constipation.
Intraligamentary tumor during its growing moves apart the broad ligament of the
uterus. As the ureters are passing in the lower areas of parametrium, the tumor
results in pressure upon ureters leading to hydroureters or hydronephrosis.
Cyclic menstruation is present but it is painful (algomenorrhea).
Submucosal location of uterine fibroid is characterized by cramping cyclic
menorrhagia which has been changed into acyclic bleeding.
Monthly appreciable bleeding leads to the secondary iron deficiency anemia.
Characteristic dystrophical myocardial changes called "myom' heart" result from
the secondary anemia and chronic hypoxia and are often found in patients with
fibromyoma. Liver function is frequently broken in these patients. Probably, these
changes are the result of steroid hormones metabolism dysfunction. Hypertrophy
of the left ventricle, myocardial dystrophy, ischemic heart disease, idiopathic
arterial hypertension are also present in these patients. In most of the patients after
fibromyoma removal the arterial pressure is reduced to the normal level. This fact
confirms the idea of pathogenetic connection of fibromyoma with changes in
myocardium and rising of arterial pressure.
Diagnosis. History of the patients includes hereditary predilection (myoma in
mother and other reproductive organs tumors in close relatives); menstrual
dysfunction, late beginning of menarche and metabolism infringement (obesity,
diabetes mellitus). Reproductive dysfunction (infertility, pregnancy loss), induced
abortions (mucous and myometrium trauma should lead to endometrial receptor
device changes),extragenital diseases, which caused endocrine and ovarian
disordes, in particular can be present in these patients.
Bimanual examination in uterine fibromyoma has characteristic signs. It includes
the presence of a large midline mobile pelvic mass with the regular contour. The
mass usually has a characteristic "hard" feel or solid quantity.
Additional methods of investigation are used for confirmation of the diagnosis.
 uterine sounding
 curettage of uterine cavity
 Hysterography
 Hysteroscopy
 Laparoscopy
Pelvic ultrasonography is the most common method to confirm the uterine myomas
presence. The ultrasonographer may suggest location, quantity, size of uterine
fibroids, their sructure, presence of destructive changes. Dynamic observation
enables to supervise efficiency of the conservative therapy, tumor growing, or, on
the contrary, its reduction under the influence of treatment.
Uterine fibroids' complications
Prolapse of submucous fibroid (cervical protruding myoma)
Submucous fibromyoma is accepted by uterus as an ectogenic body. Fibroid
descent to the inferior portion of uterus, irritating the isthmus receptors. It results in
myometrial contractions, cervical dilation and uterus pushes out fibroid into
vagina. Pedunculated tumor is connected with uterus. If pedicle is short, it can
result in difficult complication — oncogenetic inversion due to prolapse of the
submucous fibroid. Speculum examination should be performed for confirmation
of this diagnosis: cervical protruding myoma is visible.
Treatment Submucous tumor can be easily removed by the incision of long
pedicle by clamping the base through the cervix. The pedicle is then ligated. Such
removal of fibroid can lead to uterine perforation when the pedicle is short and
wide. These patients need hysterectomy.
Torsion of uterine fibroid
Torsion of uterine fibfoid is a very common in subserous location. Clinically it is
characterized by crarfiping pain, signs of peritoneal irritation, fever, urinary
frequency and symptoms of rectal pressure. In this situation necrosis and infection
are common.
Surgical treatment Myomectomy is more commonly done when abdominal
myoma location. Myomectomy should be the operation of choice in case of single
subserous pedunculated tumor
Uterine fibroid' necrosis
Necrosis of uterine fibroid results from blood supply disorder of the tumor,
occuring
due to rapid
growing, pregnancy,
mechanical
accident, and
postmenopausal atrophy. It leads to tumor edema and pseudocapsule hemorrhages
Clinically it is characterized by cramping pain which enforces during palpation.
Signs of peritoneal irritation are found. Fever and leukocytosis accompany severe
degeneration.
Treatment is surgical removal.
Uterine fibroid' suppuration
Uterine fibroid's suppuration arises primarily very seldom. Sometimes it is a result
of necrosis. Submucous and interstitial uterine fibroids may be suppurated. The
serious septic state demands supracervical hysterectomy (subtotal) or total
hysterectomy.
Pseudocapsule' and uterine fibroid' vessels rupture
Pseudocapsule' and uterine fibroid' vessels rupture happens very seldom. It is
accompanied by severe pain, signs of intraabdominal hemorrhage (hemorrhagic
shock).
Uterine myoma and pregnancy
Pregnancy at fibromyoma of uterus comes mainly at subserous and interstitial
location of uterine fibroids. Submucous fibroids manifest with pregnancy
progressing.
Diagnosis of pregnancy in such patients represents appreciable difficulties. During
the pregnancy there is a threat of its interrupting as the result of fibroid blood
supply disorder (its necrosis, pseudocapsule hemorrhage). The function of urinary
bladder and rectum is broken. Fetal position is frequently incorrect — oblique or
transversal one. Breach presentation is common if the myoma does not let the fetal
head get into pelvic inlet. Preterm rupture of amniotic fluid, primary and secondary
dystocia of labor are common.
Cesarean section should be pcrfoimed if the nodes are placed behind the course of
the genital canal and block the plane of pelvic inlet. Vaginal delivery is
recommended in all other cases of labor. Postpartum hemorrhage happens in the
third period of labor. Uterine fibroid should undergo involution until their
complete regress in women with high-grade lactation during the further duration of
puerperium.
TREATMENT OF UTERINE MYOMA
Treatment of fibromyoma should be operative and conservative.
Indications to operative treatment are: myomatous uterus larger than 12-week of
pregnancy, acceleretion of tumor growing, presence of such symptoms as pam,
bleeding, secondary anemia; myoma's complications; suspicion on malignant
degeneration and combining with endometriosis and endometrial hyperplasia.
Operative treatment is performed in case when the patients have contraindication
to hormonal treatment. These contraindications are: thromboembolism and
thrombophlebitis, varicose phlebectasia, hypertension, operation concerning
malignant tumors m the past, no effect from hormones.
Surgical interventions are divided into radical and conservative — plastic ones.
Radical operations are in uterine removal — total hysterectomy or supracervical
hysterectomy
Hysterectomy should be performed in 45-year-old women and older during tumor
growing in menopause, presence of cervical and endometrial pathological changes
(dysplasia, erosion, polyps, scars), combination of fibromyoma with precanserous
lesions of uterine cervix and uterus, endometriosis, cervical and isthmic myoma
Supracervical hysterectomy is performed in all other cases
Conservative-plastic operations are carried out for reduction or preserving of
female menstrual and reproductive functions. Their using is justified in young
women for anatomo-functional safety of uterus, fallopian tubes, ovaries and
ligaments.
Conservative treatment of uterine fibromyoma has been confirmed pathogenetically and is directed on correction of hormonal state, treatment of anemia
and metabolic dysorder, inhibition of tumor growing.
Indications. Conservative treatment is recommended at any age, lr case of myoma
duration with poor symptoms or without any symptoms, at presence of
contraindications to operative treatment.
Conservative therapy includes a diet with the usage of products, which contain
A,E,K,C vitamins, such microelements as copper, zincum, lodum, iron, antianemic
therapy, vitamin therapy, uterotomc drugs for decreasing of menstrual hemorrhage,
lodium drugs should provoke inhibition of estrogenic secretion at ovaries 0,25%
solution of potassium iodide should be taken in a dose of 15 ml once or twice per
day continuously during 6-10 months. It is nessesary to combine lodium drugs
with phytotherapy — 60 ml of potato juice per day .Electrophoresis of 1-2%
solution of potassium iodide is commonly used 40-60 procedures are needed for
the treatment course.
Hormonal therapy. Gyfotocyn is given intramusculary in the dose of 1 ml during
12-15 days since 5-7 day of menstrual cycle during 6-8 cycles. This medicine is
recommended at menorrhagia of the patient at any age.
Androgens could be applied at uterine myoma in the period of penmeno-pause Its
effect can be achieved by pituitary gland suppresion Androgens can result in
reduction of uterine size, endomenal atrophy, ovaries follicular depressing.
Methylandrostendiolum is prescribed 50 mg per day during 15 days in the
follicular phase of reproductive cycle for 3 to 4 months. Methyltestosterone is
administrated in 2 pills under the tongue three times per day during 20 days with
10-day time-out for at least 3 months.
Hestagens have been used in uterine fibromyoma because of its antiestrogenic
effect. First line progestines are Progesterone in a dose of 5-10 mg intramusculary
once per day for 10-12 days in luteal phase of a reproductive cycle or 2 ml 12,5 %
solution of 17- Hydroxyprogesterone Capronate intramusculary on 12-14 day of a
cycle for at least 3 months are prescribed.
Pharmacologic removal of the ovarian estrogen source can be achieved by
suppresion of the hypothalamic-pituitary ovarian axis by the use of gonadotropinreleasing hormone (GnRH) agonists. Buzerelinum, gozerelinum and gestrmol
belong to the essentially new medicines that are a gonadotropin-releasing luteal
hormone agonists. Buzerelinum in a dose of 200 mg is administrated subcutaneously for the first 14 days of reproductive cycle, then endonasal prescription in the
dose of 400 mkg per day for 6 months. Zoladex-Depo is applied subcutaneous in a
dose of 3,6 mg once a month for at least 6 months. This treatment is commonly
used for 3 to 6 months before the planned hysterectomy, but it can also be used as
a temporizing medical therapy until the natural menopause comes. GnRH agonists
can not only result in reduction of uterine size, but also lead to a technically easier
surgery with significantly diminished blood loss.
HYDATIDIFORM MOLE (Molar pregnancy)
Hydatidiform mole is one of the forms of trophoblastic disease (pathology of
conceptus) which is characterised by abnormal proliferation of syncytiotrophoblast and replacement of normal placental trophoblastic tissue by hydropic
placental villi. Hydropic villi are up to 3 cm in diameter and look like a mass of
grape-like vesicles.
The ethiology and pathogenesis of trophoblastic disease is unknown. Molar
pregnancy may be divided into complete mole and incomplete (partial)
hydatidiform mole. Complete hydatidiform mole is identified macroscopically by
edema and swelling of virtually all chorionic villi with a lack of fetus or amniotic
membranes. It is developed during the first weeks of pregnancy. Incomplete
(partial) hydatidiform mole is often associated with the identifiable fetus or with
amniotic membranes. Grossly, placenta has a mixture of normal and hydropic villi
that look like mosaic.
The diagnosis of invasive mole (also called chorioidcarcinoma detruens) rests on
the demonstration of complete hydatidiform mole. Hydropic villi invade into the
myometrium on different distances destroying muscle elements and vessels. It is
similar to tumor growing.
Clinic. Hydatidiform mole is characterised by such main symptoms as:
 uterine size/dates discrepancy (uterine enlargement greater than expected for
gestational dates)
 tigh-elastic uterine consistancy
 numerous painless spotting with the fragments of edematous trophoblast
(absolute sign)
 other signs and symptoms, including visual disturbances, severe nausea,
vomiting,
marked
pregnancy-induced
hypertension
(preeclampsia),
proteinuria
 absence of positive signs of pregnancy (fetus is not found by ultrasound and
physical examination, heart tones of the fetus are absent)
 "snowstorm" appearance of hydatidiform mole during the ultrasound examination
 great increasing of hormones in urine
 presence of large adnexal masses (theca lutein cysts) as the result of high
levels of ChGT
Treatment. In most cases of molar pregnancy the definite treatment is removal of
intrauterine contents. Uterine curettage is do by dilation of the cervix followed by
suction curettage (large danger for perforation), vacuum aspiration, digital removal
of mole (in the case if cervical canal passes 1-2 fingers) with the following
curettage.
With cases involving 24 weeks' gestational size, an alternative to suction
evacuation is induction of labor by prostaglandin and Oxytocin. Hysterectomy
should be performed in case of excessive bleeding. All removed tissues should
undergo histologic examination.
After reception of histological research results, that confirm the diagnosis, the
woman is sent to oncologist's consultation where they will decide whether
chemotherapy (Methotrexatum) is necessary.
IV. Control questions and tasks
1. Clinic of uterus fibromyoma.
2. Diagnostics and differential diagnosis of uterus fibromyoma.
3. Indication to surgery of uterus myoma.
4. Pathogenesis of uterus myoma.
5. Classifications of uterus myoma.
6. What is a hormonal status of the patients with fibromyoma?.
17. Methods of treatment of uterus myoma.
BENIGN 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:
 women with impairment of ovarian function
 women with postmenopausal bleeding
 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
 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:
 blastomatic unprohferative tumors (ovarian cysts)
 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)
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 blastopmatic 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.
Tratment. 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.
Corpus luteum cyst
Corpus luteum cyst is an unilateral cyclic 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.
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. 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.
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.
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.
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. 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.
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. 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.
Pseudomyxoma. Pseudomyxoma is one of the kinds of mucinous cystadenoma.
The incidence of these tumors is low. The tumor is multilocular and has a thm 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.
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.
Diagnosis is based on clinic, bimanual research, ultrasonography, laparoscopy and
hysteroscopy.
Treatment is surgical.
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 yellowcolored.
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.
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 IIIIV 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.
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.
Brenner tumor.
The Brenner tumor is a fibroepithelial tumor with gross characteristics similar to
those of fibroma. It constitutes approximately l%-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.
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 oophorectomy.
Diagnosis of benign ovarian tumors.
General and pelvic examination should be performed. Differential diagnosis should
be made with uterine fibromyoma, 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:
 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
 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
 the signs of adjacent organs compression are present during tumor' growing
 the tumors are palpated as a rule in the lateral sides of the uterus
IV. Control questions and tasks
1. Classifications of ovary tumors.
2. What is a cystoma and its special features.
3. What is a cyst?
4. Clinic, diagnostics, treatment of retentional cysts.
5. What does surgical peduncle of a cyst, a cystoma consist of?
6. What does anatomical peduncle of a cyst, a cystoma consist of?
Breast cancer is a cancer that starts in the tissues of the breast.
There are two main types of breast cancer:
Ductal carcinoma starts in the tubes (ducts) that move milk from the breast to the
nipple. Most breast cancers are of this type.
Lobular carcinoma starts in parts of the breast, called lobules, that produce milk.
In rare cases, breast cancer can start in other areas of the breast.
Breast cancer may be invasive or noninvasive. Invasive means it has spread to
other tissues. Noninvasive means it has not yet spread. Noninvasive breast cancer
is referred to as "in situ."
Ductal carcinoma in situ (DCIS), or intraductal carcinoma, is breast cancer in the
lining of the milk ducts that has not yet invaded nearby tissues. It may progress to
invasive cancer if untreated.
Lobular carcinoma in situ (LCIS) is a marker for an increased risk of invasive
cancer in the same or both breasts.
Many breast cancers are sensitive to the hormone estrogen. This means that
estrogen causes the breast cancer tumor to grow. Such cancers have estrogen
receptors on the surface of their cells. They are called estrogen receptor-positive
cancer or ER-positive cancer. Some women have what's called HER2-positive
breast cancer. HER2 refers to a gene that helps cells grow, divide, and repair
themselves. When cells have too many copies of this gene, cells -- including cancer
cells -- grow faster. Experts think that women with HER2-positive breast cancer
have a more aggressive disease and a higher risk of recurrence than those who do
not have this type.
Causes
Over the course of a lifetime, 1 in 8 women will be diagnosed with breast cancer.
Risk factors you cannot change include:
Age and gender -- Your risk of developing breast cancer increases as you get older.
The majority of advanced breast cancer cases are found in women over age 50.
Women are 100 times more likely to get breast cancer than men.
Family history of breast cancer -- You may also have a higher risk for breast
cancer if you have a close relative who has had breast, uterine, ovarian, or colon
cancer. About 20 - 30% of women with breast cancer have a family history of the
disease.
Genes -- Some people have genes that make them more prone to developing breast
cancer. The most common gene defects are found in the BRCA1 and BRCA2
genes. These genes normally produce proteins that protect you from cancer. But if
a parent passes you a defective gene, you have an increased risk for breast cancer.
Women with one of these defects have up to an 80% chance of getting breast
cancer sometime during their life.
Menstrual cycle -- Women who get their periods early (before age 12) or went
through menopause late (after age 55) have an increased risk for breast cancer.
Other risk factors include:
Alcohol use -- Drinking more than 1 - 2 glasses of alcohol a day may increase your
risk for breast cancer.
Childbirth -- Women who have never had children or who had them only after age
30 have an increased risk for breast cancer. Being pregnant more than once or
becoming pregnant at an early age reduces your risk of breast cancer.
DES -- Women who took diethylstilbestrol (DES) to prevent miscarriage may have
an increased risk of breast cancer after age 40. This drug was given to the women
in the 1940s - 1960s.
Hormone replacement therapy (HRT) -- You have a higher risk for breast cancer if
you have received hormone replacement therapy for several years or more. Many
women take HRT to reduce the symptoms of menopause.
Obesity -- Obesity has been linked to breast cancer, although this link is
controversial. The theory is that obese women produce more estrogen, which can
fuel the development of breast cancer.
Radiation -- If you received radiation therapy as a child or young adult to treat
cancer of the chest area, you have a significantly higher risk for developing breast
cancer. The younger you started such radiation and the higher the dose, the higher
your risk -- especially if the radiation was given when a female was developing
breasts. Breast implants, using antiperspirants, and wearing underwire bras do not
raise your risk for breast cancer. There is no evidence of a direct link between
breast cancer and pesticides.
Symptoms »
Early breast cancer usually does not cause symptoms. This is why regular breast
exams are important. As the cancer grows, symptoms may include:
Breast lump or lump in the armpit that is hard, has uneven edges, and usually does
not hurt
Change in the size, shape, or feel of the breast or nipple -- for example, you may
have redness, dimpling, or puckering that looks like the skin of an orange
Fluid coming from the nipple -- may be bloody, clear to yellow, green, and look
like pus
Men get breast cancer, too. Symptoms include breast lump and breast pain and
tenderness.
Symptoms of advanced breast cancer may include:
Bone pain
Breast pain or discomfort
Skin ulcers
Swelling of one arm (next to breast with cancer)
Weight loss.
Exams and Tests »
The doctor will ask about your symptoms and risk factors, and then perform a
physical exam, which includes both breasts, armpits, and the neck and chest area.
Additional tests may include:
Mammography to help identify the breast lump
Breast MRI to help better identify the breast lump
Breast ultrasound to show whether the lump is solid or fluid-filled
Breast biopsy, needle aspiration, or breast lump removal to remove all or part of
the breast lump for closer examination by a laboratory specialist
CT scan
Sentinal lymph node biopsy
PET scan
If doctor learns that you do have breast cancer, additional tests will be done to see
if the cancer has spread. This is called staging. Staging helps guide future treatment
and follow-up and gives you some idea of what to expect in the future. Breast
cancer stages range from 0 to IV. The higher the staging number, the more
advanced the cancer.
Treatment »
Treatment is based on many factors, including type and stage of the cancer,
whether the cancer is sensitive to certain hormones, and whether or not the cancer
overproduces (overexpresses) a gene called HER2/neu.
In general, cancer treatments may include:
Chemotherapy medicines to kill cancer cells
Radiation therapy to destroy cancerous tissue
Surgery to remove cancerous tissue -- a lumpectomy removes the breast lump;
mastectomy removes all or part of the breast and possible nearby structures
Hormonal therapy is prescribed to women with ER-positive breast cancer to block
certain hormones that fuel cancer growth.
An example of hormonal therapy is the drug tamoxifen. This drug blocks the
effects of estrogen, which can help breast cancer cells survive and grow. Most
women with estrogen-sensitive breast cancer benefit from this drug.
Another class of medicines called aromatase inhibitors, such as exemestane
(Aromasin), have been shown to work just as well or even better than tamoxifen in
postmenopausal women with breast cancer.
Targeted therapy, also called biologic therapy, is a newer type of cancer treatment.
This therapy uses special anticancer drugs that target certain changes in a cell that
can lead to cancer. One such drug is trastuzumab (Herceptin). It may be used for
women with HER2-positive breast cancer.
Cancer treatment may be local or systemic.
Local treatments involve only the area of disease. Radiation and surgery are forms
of local treatment.
Systemic treatments affect the entire body. Chemotherapy is a type of systemic
treatment.
Most women receive a combination of treatments. For women with stage I, II, or
III breast cancer, the main goal is to treat the cancer and prevent it from returning.
For women with stage IV cancer, the goal is to improve symptoms and help them
live longer. In most cases, stage IV breast cancer cannot be cured.
Stage 0 and DCIS -- Lumpectomy plus radiation or mastectomy is the standard
treatment. There is some controversy on how best to treat DCIS.
Stage I and II -- Lumpectomy plus radiation or mastectomy with some sort of
lymph node removal is standard treatment. Hormone therapy, chemotherapy, and
biologic therapy may also be recommended following surgery.
Stage III -- Treatment involves surgery possibly followed by chemotherapy,
hormone therapy, and biologic therapy.
Stage IV -- Treatment may involve surgery, radiation, chemotherapy, hormonal
therapy, or a combination of such treatments.
After treatment, some women will continue to take medications such as tamoxifen
for a period of time. All women will continue to have blood tests, mammograms,
and other tests following treatment.
Women who have had a mastectomy may have reconstructive breast surgery,
either at the same time as the mastectomy or later.
V. List of recommended literature
1. Danforth’s Obstetric and gynaecology.-Seventh edition.-1994.-P.1023-1055
2. Gynecology.-Stephan Khmil, Zina Kuchma, Lesya Romanchuk.-2003.P.251-263
3.Gynaecology illustrated. David McKay Hart, Jane Norman.-Fifth Edition.2000.-P.269-271