The risk of receiving a surprise gynaecological cancer diagnosis

Posted 10 years ago by Andreas Obermair and Andreas Obermair

A 34 year old patient recently underwent a gynaecological laparoscopy for a mass suspected to be benign endometrioma, but following pathology testing, the diagnosis took a nasty turn.

The patient’s mass actually turned out to be a clear cell cancer, which then required me to become  involved. The gynaecologist was stressed and reassured both the patient and myself that she had done everything possible to minimise the risk of a surprise cancer diagnosis.

As specialists, we make strenuous efforts to minimise a patient’s risk of being unexpectedly diagnosed with a malignancy (cancer) during laparoscopic surgical procedures.

The trouble is, there is no known way to eliminate this risk entirely. Unfortunately, many cancer detection tests will never be 100% accurate.

The unexpected finding of a cancer causes much stress to patients as well as doctors, it triggers significantly more work for everyone involved, and is linked to inferior patient outcomes.

Why do unexpected malignancies occur?

In SurgicalPerformance.com, the risk of an unexpected cancer diagnosis is 0.56% in all operations for ovarian cysts, and 0.32% for all endometriosis resections.

Sometimes, unexpected malignancies can be discovered during surgery because no single diagnostic test is 100% accurate. The value of tumour markers for ovarian cancer is limited and for most other gynaecological cancers, there is no tumour marker available.

Serum CA125, (a protein produced by a large number of tissues) can signal cancer when found in the blood at elevated levels, and is detected in almost all patients with advanced ovarian cancer.

The trouble is, it rarely makes itself known in early stage ovarian cancer.

In addition, certain cell types, such as clear cell cancers, often do not produce Serum CA125 and are known to fly under the radar. For non-epithelial ovarian cancers this is a similar case.

Even more problematic is the fact that some benign conditions, such as fibroids or adenomyosis, also cause elevated serum CA125 levels.

Ultrasound may also fail to detect early stage ovarian cancer. An ultrasound reports on the size and structure of a cyst, and small cancerous components can be easily missed. On the other hand, some areas within an ovary which look suspicious on ultrasound, sometimes turn out to be innocuous.

What are the implications for patients?

If the rupture of a benign tumour occurs during laparoscopic surgery, the outcome for the patient is largely harmless.

However if an ovarian cyst bearing cancer cells is ruptured, it will cause the tumour to worsen to a higher stage cancer, leading to the need for chemotherapy (which would have otherwise not been necessary), additional surgery and a worse prognosis.

Patients with stage 1a tumours typically have higher than 90% survival rate at the 5-year mark, yet for patients diagnosed with stage 1c tumours, the survival rate slips to 80% or less.

Four important things your gynaecologist should do in the case of discovering a suspicious cyst during surgery

At some point during their career, all gynaecologists will detect ovarian cancer during surgery for what they initially assumed to be a harmless ovarian cyst, or detect uterine cancer in what seemed to be a fibroid uterus.

1. If cysts look doubtful or suspicious, they should never be ruptured or have their content spilled. Rather, it is advisable to remove the whole ovary in one piece, to avoid spillage of content into the abdominal cavity.

2. Any cysts should be removed through an endobag, which is a small plastic bag the cyst can be wrapped into.

3. In case of abnormal uterine bleeding, a curette should be performed prior to a hysterectomy.

4. If concerns still exist after the curette, any measures should be undertaken to avoid morcellation of the uterus to avoid any spill of tissues.

Lowering the risk of receiving a surprise diagnosis

While it is widely accepted that gynaecologists will detect a cancer unexpectedly from time

to time, it is unusual if some gynaecologists run into this problem more frequently than others.

Gynaecologists have sophisticated tools available allowing them to track their performance findings, and find out their individual rate of unexpected detection of cancer or ovarian cyst rupture.

Access to this statistical information is private and confidential to ensure doctors needn't be afraid of sanctions.

Consulting with a well-trained O&G specialist who stays up-to-date with clinical technology and technique, is your surest path to the best treatment for adnexal masses.

He or she will be able to perform and interpret all the most relevant tests, and evaluate your individual risk factors, to give you the most reliable advice on your treatment options.