Posted by Article on 2/5/2002, 11:37 am

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. 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 actual removal. Surgery, therefore, becomes mandatory. Some types of neoplastic cysts can be "shelled" out of an ovary, allowing a patient--especially a young woman with childbearing ahead of her--to leave the operating room with as much reproductive tissue as she came in with. Indeed, the age of the patient and her plans for children play an important role in the type of surgery used. Laparoscopy can often be used to surgically treat a patient, reducing the whole affair to an out-patient episode. 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 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. Even a part of a jaw bone isn’t unheard of. Glandular tissue 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. Some benign tumors can have estrogen production with resulting menstrual problems. 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 last week, 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. 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. Hormonal imbalances, like 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. 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. ©2000 Gerard M. DiLeo, M.D., F.A.C.O.G;

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