(I first wrote this article in September, 2008. Subsequent additions were made in March 2012 and November 2016.)
(For the non-medical fraternity, I have italicized the technical sections of this article, that can easily be skipped without missing out on the storyline.)
This is the true story of a young 13-year-old girl.
She had been diagnosed with a large abdominal tumor and the consensus of opinion of the doctors in her hometown was that she suffered from an advanced, untreatable cancer, that was best left alone. She was brought to Mumbai from her remote village in central India in the slender hope that something could be done for her.
This is a heart-wrenching trend that occurs far more often that one would care to admit. Where poverty-stricken patients from the interiors of India sell everything they own and travel huge distances to the major cities like Mumbai, Calcutta, Delhi etc., to seek medical services. Only to be told, often within a few hours of arrival, that nothing could be done for them and it would best that they went back home.
In this particular case however, despite it’s ominous appearance, there was an outside chance that it could well be a treatable disease.
She did come from a very poor family and initial investigations were kept to the bare minimum. Just enough to confirm the tumor type, based on which a decision would be made on whether to proceed with aggressive treatment with a curative intent or adopt a more palliative approach.
This 13-year-old girl presented with abdominal distension that could easily be mistaken for advanced state of pregnancy. It was first noticed a year ago and was gradually increasing in size. Though initially painless, she did complain of a dull pain for the past month or so.
On examination there was a hard, fixed, non-tender, abdomino-pelvic mass.
An Ultrasonography of the abdomen and pelvis (done previously in her hometown) reported the presence of a huge, solid tumor arising from the pelvis and extending into the abdomen.
Tumor marker tests were then performed. Elevated levels of BHCG (Beta Human Chorionic Gonadotropin) clinched the diagnosis of a Germ Cell Tumor of the Ovary.
In short, the initial investigations confirmed the diagnosis of an unusual type of ovarian cancer.
Germ cell tumors are a relatively rare type of ovarian cancer that tends to occur in younger females, often in children. These are exquisitely sensitive to treatment, and, even in advanced cases, the cure rates are excellent.
This diagnosis instantly changed the prognosis from a deadly and terminal disease to one that was eminently curable despite its huge proportions!
Usually ovarian cancers require surgical removal of both ovaries and the uterus. However, in germ cell tumors, fertility-sparing surgery is often possible, (sparing one ovary and the uterus) without compromising survival. Which is great, as many of these patients are young, often in their teens. Most of the patients who undergo fertility sparing surgery will retain menstrual function and many will go on and attain pregnancy if they so desire.
An exploratory laparotomy was performed under general anesthesia. Intra-operative findings revealed a huge mass arising from the left ovary with adherent small bowel loops. There was also mild acites. The right ovary was normal.
A comprehensive abdomino-pelvic staging and fertility sparing (left salpingo-oophorectomy) cytoreductive surgery for ovarian malignancy was performed.
Surgery entailed removal of the left ovarian tumor. The right ovary and uterus were retained preserving her ability for menstrual and hormonal function and even, possibly, future child bearing.
She made an uneventful post-operative recovery following which she underwent a complete course of chemotherapy.
Chemotherapy drugs are expensive and to her good fortune, a total stranger, whose mother was being treated simultaneously at the same hospital, was sympathetic to her cause, and provided the financial support that allowed her to complete her treatment.
She followed up regularly for a year thereafter.
September 2008 (1 year later):
On her last visit, before she finally returned to her village, her tumor markers had returned to normal, there was no evidence of recurrence and her scars had healed well. Her menses had resumed which meant that there was every possibility of her starting a family and living a normal life.
From a purely medical standpoint this was a success story. There were however, other issues that we were concerned about.
Apart from the slight probability of recurrence, this 13-year-old had to undergo major surgery with its attendant ugly scars, and months of toxic chemotherapy with its own set of side effects, not least of all the severe loss of hair rendering her absolutely bald. Adding insult to injury was the fact that she was now permanently stamped with the dreaded ‘Cancer Patient’ Label
To say her psychological scars far exceeded her physical ones would be a gross understatement.
Rural Indian culture can be cruel and unforgiving and we worried about how she would cope.
March 2012 (5 years later):
A young woman walks into my consulting room. She gives me a big broad confident grin and though I smile back, I haven’t the foggiest idea as to who she is.
She has an attractive face and one couldn’t but help but notice her stunning head of hair that was plaited in a style typically adopted by girls from rural India.
It was only when I looked at her case file did I realize it was the same girl we had operated 5 years ago. She’s almost 19 years old now. All her tests reveal that she is free of disease and her menses are normal.
The reason she was brought to me after all these years was to get my blessings so that her family could initiate the elaborate Indian nuptial ritual of finding her a groom!
To me it was quite clear that there remained only one major cause for concern.
And that belonged to potential suitors in her hometown.
As, judging by her appearance and confident demeanor, I wouldn’t be one bit surprised if some Mumbai boy snaffled her up in marriage long before she even had a chance to return home!!
November 2016:“It’s a boy!”
Her uncle works for the hospital where she had undergone her treatment. So, although she was in her village and I hadn’t seen her for years, I was regularly updated on her health.
A few months ago he informed me that she was pregnant and I’ve been keeping my fingers crossed and praying that all would go well.
So you can understand why, when he dropped by my OPD this afternoon with the news that she had delivered a healthy baby boy, and that both mother and son were doing well, I have been walking on air ever since!!