Uterine or Ovarian Enlargement in patients with breast cancer

Enlargement of the uterus or ovaries is a frequent reason for referral of breast cancer patients to the Gynecologic Oncology Center. In many cases, the enlargement is detected on an abdominal-pelvic computed tomography scan obtained for staging or follow-up purposes.

Uterine Enlargement
The most common cause of uterine enlargement is leiomyoma, which is found in approximately 20-25% of women of reproductive age and approximately 50% of postmenopausal women. Leiomyomata are usually asymptomatic. Unless the disease is symptomatic or the size of the uterus has increased rapidly, patients with leiomyoma should simply be reassured and should not be subjected to surgical intervention. A sudden increase in the size of the uterus or pain associated with leiomyoma should raise concern about the possibility of leiomyosarcoma. However, such tumors are rare, occurring in less than 0.2% of all patients with leiomyoma.

If leiomyoma causes enlargement of the uterus or excessive bleeding, a total hysterectomy may be required for therapeutic or, occasionally, for diagnostic purposes.

Ovarian Enlargement
The most common cause of ovarian enlargement is an ovarian cyst.

Ovarian cysts can be classified as either nonneoplastic or neoplastic.

Nonneoplastic ovarian cysts include physiologic cysts, such as corpus luteum and endometriotic cysts. The most common neoplastic ovarian cysts are cystic teratoma (dermoid cyst), which is usually found in younger patients, and serous or mucinous cystadenoma, which occurs in patients of all ages.

In women of reproductive age, the ovaries may enlarge slightly in parallel with physiologic effects of pituitary ovarian stimulation. Physiologic ovarian cysts are simple cysts, usually unilocular on sonography. Physiologic cysts may regress by the next menstrual cycle but sometimes persist for two or more cycles. Of note, data from the Breast Cancer Prevention Trial (Chalas et al., 2005) showed that there was an increased incidence of benign ovarian cysts in women taking tamoxifen (relative risk, 1.5).

If an ovarian cyst is more than 5 cm in diameter or if there is any palpable enlargement after menopause, the possibility of a neoplastic event should be considered.

The initial evaluation should include a thorough history that specifically addresses menstrual history, sexual history, family history, tamoxifen usage, neurologic history, and associated symptoms. This is followed by a comprehensive physical examination, with the pelvic examination being the primary focus.

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The goal is to look for evidence of a pelvic mass and to determine the consistency (solid or cystic), mobility (mobile or fixed), and size of any such mass. Dysmenorrhea, dyspareunia, or pain that radiates to the upper thigh, with or without a history of endometriosis, may suggest a diagnosis of endometriosis. Pain associated with an enlarged ovary is usually related to a benign process except in the case of a rapidly growing or necrotic neoplasm of the ovary, such as a sarcoma or granulosa cell tumor.