The Cancer We Think We Know…

In those early, once-upon-a-time days when I thought I knew everything and before humility had forced itself upon my stage, a haggard middle aged woman named Mary walked into my office a week early for her appointment. It was in the young days of my career and as it happened, a patient who was scheduled for that time had not shown up. So, I agreed to see her.

She had a wild look in her eyes, and they immediately pinned me to my side of the desk. Well-groomed despite her jeans and tattered grey sweatshirt she could have been mistaken for someone ten years her junior. But she had been referred by a family doctor that I, of decidedly conventional western medical training, had come to associate with fringe issues -homeopathy, hair analyses, colonic cleansing and the like- so I prepared myself for sifting through a ream of details I could not hope to understand.

“I don’t feel well, doctor,” she started, her voice as serious and worried as her face. “I’m 41 and for the last six months I’ve had a constant ache in my lower abdomen on the left side -my pelvis, actually. My periods are light, non-painful, and as regular as a calendar with no intermenstrual spotting; I have never had any pregnancies, operations or illnesses. I’m not on any medications, don’t smoke, and have no allergies. In fact, you’re the first specialist I’ve ever been referred to.” She managed a brief smile. “I had my family doctor order an ultrasound 4 or 5 months ago months and it showed a thin, normal appearing endometrial lining of the uterine cavity, but a 4 cm. complex cyst on the left ovary. A repeat ultrasound last month found it was still there, albeit somewhat smaller.” She hesitated briefly and then added: “I’ve had this kind of cyst before but usually without symptoms, and the cyst is always  gone by my next scan.” She looked at me for a moment and finally said, “So now I’m worried, of course.”

I have to admit I was a bit taken aback that she’d already answered most of the questions I had intended to ask, so I just sighed when she appeared to have finished her summary. “You seem to know your way around medical words…”

A smile appeared briefly on her lips, but one that couldn’t disguise her anxiety. “I have a PhD in pharmacology and am doing some research at the Cancer Agency so I guess I’ve picked up a few words…” She was sitting bolt upright in her seat, but the expression on her face said she wasn’t finished so I waited for her to speak. And anyway, I was running out of questions to ask.

“I’d like you to take everything out,” she said, suddenly leaning forward over the desk.

“Meaning..?”

“Meaning uterus, tubes, ovaries… everything!” She took a deep breath. “Look, I’m really afraid that all these cysts I’ve been getting on my ovaries are telling me something. There’s not a shred of cancer in the family, but I have this feeling about my ovaries that I can’t explain: I know  there’s cancer in one of them. Don’t ask me how I know it -I just do. And it’s only a matter of time before it becomes obvious in one of the ultrasounds… maybe too much time.

“I don’t want any kids; I’m not in a relationship; and I’m willing take hormones…” She blinked. “But I can’t take cancer.”

I’d been writing all this in her chart, but I put down my pen and looked at her. “Do you mind if I examine you and then we can talk about it?”

She agreed with a shrug of her shoulders. “Okay, but don’t tell me the recurrent cysts are just the result of anovulation…”

I had to smile at that one: it was precisely what I had intended to tell her. Anyway, I couldn’t feel the cyst and I told her so when we returned to the office after the examination. She seemed surprised.

“Are you sure? I mean I’m not questioning your findings, but why would it just disappear when it was still there last month? And a complex cyst as well,” she added, obviously aware of the possible ramifications implied by the term and searching my face for answers.

“Would you mind if I repeated the ultrasound?” I could see my findings had not reduced her concern in the slightest. “And maybe I’ll order some tumour markers, just in…”

“They’re usually not very helpful at my age.” The words seemed to escape her mouth before she could stop them, so she plastered an embarrassed smile over her lips. But she did agree to the repeat ultrasound.

*

I’m afraid I forgot about her until she returned a couple of weeks later, after the ultrasound.

“Well, it was normal,” I said as soon as she sat down. “But I suspect you already know that.”

She nodded. “I still want you to operate, though.”

I sighed, looked at the ultrasound report again and then at my notes in her chart. “But that left ovary is completely normal in appearance now -both of them are. The uterus looks normal… everything  looks normal.” I riffled through the few lab tests I’d managed to convince her to take. “Your periods are normal, so I admit that it makes non-ovulation as a cause for the cysts less likely, but the tumour markers are normal, the…” I glanced at her face. “No, I’m not putting too much reliance on them, but at least they’re reassuring as well.” I could see her fidgeting in her chair all the while staring at me. “Look, I can’t just take everything out in a woman your age without some good reason.”

She crossed her arms and a stern expression captured her face.

“So, how about we consider a couple of options?” I suggested, looking her in the eyes. She blinked, and I took that for an agreement. “The first is that we repeat the ultrasound in, say, six months and then…”

She shook her head firmly, and stared at me. “What’s the second option?”

“We get a second opinion -a female gynaecologist, maybe. If she agrees, then maybe she can do the…”

“I chose you, not another doctor,” she said slowly. “If the second doctor -the female– agrees, will you do the operation?”

I have to admit I felt a little flattered by that, and I suppose it’s why I agreed. But by the time she got a reluctant agreement from the other doctor and I was finally able to book the surgery, it was six or seven months later.

I went to see her on the ward the day after the surgery. “Everything went well, Mary. The uterus and tubes appeared normal, and the ovaries were both outstanding-looking citizens.” I don’t know why I said that; I suppose I was trying to make her realize that I was happy with what I’d seen.”

“When will we..?”

“Get the pathology report? It’s probably going to take about a week. But I’m not expecting any surprises, you know,” I said with a smile as I gently squeezed her hand.

But her eyes were wiser than my words. “Now that my ovaries are out, that bad feeling I used to have is gone; you got the cancer. I can tell…” Her voice faded as she closed her eyes and drifted into a narcotic-driven sleep.

*

I called her to come in to the office as soon as I got the report.

“It was cancer all along, wasn’t it?” she said in a soft, worried voice even before she sat down.

I nodded slowly and reached  across my desk for her hand. “But it was in the uterus, not the ovaries…”

Her face softened, and her shoulders relaxed; her response was a statement rather than a question: “That’s a better cancer to have, though, isn’t it?” Then she smiled and squeezed my hand this time.

 

 

 

Dermoid

She was sitting in a black leather chair in the corner by the window holding a magazine in one hand. A small, thin woman in jeans and a black sweat shirt with  short blond hair, she watched the room like a television screen. Even in the confusion of a pregnancy-filled waiting room, she looked oddly at ease, content, smiling at the life around her: a parent at a kindergarten. She even seemed pleased to see me, although I’d never met her.

With all the problems I encounter during an average day, it is a pleasure to see someone who is happy, someone for whom the Fates have not cast a crooked die. She followed me almost casually along the long corridor to my consulting office and sat in the little hard wooden seat across from the desk as a queen might: relaxed, at ease, regal.

There was a short note from her GP outlining the reason she had been referred, but I couldn’t read the handwriting -only the name and the age: Martha, 25. “So what can I do for you today, Martha?” I said, hoping she actually knew.

She let her eyes rest on the picture hanging behind me for a moment before they fastened on my enquiring expression. A beatific smile crept slowly across her face and her eyes unlocked briefly as she considered her response. “I have a visitor,” she said finally, barely able to confine her growing enthusiasm.

My eyes narrowed for a split second before I could stop them. “A visitor..?”

“Dermoid,” she replied as factually as if she were informing me she had a sandwich in her purse and no further explanation was necessary -as if the very word would answer all I could possibly want to know.

“How..?” I wasn’t quite sure where to start.

“I had some pelvic discomfort so my GP ordered an ultrasound, and voila: 6 centimeter dermoid, left ovary.”

Succinct, factual, if a bit unconcerned, she seemed comfortable with the condition. Most people confronted with an ovarian tumour would have been worried about cancer. “Well, I’m going to have to get a bit of background but you seem quite knowledgeable about the diagnosis… I take it you’ve looked up dermoids.” She looked so calm.

She sighed and would have rolled her eyes had I not been watching her. “Of course! Wouldn’t you?”

I smiled and nodded my head. It was clear she wanted to tell me about them, so I decided to forgo the history for a moment. “So what do you understand the term to mean?”

“Want the Wikipedia explanation, or one from a university website?”

I shrugged; she probably knew more about them now than I did.

“I’ll put it in my own words then, okay?” Now she was the bright child in class who had an answer to the teacher’s question. “Dermoids are interesting,” she started, her enthusiasm visibly building as she spoke. “A dermoid is a tumour that develops almost entirely from the ectoderm -one of the primary germinative cell layers in the early embryo. Tumours that develop from the germ cells are sometimes termed teratomas.” She studied my face for a moment to see if I was understanding her. Evidently satisfied that I was, she continued. “Ectoderm develops into skin, nerves, and so on…” Pleased that I seemed to be following her, she added “Mesoderm develops into muscle, Endoderm into gut…

“So anyway, a dermoid cyst is derived from ectoderm and contains… oh, like hair, sebum, cartilage, teeth… Teeth! Can you imagine that! And sometimes even thyroid tissue…” She sat back in the chair, eyes at peace now that she had explained her rapture.

I sat back as well; she wasn’t finished.

“Dermoids are usually removed -especially the bigger ones- because they can twist, cutting off their own blood supply… And a small percentage can develop cancer. Skin cancer -can you imagine?” she said excitedly and then suddenly focussed on my face, a hopeful expression on hers. “Do you know why they develop?” She read my expression. “No, I guess not; nobody seems to have a clear explanation…” Her face brightened. “But everybody seems to have heard of them. My boyfriend’s in business school and even he knows the name.”

She paused; I blinked, happy to be able to say something. Anything. “They’re called ‘Medical Student Tumours’ because they make such an impression on medical students that they remember them years later, even if they’ve gone into Cardiology…”

She smiled contentedly, pleased to be associated with something so popular.

“But…” I wondered how to put the question. “Why did you say you have a visitor, Martha?”

This time she did roll her eyes. “Ectoderm, right?” She waited for my nod. “And Ectoderm makes brain?”

“Well, nervous tissue…” I wasn’t sure what she was getting at.

She crossed her arms and stared at me like a parent waiting for her child to make an obvious connection.

But I didn’t; I still haven’t. I know I disappointed her.

Ovarian cysts: part one

“I have pain, don’t you understand? It’s on the right side where the cyst is!” She spit the word out like it had a bad taste. For her it very likely did.

I’d never seen her before, but the family doctor had sent an old ultrasound -done a year ago- along with his consult request letter. Under her critical eye, I read the report: a simple 2.5 cm. cyst in the right ovary. Likely functional, it added…

“I’m tired of this!” she said, and she leaned over the desk menacingly. “And I want it out!” She was twenty-five and she knew what she wanted.

I suggested that I would need to examine her to see if the cyst was still present, but this met with a firm “No! My doctor has already examined me. I don’t want to go through that again.”

It’s hard to know how to proceed under such constraints, but I did manage to talk her into another ultrasound to see if it was still there. She glared at me as if I were calling her a liar.

When she came back to the office a week or so later after the ultrasound had been done, she was no less angry. She sat on the edge of her chair, leaned over the desk again, and pounded it with her fist. “I told you there was a cyst! The ultrasound technician showed it to me! You’ve wasted all this time when I told you I had a cyst…”

I tried to keep smiling while I opened up her chart to look at the new ultrasound report. She had a cyst alright, but this time it was in the left ovary. The right ovary was totally normal. Her pain was not coming from the cyst.

So why the little anecdote? It’s certainly not to belittle the patient, or conclude that she had no pain. It’s just that there are many types of cysts, and not all of them should arouse concern in a young woman. A lot of them don’t cause pain and most of them go away. So I thought I would describe one of the more common types and very briefly outline what I mean.

First of all, the ovary is a very active organ throughout the child-bearing portion of a woman’s life. Each month -if she’s not pregnant or on the birth control pill, for example- a tiny little egg is stimulated to develop by a chemical signal from the brain: the follicle stimulating hormone (FSH).  It does so in a little fluid-filled cavity known as a follicle. This signal gets feedback from the egg so it turns off when the egg is mature, or increases in intensity if the egg is not responding.  As the development proceeds, the follicle gets larger. When the egg is finally mature, the follicle bursts open liberating the egg so it can be picked up by the Fallopian tube.

But suppose the little microscopic egg doesn’t respond very well and never really matures -maybe because of stress, or age -or even because that particular egg is not very sensitive? Well, the follicle gets more and more fluid in it as the FSH increases and pretty soon it’s no longer called a follicle -now it’s a cyst. And because it’s part of the normal functioning of the ovary,  we call it a functional cyst. Or a follicular cyst. Or even a simple cyst. These can get fairly large (up to 4 or 5 cm. diameter) but they’re generally quite temporary and eventually disappear (reabsorb). They seldom cause symptoms although if one bursts, it can be painful for an hour or two. In other words, many people likely have cysts without knowing about them.

What are reassuring features on an ultrasound? Well, think of a tiny balloon filled with water. It would have thin walls -no lumps or thickenings; no ultrasound echoes in the fluid; no increased blood flow to the cyst (they can measure this nowadays using Doppler effects); and a size less than, say, 4 or 5 cm. And if so, what to do? Well, we generally do another ultrasound two or three months later to see if it’s till there or has changed in some way. But otherwise, nothing.

Ovarian cysts should be investigated once they’re discovered, of course, but they don’t all need treatment. They aren’t all bad.

And that patient? I eventually laparoscoped her because of her on-going pain and found endometriosis. Normal looking ovaries, though.