It is commonplace knowledge amongcaregivers that the abdomen, in terms of lesion and surgical interventions, is full of surprises. It is not uncommon for a surgeon to be confronted with an entirely different thing from what he had in mind before the commencement of an operation.
This has led to some rookies and the uninitiated to use the words like ‘misdiagnosis” and “wrong diagnosis.” Thus you find surgeons, when writing post-operative notes, would subtitle their description with: Indication for surgery; operating findings, and procedure. This is because anything is possible, even when you think that it is obvious.
Even with the current state-of-the-art imaging equipment that have made diagnosis easy and sometimes derailing, surprises still remain the name of the game. So was the case of this 55-year-old woman, who presented acute abdomen. A poor historian you might refer to her. She claimed that the pains have been recurring for quite a while. But this time, the pain was becoming unbearable.
On examination, there was an obvious abdominal mass that was solid in consistency. An impression of Uterine Fibroid, with possible hyaline degeneration, was considered A conservative approach towards management was suggested, but she insisted that she’d had enough and wanted the tumor removed. Ultrasound study showed that it was a pelvic mass measuring about 12cm in its widest diameter. There was free fluid collection in the abdominal cavity. It was not an emergency so to speak in that perspective. She was given fluid and analgesics and scheduled for surgery the next day.
When we opened her up, what we saw was not a uterine tumor, but a multi nodular solid tumor creamy white to yellow colouration. Though midline in position was actually from the right of the womb—Right Adnexa. It was an ovarian tumor. Curiously for an ovarian tumor that size, one expected some form of irritation of the peritoneum with resultant fluid collection in the abdomen known as ascitis. There was none. The first impression we had on encountering this mass was an ovarian cancer. In our environment, at this size, there were bound to be involvement of the bowel, especially the small intestine. We inspected the bowel and it was clean. The tumor was excised together with the right uterine tube. Again, we were not convinced that the tumor could account for the pains that necessitated the surgery. The tumor was not twisted on its stalk and there was no evidence of haemorrhage into the tumor. There were no areas of cell death or necrosis.
We were convinced that we had not solved the problem and decided to look in the area of the appendix. And hell and behold, it was inflamed and adherent to the Caecum. We had to remove it, being convinced that it was the cause of the discomfort.
You can imagine when people talk about pre-operative wrong or misdiagnosis: how it could come about. The histology report had an unmistakable description of transitional epithelial cells populating the tumor with fibrous tissue surrounding them. Transitional epithelial cells are largely derived from the urinary system and are aptly described as UROEPITHELIUM. The pathologist’s conclusion was consistent with Brenner’s tumor. That were an exciting moment and a relief to the surgeon, who wouldn’t have to worry about the anxiety of watchful waiting in a case of advanced malignancy before a burn out.
This tumor was first described by a German surgeon, Fritz Brenner, in 1907. It is a subtype of a group of NEOPLASM that originates from the cells and connective tissue of the surface of the ovary often referred to technically as Surface-epithelial-stromal tumor. More than 90 per cent of these tumors are benign but some can become malignant. There are some that are referred to as borderline with regards to their tendency of becoming cancerous. It should also be noted that about 95 per cent of ovarian cancers are derived from the surface of the ovary. They are also known as ovarian adenocarcinoma.
Brenner tumor, most of the times, are incidentally encountered during routine pelvic examination or during abdomino-pelvic exploratory surgery. This tumor, in very rare occasions, can occur in other locations like the male testes, which may not be too surprising due to its uroepithelum cellular origin. On gross examination, Brenners are solid and sharply circumscribed giving it a multi-nodular appearance on the surface. It is pale yellow in colour with white strands of fibrous tissue. As a rule to occurs on one ovary at a time and in a lot of instances would incorporate some part of the uterine tube. This has also led to very strong connection with Walthard Cell nests, which are clusters of cells commonly found in the connective tissue of the Fallopian tube.
Because of the marked similarity of the epithelium of Walthard cell rests, Brenner tumor and the Uroepithelium of the lower urinary tract, it has been suggested that it is their HISTOGENIC ORIGIN. When slides are prepared of Walthard cell nests and Brenner’s tumor and stained with Haematoxylin and Eosin, you can hardly tell the difference with the presence of the characteristic “coffee bean nuclei” in both specimens. These nuclei are so described be they long, elliptical and have a groove in their long axis, the shape of a bean seed.
Finally, with Brenner’s tumor the surgeon can always go to sleep after its removal. The fear of malignancy and distant spread or metastasis, unlike you have had in ovarian cancer with its features of weight loss, ascitis and pallor, are rare. There is no space for comparison here, but suffice it to say that ovarian cancer patients naturally look sick and wasted. On the other hand patent with uterine fibroid tend to have cyclic pains and heavy and prolonged bleeding during their menses. This , of course, will be in sync with their cycle. But with Brenner no symptoms may be attributable for a very long time and may even go undetected during a lifetime. It has been suggested that if the caregiver is convinced on encountering it during surgery for another reason and the size is not much he should jolly well let the sleeping dog to lie.
When the patient came around from anaesthesia, I asked her how long she had been feeling the stone in her tummy. She confessed that what really bordered her were the pains in her abdomen. And for the tumor, she wouldn’t care that it has been there for 29 years! She thought that it was normal, but that now she’d seen it, she feels relieved.