When Benign Isn’t Better and Malignant is Preferred

I take care of people with tumors. Often, I’m the one who tells them their diagnosis. Sometimes, it’s a disease they haven’t heard of, so one of the most common questions I get is, “Is it benign or malignant?” As you might imagine, everyone wants their tumor to be benign. Benign is better, right?

Not always.

At the moment, I’m struggling with a very difficult case. X is a teenager who has had a tumor for 5 years. In the beginning he had some pain and a lump on the side of his head. A biopsy was thought to show a lymphangioma (a benign collection of abnormal lymph vessels). The mass continued to grow, so he had surgery to decrease the size of the tumor. When that tissue was removed, the pathologist thought it was something called a granular cell tumor (also benign). Unfortunately, it grew back, and this time it damaged his eye enough to make him blind (in that eye). He had a larger surgery which relieved some of the pain and pressure, but only temporarily.

Now the tumor has grown even bigger. It was biopsied earlier this month. This time the pathologist can’t make a diagnosis. It’s been sent to other national experts for their opinions. It may still be benign. Is that a good thing? Not necessarily.

If it’s benign, it won’t respond to chemotherapy. If it’s benign, it may not respond to radiation. And yet, it’s still causing him pain and it’s still disfiguring. He misses a lot of school and is very self-conscious about his appearance.

If it’s benign, the only therapy that will help is surgery, and given how many times this tumor has grown back, it will require a complete resection to cure. And a complete resection will remove half his face. Literally.

What if it were malignant? If it were malignant, we could use chemotherapy and/or radiation before surgery. This would probably shrink the tumor significantly. Then it could be removed with a much less disfiguring operation.

I have another patient, about the same age, who has a rhabdomyosarcoma (cancer of skeletal muscle) in about the same place. Who is worse off, the patient with cancer, or the one with a benign tumor? Well, the patient with cancer has a 90% chance of being cured with a combination of chemotherapy and radiation, with minimal cosmetic consequences. The patient with the benign tumor may not die of his disease (although he could), but is in terrible pain and will require a horrific disfiguring surgery to get rid of the tumor.

Slides from X’s most recent biopsy are being reviewed at another hospital right now. I hope they diagnose a malignancy.