Adenocarcinoma of Breast Is a kind of carcinoma that begins in glandular tissue (tissue that makes and secretes a substance). The ducts and lobules of the breast are glandular tissue; consequently cancers beginning in these organs are sometimes called adenocarcinomas.
Most breast cancer grows in glandular tissue and is categorized as adenocarcinoma. The earliest type of the disease, ductal carcinoma in situ (DCIS), grows exclusively in the milk ducts. The most common kind of breast cancer, invasive ductal carcinoma (IDC), grows from DCIS, extends by means of the duct walls, and invades the breast tissue. Invasive ductal carcinoma is called infiltrating ductal carcinoma as well.
The vast majority of breast cancers initiates in the glandular tissues of the breast and is classified as adenocarcinomas. Both the lobular tissues, which create milk, and ductal tissues, which are engaged in the assigning of the milk to the nipple, are regarded glandular tissues and, consequently, might give increase to adenocarcinomas. The most usual variety of adenocarcinoma is recognized as infiltrating ductal carcinoma, a tumor that typically manifests itself as a single hard lump not simply changeable. Just about 80 percent of all cases of breast cancer diagnosed are infiltrating ductal carcinomas.
The main risk factors for breast cancer are:
- Increasing age
- A family history of breast cancer
- Hormonal factors: women who begin menstruation early, have a late menopause, or have late or few pregnancies
- Excess alcohol use (daily consumption of >2 standard drinks)
There is also some evidence that long-term hormone therapy (e.g. use of the oral contraceptive pill or hormone replacement therapy (HRT)) may increase the risk of breast cancer.
Adrenal Hyper/Hypofunction Cushing’s syndrome results from a dysfunction within the adrenal cortex leading to hypersecretion of glucocorticoids. In some patients undergoing steroid therapy this syndrome may be an iatrogenic cause and will generally recede once the steroids are discontinued.
An analysis of the plasma and urinary cortisol is the most frequent form of diagnostic testing, but MRI and CT may be used to assess the presence of pituitary adenomas, which can increase ACTH (adrenocorticotropic hormone) secretion and is one cause of Cushing’s syndrome.
The excess production of glucocorticoid hormones in Cushing’s syndrome may be attributable to generalized bilateral hyperplasia of the adrenal cortex, or it may be a result of a functioning adrenal or even nonadrenal tumor. It can also be the result of the exogenous administration of cortisone. Excess secretion of glucocorticoid hormones mobilizes lipids and increases their level in the blood. This produces a characteristic obesity that is confined to the trunk of the body and is associated with a round, moon-shaped face and a pathognomonic fat pad that forms behind the shoulders (buffalo hump). Retention of salt and water results in hypertension. The skin is thin and does not heal well after injury. Female patients tend to have male characteristics because of an increased production of androgens, and their menstrual cycles are usually quite irregular.
Generalized enlargement of the adrenal glands is best demonstrated by CT, which shows thickening of the wings of the adrenal gland, which appear to have a stellate or Y-shaped configuration in cross section. Ultrasound can also show diffuse adrenal gland enlargement.
Cushing’s syndrome produces radiographic changes in multiple systems. Diffuse osteoporosis causes generalized skeletal demineralization, which may lead to the collapse of vertebral bodies, spontaneous fractures, and aseptic necrosis of the head of the femur or humerus. Widening of the mediastinum as a result of excessive fat deposition sometimes develops in Cushing’s syndrome and can be confirmed by CT. Hypercalciuria caused by elevated steroid levels can lead to renal calculi and nephrocalcinosis.
Imaging of the sella turcica by conventional tomography or CT is important in the routine assessment of the patient with Cushing’s syndrome. Most patients with nontumorous adrenal hyperfunction are found at surgery to have an intrasellar lesion. It is important to emphasize, however, that small pituitary microadenomas may be present in asymptomatic patients. The modality of choice to detect a functioning microadenoma causing adrenal hyperplasia is contrast-enhanced MRI. After adrenal surgery, a pituitary adenoma develops in up to one third of the patients and produces progressive sellar enlargement. For this reason, yearly follow-up sellar tomograms may be indicated after adrenalectomy.
Treatment for Cushing’s syndrome depends on the cause of the excess production of glucocorticoid hormones. Surgical resection is the treatment of choice to eliminate the excessive hormone production. Medical suppression of abnormal endocrine stimulation and radiation therapy directed to the hyperfunctioning tumor are alternatives if the tumor is inoperable.
Addison’s disease Is a rare disease of primary adrenal insufficiency. It most frequently affects women between the ages of 30 and 60 years and generally results from an autoimmune destruction of the adrenal cortex. It may also be caused by infection, neoplastic disease, or adrenal hemorrhage. Addison’s disease is characterized by elevated ACTH accompanied by inadequate corticosteroid synthesis.
The clinical manifestations of adrenal insufficiency vary from those of a chronic insidious disorder (easy fatigability, anorexia, weakness, weight loss, and increased melanin pigmentation) to those of an acute collapse with hypotension, rapid pulse, vomiting, and diarrhea.
The most common cause of adrenal insufficiency is the excessive administration of steroids. Primary adrenocortical insufficiency (Addison’s disease) results from progressive cortical destruction, which must involve more than 90% of the glands before clinical signs of adrenal insufficiency appear. In the past, Addison’s disease was usually attributed to tuberculosis; at present most cases reflect idiopathic atrophy, probably on an autoimmune basis. In areas where the disease is endemic, histoplasmosis is an occasional cause of adrenal insufficiency.
Signs and symptoms include weight loss, fatigue, weakness, nausea, diarrhea, and orthostatic hypotension. The most common diagnosis involves laboratory tests for levels of plasma cortisol and ACTH. Treatment includes the use of replacement hormone therapy in combination with a special diet. If left untreated, this disorder may progress to a life-threatening adrenal crisis.
Acute inflammatory disease causes generalized enlargement of the adrenal glands, which can be demonstrated by a variety of imaging techniques. MRI can differentiate adrenal masses better than CT, but MRI cannot distinguish a tumor from an inflammatory process. Other radiographic findings occasionally seen in patients with adrenal insufficiency include a small heart and calcification of the cartilage of the ear.
Corticosteroids produce a fast recovery and must be administered regularly for the patient’s survival. Morbidity and mortality are high without treatment.
Carcinoma In Situ of Breast The most common type of breast cancer is ductal carcinoma, which begins in the cells of the ducts. Ductal carcinoma in situ (or DCIS) refers to the most common type of noninvasive breast cancer in women. In situ, or “in place,” describes a cancer that has not moved out of the area of the body where it originally developed. In ductal carcinoma in situ, cancer cells are present inside the milk ducts but they have not yet spread through the walls of the ducts into the fatty tissue of the breast. For this reason, nearly 100% of women diagnosed at an early stage can be cured. The best way to monitor and prevent getting ductal carcinoma in situ is with a yearly mammogram. Left unchecked, it may develop into invasive breast cancer.
DCIS is often first detected by a mammogram (an x-ray examination of soft breast tissues used to identify lumps, cysts, tumors, and other abnormalities).Ductal carcinoma in situ (DCIS) frequently shows characteristic mammographic features, the most common of which is microcalcification. Invasive cancers usually arise directly from an area of DCIS.
Suspected DCIS is often confirmed by a breast biopsy in which a small sample of cells is removed for further examination under a microscope. Types of minimally invasive breast biopsy include:
- Fine needle aspiration biopsy (FNAB): a very small needle removes fluid and tiny fragments of breast tissue for microscopic examination
- Core needle biopsy (CNB): a larger needle removes a cylindrical sample of breast tissue for microscopic examination
DCIS is a Stage 0 cancer—the earliest form of breast cancer. Stage 0 breast cancer is a contained cancer that has not spread beyond the ductal system (to the lymph nodes or other areas of the body). The cure rate for DCIS is close to 100% provided that an accepted standard method of treatment is followed.
Physicians do not typically remove the axillary (underarm) lymph nodes in DCIS patients because the cancer is usually confined to the breast ducts. Thus, a lumpectomy (followed by radiation) or a simple mastectomy is usually standard treatment. Rarely, however, larger or more aggressive DCIS tumors have the potential to travel to the lymph nodes or into the bloodstream.
Ectopic Pregnancy Ectopic pregnancy refers to the development of an embryo outside the uterine cavity. It occurs in approximately 10% to 15% of 1000 pregnancies. The most common site for an ectopic pregnancy is the fallopian tube (95%), but it may also occur in the ovary, cervix, or abdominal cavity. In the case of a tubal pregnancy, the fallopian tube distends to accommodate the growing embryo, causing blood vessels to rupture. This may produce serious internal hemorrhage and can be life-threatening. If a tubal pregnancy goes untreated, the embryo will develop and survive for only 2 to 6 weeks.
Ectopic pregnancies are more common in women who have had PID (pelvic inflammatory disease) or have a partial obstruction of the uterine tube. The cause of tubal pregnancies is obstruction of the normal passageway for the ovum. Although ectopic pregnancy is a life-threatening condition, responsible for up to one fourth of maternal deaths, the diagnosis is missed by the initial examining physician in up to three fourths of cases. Ectopic pregnancies are often associated with urine or plasma levels of human chorionic gonadotropin (HCG) that are substantially lower for the expected date of gestation than those in patients with normal intrauterine pregnancies.
Ultrasound is the major imaging modality for diagnosing ectopic pregnancy. The classic appearance consists of an enlarged uterus that does not contain a gestational sac and is associated with an irregular adnexal mass, an “ectopic fetal head,” or fluid in the cul-de-sac. Diagnosis is confirmed via laparoscopy.
Common signs and symptoms associated with ectopic pregnancy are the same as those of early pregnancy, but distension of the tube causes acute abdominal pain and tenderness. If internal hemorrhage occurs, loss of blood can cause fainting and shock. Emergency surgical intervention before a fatal hemorrhage occurs is required. The treatment is surgical removal of the embryo and the affected uterine tube.
Fibrocystic Breast Disease An overgrowth of fibrous tissue or cystic hyperplasia results in fibrocystic breasts. It generally appears as a smooth, well-circumscribed mass with no invasion of surrounding tissue.
This condition may be unilateral; however, it is most frequently bilateral, with variably sized cysts located throughout the breasts. The severity of this disorder varies greatly, and it is believed to result from fluctuations in the hormone levels during the menstrual cycle. The size of the cyst usually changes with the menstrual cycle, as does the amount or type of fluid in it.
The most common sign or symptom associated with fibrocystic breasts is a mass or masses that increase in size and tenderness immediately before the onset of the menstrual period. The texture of the breast tissue is ropy and thick, especially in the upper outer quadrant of the breast.
Sonography is extremely useful as a follow-up to mammography in differentiating solid masses from cystic masses in women with fibrocystic breasts. Large cysts are commonly aspirated for cytologic evaluation of the fluid. If the aspiration is unsuccessful, surgical biopsy is often performed. Although controversy exists about the correlation between fibrocystic breasts and an increased incidence of breast cancer, it is well known that a fibrocystic condition may mask a coexistent cancer. High-risk patients require monitoring of the cystic lesions for possible conversion to a cancerous process.
Treatment of the condition is largely symptomatic, including a monthly breast self-examination and proper support. The most conservative treatment addresses pain management, usually by dietary modifications and reducing caffeine intake. If dietary changes do not reduce pain to a tolerable level, drainage of the cyst may be performed. Hormonal therapy with synthetic antiestrogens that block estrogen and progesterone is used in cases of cyclical pain. However, these drugs may produce intolerable side effects. Surgery is not the most effective treatment unless there is only a single cyst (and most patients have multiple cysts).
Hodgkin’s/Non-Hodgkin’s Disease Lymphomas are neoplasms of the lymphoreticular system, which includes the lymph nodes, the spleen, and the lymphoid tissues of parenchymal organs, such as the gastrointestinal tract, lung, and skin. They are usually divided into two major types: Hodgkin’s and non-Hodgkin’s lymphomas. Ninety percent of cases of Hodgkin’s disease originate in the lymph nodes; 10% are of extranodal origin. In contrast, parenchymal organs are more often involved in non-Hodgkin’s lymphomas, about 40% of which are of extranodal origin.
Hodgkin’s disease has an unknown cause and commonly affects individuals between the ages of 20 and 40 and those over 60 years of age. It tends to affect men slightly more often than women. Common signs and symptoms associated with Hodgkin’s disease are general malaise, fever, anorexia, and enlarged lymph nodes. Mediastinal lymph nodes are often visible on a chest radiograph, and definitive diagnosis is made via biopsy of the lymphatic tissue. Reed-Sternberg cells differentiate Hodgkin’s lymphoma from other types of lymphatic disease. As with other neoplastic disorders, Hodgkin’s disease is staged according to the extent of the disease, most commonly using the Ann Arbor staging system.
The signs and symptoms of NHL are varied. In a few cases, the patient manifests general lymphadenopathy before developing lymphoma. Many patients also have anemia. Diagnosis is made from a histologic examination of the diseased tissue to differentiate NHL from Hodgkin’s disease, leukemia, and metastatic disease.
Mediastinal lymph node enlargement is the most common radiographic finding in lymphoma. It is seen on initial chest radiographs of about half the patients with Hodgkin’s disease and about one third of those with non-Hodgkin’s lymphoma. Mediastinal lymph node enlargement is usually bilateral but asymmetric.
Involvement of the pulmonary parenchyma and pleura usually occurs by direct extension from mediastinal nodes along the lymphatic vessels of the bronchovascular sheaths. Radiographically, this may appear as a coarse interstitial pattern, as solitary or multiple ill-defined nodules, or as patchy areas of parenchymal infiltrate that may coalesce to form a large homogeneous mass. At times, it may be difficult to distinguish a superimposed infection after radiation therapy or chemotherapy from the continued spread of lymphomatous tissue. Pleural effusion occurs in up to one third of patients with thoracic lymphoma. Extension of the tumor to the pericardium can cause pericardial effusion.
About 5% to 10% of patients with lymphoma have involvement of the gastrointestinal tract, primarily of the stomach and small bowel. Gastric lymphoma often is seen as a large, bulky polypoid mass, usually irregular and ulcerated that may be indistinguishable from a carcinoma. A multiplicity of malignant ulcers or an aneurysmal appearance of a single huge ulcer (the diameter of which exceeds that of the adjacent gastric lumen) is characteristic of lymphoma. Additional findings suggestive of lymphoma include relative flexibility of the gastric wall, enlargement of the spleen, and associated prominence of retrogastric and other regional lymph nodes that cause extrinsic impressions on the barium-filled stomach. Other manifestations of gastric lymphoma include thickening, distortion, and nodularity of rugal folds and generalized gastric narrowing caused by a severe fibrotic reaction.
Lymphoma can produce virtually any pattern of abnormality in the small bowel. The disease may be localized to a single intestinal segment, it may be multifocal, or it may cause diffuse involvement. The major radiographic appearances include irregular thickening of mucosal folds, large ulcerating masses, and multiple intraluminal or intramural filling defects simulating metastatic disease.
Skeletal involvement can be demonstrated in about 15% of patients with lymphoma. Direct extension from adjacent lymph nodes causes bone erosion, especially of the anterior surface of the upper lumbar and lower thoracic spine. Paravertebral soft tissue masses may occur. The hematogenous spread of lymphoma produces a mottled pattern of destruction and sclerosis, which may simulate metastatic disease. Dense vertebral sclerosis (ivory vertebra) may develop in Hodgkin’s disease.
Diffuse lymphomatous infiltration may cause renal enlargement, with distortion, elongation, and compression of the calyces. Single or multiple renal nodules or perirenal masses may displace or distort the kidney. Diffuse retroperitoneal lymphoma can displace the kidneys or ureters and obliterate one or both psoas margins.
Once the diagnosis of lymphoma is made, it is essential to determine the status of the abdominal and pelvic lymph nodes. This is necessary both for the initial staging and treatment planning and for assessing the efficacy of treatment and detecting tumor recurrence.
Although lymphography was the procedure of choice in the past, MRI and positron emission tomography (PET) are now the noninvasive techniques employed to demonstrate lymphomatous involvement of the abdominal and pelvic nodes. In practice, CT of the chest, abdomen, and pelvis is generally the first imaging procedure used in staging lymphoma patients. This is especially true for those with non-Hodgkin’s lymphoma, which tends to produce bulky masses in the mesenteric and high retrocrural areas. An abnormal CT scan may eliminate the need for more invasive procedures; a normal CT scan obtained at 2-cm intervals can exclude retroperitoneal adenopathy with a high degree of confidence. CT is usually used because of standardization and repeatability for patients. Malignant nodes appear round or oval and their transverse-to-longitudinal ratio is greater than 2. A narrow or absent hilus of the node also suggests malignancy.
Ultrasound can detect enlarged retroperitoneal nodes, characterize them, and measure them accurately. For retroperitoneal adenopathy, ultrasound is 80% to 90% accurate, and it has the ability to detect extranodal disease, which typically produces discrete hyperechoic masses. MRI is considered the superior technique because it can detect subtle detail using multiple sequences.
Gallium scans may illustrate increased nodal uptake (indicating swelling or inflammation), and it can assess the response to treatment and detect early recurrence of tumor tissue. PET imaging using fluorodeoxyglucose (FDG) uptake is considered superior to the gallium scan and CT because it can detect microscopic tumor foci and alterations in function within normal-size nodes. PET also has the ability to distinguish large nodes that contain tumor from those that have only benign reactive changes. PET can also be used to monitor the effectiveness of the therapy and identify tumor recurrence.
To ensure proper diagnosis and staging of both Hodgkin’s and non-Hodgkin’s lymphoma, biopsies are performed to extract cell and tissue samples. Free- hand fine needle aspiration biopsy works best for superficial nodes, whereas CT-guided or ultrasound-guided biopsy is required for deep node evaluation. Patients unable to tolerate surgical procedures may undergo a large-needle core biopsy to determine the extent of the disease before beginning treatment.
The best treatment available for Hodgkin’s lymphoma is multidrug chemotherapy and high-dose radiation therapy. Hodgkin’s disease is most commonly treated and cured with a combination of radiation and chemotherapy. Stage I and stage IIA Hodgkin’s lymphoma can be treated with radiation therapy alone and are associated with a 5-year survival rate of 85% to 90%. Stage IV Hodgkin’s disease has approximately a 70% to 80% complete remission rate, with more than 50% of patients remaining disease-free for up to 15 years.
For non-Hodgkin’s lymphoma, more aggressive chemotherapy is required if the disease process is diffuse, whereas conservative chemotherapy is used for low-level disease. Bone marrow transplant may be necessary.
Ovarian Disease Polycystic ovarian syndrome (PCOS) is a hormonal problem that causes women to have a variety of symptoms. It should be noted that most women with the condition have a number of small cysts in the ovaries. However, women may have cysts in the ovaries for a number of reasons, and it is the characteristic constellation of symptoms, rather than the presence of the cysts themselves, that is important in establishing the diagnosis of PCOS.
PCOS occurs in 5% to 10% of women and is the most common cause of infertility in women. The symptoms of PCOS may begin in adolescence with menstrual irregularities, or a woman may not know she has PCOS until later in life when symptoms and/or infertility occur. Women of all ethnicities may be affected.
The principal signs and symptoms of PCOS are related to menstrual disturbances and elevated levels of male hormones (androgens). Menstrual disturbances can include delay of normal menstruation (primary amenorrhea), the presence of fewer than normal menstrual periods (oligomenorrhea), or the absence of menstruation for more than three months (secondary amenorrhea). Menstrual cycles may not be associated with ovulation (anovulatory cycles) and may result in heavy bleeding.
Symptoms related to elevated androgen levels include acne, excess hair growth on the body (hirsutism), and male-pattern hair loss.
Other signs and symptoms of PCOS include:
- obesity and weight gain
- elevated insulin levels and insulin resistance
- oily skin
- skin discolorations
- high cholesterol levels
- elevated blood pressure
- multiple, small cysts in the ovaries
Any of the above symptoms and signs may be absent in PCOS, with the exception of irregular or no menstrual periods. All women with PCOS will have irregular or no menstrual periods. Women who have PCOS do not regularly ovulate; that is, they do not release an egg every month. This is why they do not have regular periods and typically have difficulty conceiving.
No one is quite sure what causes PCOS, and it is likely to be the result of a number of both genetic (inherited) as well as environmental factors. Women with PCOS often have a mother or sister with the condition, and researchers are examining the role that genetics or gene mutations might play in its development. The ovaries of women with PCOS frequently contain a number of small cysts, hence the name. A similar number of cysts may occur in women without PCOS. Therefore, the cysts themselves do not seem to be the cause of the problem.
Because of the menstrual and hormonal irregularities, infertility is common in women with PCOS. Because of the lack of ovulation, progesterone secretion in women with PCOS is diminished, leading to long-term unopposed estrogen stimulation of the uterine lining. This situation can lead to abnormal periods, breakthrough bleeding, or prolonged uterine bleeding in some women. Unopposed estrogen stimulation of the uterus is also a risk factor for the development of endometrial hyperplasia and cancer of the endometrium (uterine lining). However, medications can be given to induce regular periods and reduce the estrogenic stimulation of the endometrium.
Changes in skin pigmentation can also occur with PCOS. Acanthosis nigricans refers to the presence of velvety, brown to black pigmentation often seen on the neck, under the arms, or in the groin. This condition is associated with obesity and insulin resistance and occurs in some women with PCOS.
Uterine Fibroids Fibroids (leiomyomas) of the uterus are benign smooth-muscle tumors that are very common; they are often multiple and vary greatly in size. Growth of fibroid tumors is stimulated by estrogen. They develop only during the reproductive years and tend to shrink after menopause. Abnormal bleeding between periods or excessively heavy menstrual flow is the most common symptom. Large tumors may project from the uterus, causing pressure on surrounding organs, resulting in pelvic pain. They can also interfere with delivery or, if on a stalk (pedunculated), protrude into the vagina.
Uterine fibroids are by far the most common calcified lesions of the female genital tract. They have a characteristic mottled, mulberry, or popcorn type of calcification and appear on plain abdominal radiographs as smooth or lobulated nodules with a stippled or whorled appearance. A very large calcified fibroid occasionally occupies the entire pelvis or even extends out of the pelvis to lie in the lower abdomen.
During excretory urography, persistent uterine opacification is often seen in patients with an underlying uterine fibroid tumor. The tumor typically presses on the fundus of the bladder, causing a lobulated extrinsic impression that differs from the smooth impression usually seen with ovarian cysts. Extension of a fibroid into the adjacent tissues (parametrium) may cause medial displacement of the pelvic ureter or ureteral compression leading to hydronephrosis.
Endovaginal (transvaginal) ultrasound is the best modality to demonstrate small and submucosal uterine fibroids. MRI is more sensitive than CT or ultrasound, but it is indicated only when ultrasound is inconclusive in differentiating between uterine and adnexal masses or between leiomyoma and adenomyosis, and when searching for submucosal fibroids in the patient with unexplained bleeding.
In many cases no treatment is required. Medications can induce a temporary chemical menopause that causes a temporary shrinkage of the fibroid. If bleeding and fibroid size cannot be controlled with medications, surgery is performed. In younger women and for superficial fibroids, a myomectomy (removal of the leiomyoma) is performed to preserve the uterus. Large or multiple tumors usually require hysterectomy, especially if childbearing is complete. Many new therapeutic techniques are available—multilaser technique, myolysis (electrical coagulation of the myoma), uterine artery embolization—and various medications have proven to be effective.