Ovarian cancer in young women is remote but not impossible

It was the first Monday morning of December. A dry and windy morning. The usually green hills overlooking our large referral hospital had turned brown, reflecting the morning sun in a somewhat desolate mirage. Not a drop of rain had descended on this part of the world in six months, it was the driest. That morning found myself in the gynecology ward, reviewing patients, giving treatment plans, completing abortions, both natural and induced, and listening to the frantic rage of the wind as it threatened to deroof our hospital.

Demetrius, a 28-year-old female, was rushed into our ward. She was admitted directly to the ward because the usual admitting process was slow on that day, and the theatre was occupied with another case at its tail end. She came with a distended abdomen and severe abdominal pain. Her belly was swollen and still. At that instance, the 5Fs of abdominal distention flashed through my mind in what seemed like an impulse. These are fetus, feces, fluid, fat, and fatal growth. Demetrius told me there was no possibility of her being pregnant, she had seen her periods just a week before, and the pregnancy test was negative. No fat could be that painful, and most definitely, it couldn't be fecal matter; hers was likely a fatal growth or fluid or fatal growth with fluid.

"Doc, Ultrasound ilishafanywa iko hapo Nursing station, "Nurse Maureen said, almost whispering as she turned away her urban locks to set free her eyes. Her tone reflected the urgency of the matter. She is a beautiful nurse, beautiful but untouchable. She only yields to the big fish, not interns.

The Ultrasound showed a complex cyst with multiple septations. Complex cysts are often associated with cancer. A cyst is a fluid-filled sac that can occur anywhere in the body. They can be either non-cancerous or cancerous. The non-cancerous one is benign, and the cancerous one is malignant. Demetrius was 28, and the possibility of cancer was remote but not impossible; anything is possible in medicine. Blood samples had been taken in the ambulance that brought her to the hospital, and the requests were written. Still, the tests had not gotten to the lab. "Naomba mnifanyie hii test huko kwa lab tukiendelea na matibabu," I asked the relatives handing them over a laboratory form with laboratory tests, including cancer markers ticked.

The tests came back about half an hour later as the theatre was getting ready. The anesthesiologist called and requested for the most important results from the ordered panel of tests to enable him to monitor Demetrius during her induced sleep. Most parameters were normal except for the cancer markers which were elevated, much to our disbelief. "Ovarian Cancer? 28-year-old. with no other symptoms apart from abdominal pain and distention? It cannot be," my consultant said as he shook his head from side to side while hurrying to the theatre to get ready for the operation. Clinical intuition is better than a weak test, quips Siddhartha Mukherjee in his book 'The laws of medicine,' and at that moment, instinct mattered more than anything else. The gynecological oncologist, who was around that day, was not convinced either. He recommended an operation because the cyst had twisted on itself, anyway.

"We are still not very certain what this is, but the consultant thinks it is most likely non-cancerous. The reliable way to confirm the behavior will be to look at the tissue itself. For now, you need an emergency operation; tissue from the collected specimen will be taken to the lab for histology," I said, trying to summarize the whole discussion with Demetrius. She fell off her hospital bed in protest. "No way!" she said as she collapsed to the ground, panting in shock and disbelief. "Ishindwe katika jina la Yesu, Daktari mimi siwezi kuwa na cancer, "and then she went silent from the anxiety and seeming lapse in communication. We gently lifted her to the stretcher and rushed her to the resuscitation room. Luckily, she woke up before the resuscitation began. She later consented to the operation at the bedside after a brief but thorough counseling on the pros and cons of the operation.

The air in theatre 9 was cold and dense with the metallic smell of raw blood and chlorine from the disinfecting agents and the previous operation. Having seen me operate before, Dr. Murima insisted I open the skin and leave him to dissect the cyst. That was the work of a novice; you open the door and close it, and whatever happens in the room has little to do with you on most days, depending on who you are operating with. I steadied my hands and sliced downwards through the lower abdomen from the umbilicus; the wound responded immediately with the oozing of blood as if the skin was protesting, giving in but fighting back. The smoke from the cauterization knife rose gently above, reflected the theatre lights, and then diffused through the ventilation as though it were some smoke from the embers of a dying fire.

The intestines are often messy and need to be handled with the utmost care, especially at the time of incision and dissection of the cyst. One wrong move can double or triple the operating time, again, this depends on the general surgeon on call. There we were, an expert and a novice, clad in green sterile garments, side by side, mutilating the human body, one in the glory of making an incision and the other with the reproach and caution of experience.

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The cyst was in sight after we had split the rectus sheath, a strong piece of tissue covering the abdominal muscles; the cyst looked like a balloon filled with water as it shook relentlessly in the abdomen, spurring some excitement inside the boy in me.

"Daktari, you are getting excited. Please don't poke the cyst because we don't know what is in there," Dr. Murima's voice rose above the operating field, penetrating the thick silence that had reigned the theatre. His, was a soft voice by all means, but the tone carried with it loads of caution. This was my moment; there was no way I could open Pandora's Box. About half an hour later, Dr. Murima took over the operation, dissecting the cyst from his side. The cyst was large, about one foot on its longest and most expansive sides, but in the hands of Dr. Murima, removing this was not going to be a challenge at all, even if he was operating on his' anticlockwise side.'

He removed the cyst intact and dissected the roots; it had twisted on itself, almost as if defying its own will to live, threatening the host in the process. Dr. Murima was careful not to pop it. It was rushed to the pathology lab as the operation continued. I closed the skin, dressed the wound, wrote down the notes as dictated by the boss, and went home.

The results came in a few days later and alleviated our fears; the histology of the specimen had come back negative for cancer. It was, after all, a benign swelling of the ovaries. I was happy for Demetrius as she continued to recover in the ward.

When I let her know the histology findings, she had done well post-op. She was resting peacefully on her bed. Her drip was done, and blood flowed back defiantly from her veins through the infusion set to fill the void left by the fluids as if defying the laws of gravity.

"Hi, Demetrius; how are you feeling today?"

'I am doing well, doc, thanks," she said,

"Some good news, the results came back with a non-cancerous diagnosis."

She outlined a beautiful smile as she covered her face to hide her joy.