Benign Ovarian Tumors
In "The Good " I described how a normal functioning ovary can swell a monthly egg-producing follicle into what's termed a functional cyst, and how that's normal and harmless. Here will be discussed something entirely different--a true neoplasm.
"Neoplasm," a word of Latin and Greek origin meaning "new growth," is not an exaggeration of normal function, but is actually disease. If birth control pills cannot make an ovarian cyst go away, or if a screening blood test is suspicious, then a true neoplasm is suspected. Neoplasia can be either benign or malignant, or as I've designated them, bad and ugly. What I actually mean, though, is bad and worse. Even though benign neoplasms are curable, I've labeled them "bad" because they usually entail surgery of some sort. And of course malignancy is a different story altogether (see next link). Another word, tumor, is synonymous with neoplasm, so it also can be either benign or malignant.
The Frozen Section
A diagnostic problem is that most benign tumors or neoplasms of the ovary can have a malignant counterpart, and it is often impossible to tell the difference without actually removing them and putting samples of them under a microscope. In this way, a pathologist can render a diagnosis you and your doctor can rely on. This usually takes several days to make it back to the chart, so it's not very useful at the time of surgery.
Why is this important? For one thing, many women in such a jam may want to still have children, so it's important to them that they leave an operating room with as much reproductive tissue as they came in with, minus the diseased tissue, that is. A malignancy will dash these hopes, but a woman, although upset over the outcome, will understand if a doctor has to remove "everything" if there's cancer and her life would otherwise be at stake. A benign tumor, on the other hand, while assuring the greatest degree of safety by removing everything, may offer the option of leaving a tube, ovary, and uterus such that she can still get pregnant and bear children. It surely would be nice to have a technique to tell which way the surgery can go without waiting a few days for the pathology report to come out.
The "frozen section" is a technique in which, once the tumor (benign or malignant) is removed, but before the patient is closed, it can be subjected to microscopic techniques that can render pretty good accuracy. Trouble is, it's not guaranteed accuracy, so that if it is read benign and the rest of a woman's reproductive organs are left in place, and then the permanent report were to demonstrate evidence that the frozen section was wrong and that it really was malignant, there would have to be a second operation. It's bad enough hearing that your tumor was malignant, and then that you can't have children, but adding yet another operation to the mix will make for one bummed out patient.
But being able to get pregnant if these are your plans is worth this small risk, because usually the results of the frozen section agree with those of the permanent preparations and reports. On the other hand, if your "birthin'" days are over, a frozen section is only necessary if you're heroic for saving ovarian tissue for hormonal support, which isn't considered the best idea, although allowable (with caution) with some benign tumors. If you're inclined to that, then you're going to have to be a good sport about being watched like a hawk, with frequent ultrasounds and blood work. (Frequent means every 3-12 months, depending on how long past the incident you go without any suspicion.) Indeed, the age of the patient and her plans for children play an important role in the type of surgery used.
Can laparoscopy be used? Wait a sec? What the heck is laparoscopy?
Laparoscopy is a technique in which, as an outpatient, under a brief period of general anesthesia, small incisions are made in your navel and below your pubic hair line to allow a doctor to look into your belly with a lighted scope. With access from the other small incisions (5 mm-10mm), pole-like instruments can be used to manipulate, cut out, or drain cysts or tissue. With such small incisions, recover is very fast and you're home by supper time.
Laparoscopy, like any surgical procedure--minor or major--requires that a doctor chooses the laparoscopy candidate wisely. There are certain conditions in which laparoscopy should not be used.
- Definite malignancy is one of them, because the amount of surgery (lymph node dissecion, for instance) does not lend itself well to the limited dexterity of a laparoscope where ten fingers would do better through a regular incision. There are those surgeons who claim they can do such involved surgery via laparoscopy, but they are usually in larger centers or have an overwhelming amount of experience doing this.
- If the diagnosis is uncertain and directly looking at a cyst through a laparoscope makes your doctor feel that more than likely it's a malignancy, spilling the contents by draining it before trying to drag it, collapsed, through the small laparoscopic incision might theoretically risk spread. Theoretically. Lately, the literature has been less concerned with this, but the final word hasn't been said yet.
- If there is extensive scarring from an inflamed ovarian mass, like in endometriosis, there could be damage to underlying pelvic structures or bowel in trying to peel away the ovarian mass from these otherwise normal structures. Damage to a ureter (urine tube) or bowel will make necessary further surgery or even a colostomy.
As scary as all of this sounds, most doctors have a very good intuition on who makes the best laparoscopy candidate. But no patient should go into any laparoscope procedure "guaranteed" that they won't wake up with a surprise "regular" incision.
Even though a benign neoplasm, or tumor, of the ovary is curable through removal, there are other considerations. Some, if ruptured upon removal, can be irritating enough to cause peritonitis, much like a ruptured appendix, even though the contents are benign. An example of this is a “dermoid” cyst (teratoma), which is evidence of the ovary’s ability to mysteriously convert its tissue into almost any type.
In the case of a dermoid, hair, brain tissue, and teeth are often present. Weird. Even a part of a jaw bone isn’t unheard of. Glandular tissue in a dermoid can function to cause hyperthyroidism or adrenal-like problems. The glandular and other clinical manifestations can cause confusion in the diagnosis which delays addressing the real problem, which is of course gynecological. Spilling the contents of a dermoid cyst, as mentioned above, can delay recovery with its resulting peritonitis.
If a “fibroma” of the ovary puts out estrogen, a patient may present with no periods at all and feeling like she’s pregnant. Other cysts can have serous or mucous products which can swell an ovarian cyst to extremely large sizes. Numerous twenty-pound (or more!) benign mucinous tumors have been documented.
A functional cyst, as described the previous article, "The Good" can disappear on its own or with the temporary use of birth control pills. A true neoplasm, even when benign, necessitates removal for the following reasons:
1. It can enlarge and its sheer size can cause an ovary to twist upon itself leading to gangrene. This is called “torsion,” and death of the ovary occurs because the blood supply is twisted off. At the time of surgery care must be taken not to untwist a dead ovary without clamping the veins leading away, lest toxic substances get into the circulation. (Even functional cysts can get big enough to do this, and it's not unheard of removing a functional cyst that has come to this.)
2. A diagnosis is always in doubt until surgery provides tissue for the pathologist to name the abnormality. Being too conservative can be dangerous.
3. And between the bad (the benign tumor) and the ugly (malignancy) are the cysts called benign tumors of “borderline malignant potential.” A patient's age and fertility plans have to be the most pertinent concern for the GYN surgeon in planning the surgical strategy when this tumor of fuzzy designation occurs. Frank discussion between the doctor and patient must include several “what-if?” considerations so that a carefully mapped out flow sheet can be followed depending on the findings at the time of exploration. A malignancy, unfortunately, makes childbearing a secondary consideration, and it is tragic when treating the disease to save a young woman's life renders her sterile by forcing the hand of the surgeon to perform hysterectomy and removal of tubes and ovaries. We gynecologists always dread the malignancies
Even though surgery is the ultimate diagnostic step, there are some differences between the benign and the malignant on ultrasound. Size and consistency of the cysts can give reassurances or warnings. A large cyst with multiple compartments is a more chilling presentation. A simple cyst (one chamber), especially if smaller than 6 centimeters, is usually a benign tumor.
Other types of cystic structures can lead a patient into surgery:
- Swelling of the fallopian tube, especially when its route of drainage has been cut off (as in tubal ligation or infection), can lead to significant swelling of this structure into a huge balloon-animal-like structure. Of course on ultrasound these convolutions can mimic an ovarian cyst that has a lot of chaotic structure, leading a doctor to think the sky is falling. Surgery for what is thought to be an ovarian malignancy turns out to be simply the removal of a tube.
- Remnants of the male reproductive tract can swell around the tubes. Because they’re not actually part of the tubes or ovaries, they’re referred to as “paratubal” cysts. They can become large enough to be confused with ovarian benign tumors indicating surgery.
- Insulin resistance, thought to cause Polycystic Ovarian Syndrome (PCOS), in which the cycle gets jammed up because of inability to ovulate, leaves the cycle stuck in the first half, with stimulation of this phase causing multiple follicles to heap upon each other. This can create quite a mass and lead to surgery.
- Sometimes a functional cyst can bleed into itself. This is ordinarily harmless, and the blood will resorb, but all of the clots can make a cyst look falsely malignant on ultrasound! Sometimes being a gynecologist is a tough job.
- And then again, there's our old nemesis, endometriosis.
Endometriosis is like endometrium.Endometrium is the tissue that builds within the uterus and then falls apart as a "period" when the hormones crash at the end of each cycle. I say endometriosis is "like" endometrium, because no one really knows for sure the way it can end up it remote parts of the body, which ruins the classic explanation--that it leaks backwards through the tubes, spilling and implanting in the pelvis. But enodmetriosis lesions in the brain, nose, navel, and lungs have been documented. (Reports of nosebleeds with each period, for instance.) Endometrial-like tissue, unless it ends up on a tampon, tends to cause inflammation and scarring where it sits. The truth is, this tissue is meant to either be used to implant a fertrilized egg with pregnancy or to be discarded. Anything else is trouble.
The body, in its wisdom, tends to want to wall off infected or inflamed sites. A good example of this is the ol' zit...or even an abscess. Inflammation from endometriosis is no different, and the body will mobilize bowel and bowel fat in the abdomen to stick to these areas. Such scarring is referred to as adhesions. Unfortunately, bowel, tubes, and other structures are meant to be unencumbered, not stuck to fresh, active--or alternately, old, burned out--endometriosis sites, so that when they try to function, they're twanged, causing pain. Or worse, infertility.
At the risk of offending the Menstrual Society (and there really is one), periods can be a mess. If you cram one into a site that cannot drain or be discarded, you're likely to get one ugly looking ultrasound picture. Because blood shows up on ultrasound as a mixture of echos, it can even look malignant, prompting surgery. Such surgery isn't unnecessary, just incorrectly provoked, because treatment for an organized mass of endometriosis in the ovary usually requires surgery. Laparoscopy is very useful in getting the truth out of a nasty looking ultrasound picture.
Endometriosis, more likely if you've had a family with it, is a benign process, which is why I've included it with the benign tumors. But it's hardly innocent. Few things have caused as much heartache, especially in infertile couples, as endometriosis.
Women should maintain a schedule of routine pelvic exams for two reasons. First, the bad and the ugly, that is, the benign and the malignant ovarian tumors, often have no symptoms at all and are caught as an incidental finding in a routine GYN check-up. Second, even the benign tumors can possibly undergo malignant transformation, and catching this in time could make the difference whether a woman loses her fertility or even her life. When dealing with true neoplasia, we really have nothing to gain in waiting.