This is now the second half of the 1980s, I’ve been a consultant surgical pathologist at the Royal Hampshire County Hospital in Winchester since 1980, and I get a phone call from a friend in Malta who says his wife has just been diagnosed with ovarian cancer and asking me whether I would mind reviewing the histological slides before she starts chemotherapy. No problem – confirming ovarian cancer should be straightforward.
This lady was around 50 years old and had consulted her doctor, and then a gynaecologist, because of some pain and redness around her umbilicus. A right ovarian mass was diagnosed and she underwent a bilateral oophorectomy and total hysterectomy. At operation, besides the right ovarian mass and some fluid in the pelvic cavity, a portion of omentum was found stuck in a small umbilical hernia, was extracted from the hernia sac, excised and also sent for pathological examination.
The perimenopausal uterus and left ovary were unremarkable on the histological sections. The right ovarian mass looked like a serous cystadenoma, but serous cystadenoma type cells were noted sitting on the peritoneal surface of the ovarian cystic tumour. Furthermore, there were small well-circumscribed nests of similar serous well-differentiated neoplastic cells in the portion of omentum removed from the umbilical hernia sac. These findings had been interpreted in Malta as a well-differentiated ovarian serous cystadenocarcinoma with omental and peritoneal cavity spread.
Fortune would have it that I had just come across a paper by Steven Russell, an Australian pathologist claiming, that a previously unrecognised category of ovarian neoplasia, was a serous cystadenoma-like ovarian mass often accompanied by what he called “benign implants” (looking like mini serous cystadenomas) in the omentum and on pelvic peritoneal surfaces. He claimed this was not malignant metastatic disease but a “field change” within the female pelvic peritoneal cavity resulting in multiple locally-arising (non-metastatic) tiny serous cystadenoma-like “benign implants”. He also claimed that very often these “benign implants” regressed after the main ovarian tumour was removed.
How had he reached this rather implausible story? He claimed he had reviewed his department’s ovarian cancer records and found that a small number of patients were still alive a number of decades later, suggesting incorrect diagnoses. On reviewing their histological findings he came to the conclusion that these cases represented a category of multifocal Mullerian serous neoplasia that was not fatal and that could be adequately controlled and cured surgically without any need for chemotherapy. Some years later, when his findings were confirmed in the US and Europe, this category of ovarian neoplasia became known as “serous ovarian tumour of borderline malignancy”.
I phoned her husband to tell him that I did not think she had ovarian cancer and sent him a brief written statement of my opinion based on the fact that his wife’s findings tallied with Russell’s descriptions of this “new” category of non-fatal ovarian neoplasia. I then got a call from Professor Frederick Fenech, a personal friend of the husband, who asked me whether I was sure she needed no further action but only observation. I replied that if she was my wife, that is all I would recommend.
The husband asked me to arrange a consultation for his wife with a London gynaecologist. Her histological slides were also reviewed by a London pathologist and reported as serous cystadenocarcinoma with peritoneal and omental metastatic spread – same as the Malta diagnosis. The couple came to London where a scan was reported to have found a recurrent mass in the right iliac fossa and the gynaecologist recommended an exploratory laparotomy. Distressed and confused, the couple declined further surgery in London and returned to Malta where, a repeat scan by Dr Malcolm Crockford, found gas in the caecum and no mass in the right iliac fossa.
This lady had no further treatment, is now in her eighties and enjoys excellent health. Her husband suffered from ischaemic heart disease and died suddenly several years ago.