Fayetteville Women's Clinic
William Harrison M.D.
1011 N. College, Fayetteville, Arkansas
(479) 442-8166

A THANKSGIVING STORY

I first saw "Mary" in the spring of 2001. She was 37, had one child, age 21, and was pregnant for the fourth time. She was unmarried and about 12 weeks pregnant. She had waited to seek an end to her pregnancy - even though she had known she was pregnant for almost 5 weeks - not because she had difficulty with her decision, but because she had miscarried two times after her one delivery, and was hoping she would again.

Mary was recently divorced, unemployed, living with her parents in a town of less than 500. She had become sexually active at age 15, not an uncommon age to be initiated into the pleasures of coitus in the sex soaked atmospheres of even our most remote and seemingly innocent small towns. (Today, even Mayberry would get "Friends" and its various competitors, and many young people go to their local churches for BTU, MYF and ETC to meet compliant members of the opposite sex and get laid.) It was not so different when Mary was 15, though TV back in the 80's was a little less explicit in extolling the joys of unfettered and creative sex with a lot of partners. Mary had had only six sexual partners, including her former husband, possibly because she had married so young. Among many of my patients today, this is on the low end of the scale for women in Mary's situation.

On that occasion in the spring of 2001, Mary had an uncomplicated abortion, paid for by her parents, since she had no income and didn‚t want her former husband, by whom she was pregnant, to learn of the abortion.

She didn't return for her post abortion checkup, but had no post-operative problems.

Mary didn't consult a physician again until she returned to my office, ostensibly for a routine Gyn exam and birth control in late October, 2003. In the space provided on the intake history where the patient is to record the reason for the visit, Mary had written, "hardness and knots in stomach may have cracked ribs, knot moves, about the size of a golf ball & comes & goes since Sept 10 because that was when I was supposed to start a period & I got a hug that poped really loud & for about 3 or 4 wks couldn't move freely at all & this knot appears."

She gave the date of her last period as 8-10-03.

When I examined Mary, I noted a lower abdominal mass, extending almost to her umbilicus. It was very firm and felt much like a 16- to 18-week pregnancy. We did a pregnancy test - positive. I did an ultrasound that revealed a 12-week pregnancy and a five to six centimeter benign appearing ovarian cyst. Mary had recently remarried and was not sure if she would have the baby or abort. She and her new husband, who has children from a previous marriage, had not been using contraception, partly because they were considering having a child and partly because they didn‚t believe that she would get pregnant - her being 40 years old and having not gotten pregnant during the two years of their courtship. Both have minimum wage jobs with no benefits, and if they had the baby, she planned to deliver at home, as she had with her first pregnancy.

Ovarian cysts are very common in early pregnancy. These are usually benign structures comprised of a cystic corpus luteum, which is a yellow body necessary to the maintenance of early pregnancy. Though this cyst was larger than most, it had all the benign characteristics of the thousands of corpora luteums that I had seen in thousands of other pregnancies. It was almost perfectly round, smooth walled, single chambered, fluid filled and emitted no internal echoes. It was, by every criterion with the possible exception of size, a routine early pregnancy structure.

I informed Mary of the cyst and that it was probably benign, but that if she chose to abort, I would want to make certain that it disappeared after the abortion.

After talking with her husband, Mary decided based on multiple factors that she would abort. She was now 13 weeks pregnant and we scheduled the abortion the next day. Mary‚s abortion was uncomplicated, and again she did not return for her post- operative visit. However, about three weeks after this abortion, Mary noticed that her lower abdomen contained a large mass, much as it had before. This time the mass was tender and she could not sleep on her stomach. Four weeks after the abortion, she returned to the office, concerned that she was still pregnant. Again, I examined her and did a pregnancy test. This time the test was negative. Now an ultrasound of her „pregnancy‰ revealed a much larger cystic mass, but still with all benign characteristics other than size. I felt that it was highly probable that this was an ovarian tumor and, given the way it looked, a benign serous cystadenoma of the right ovary about 12 centimeters in diameter.

I discussed my findings and the probable diagnosis with Mary and suggested that we remove the ovary as soon as we could complete the necessary workup and get her on the operating schedule. I have been in practice over 30 years and have seen some very few ovarian cancers present with a similar ultrasound picture, so I prepared Mary for the possibility of this diagnosis. This was on Thursday before Thanksgiving, and she wanted to know if she could delay surgery until after the Thanksgiving and Christmas holidays. Though I don‚t believe in angels, there might have been one sitting on my shoulder that morning whispering, "No, no, Mary." I said, "Let's do this as soon as we can. This tumor has grown significantly in the last four weeks. Right now, it seems to involve just the ovary. I still think this is benign, but I want to do this as soon as we can."

We obtained a CA125, a chemical that is sometimes elevated in the blood of women with ovarian tumors. It was normal. We got an x-ray of her kidneys that showed only a large mass rising out of the pelvis consistent with an enlarged uterus, and no obstruction of the ureters, the tubes that drain the kidneys and are sometimes affected by large ovarian tumors. My ultrasounds of the pelvis had confirmed that there was no excessive intra-abdominal fluid (this is called ascites, an abnormal amount of free fluid in the abdomen and a grave prognostic sign in cases of ovarian enlargement). Her chest x-rays were normal as was her blood count, except for an elevation in her white blood cell count. We were unable to determine exactly what this elevation resulted from, but the count returned to normal the day after surgery.

On the day of surgery, we opened her abdomen, having obtained permission possibly to do a total abdominal hysterectomy, omentectomy and pelvic lymph node resection. When I opened the abdomen, I collected pelvic washings to look for malignant cells floating free in the abdomen should the tumor prove to be cancer.

The ovary was markedly enlarged, as expected. The other ovary was small and benign appearing. The lining of her abdomen and bowel was free of tumor implants as were the ovarian surfaces. This was obviously a benign ovarian serous cystadenoma, as I had suspected. I started to just shell out the cyst, but then - that angel again - I thought, Nope, I'm going to take that ovary and tube and open it up and make sure what we are dealing with. So I did. I opened the cyst. It contained a large amount of a bloody, watery fluid. I inspected the interior of the cyst wall and saw nothing untoward. Now I thought, I should get a frozen on this, but they don't have insurance and I've looked a hundreds of these. I‚ll save them the money and forego the frozen. It‚s obviously benign. And I discarded the peritoneal washings. Sometime just before this, perhaps when I decided the tumor was benign, is when the angel left my shoulder. Maybe she thought I knew what I was doing and no longer felt needed.

On Tuesday evening, after her surgery at noon two days before Thanksgiving, I sat down with Mary, who looked great, and told her that it was highly likely that this tumor was benign and that if she continued to progress well, I would release her Thanksgiving morning.

Very early on Wednesday morning I woke with nausea and diarrhea. I felt pretty awful and canceled my morning patients. I visited Mary at noon, she looked great, and I told her again that I felt that the tissue would be benign and she could go home on Thanksgiving morning. Late that afternoon, I received a call from the pathologist. "Did you open the specimen, Bill?" he asked. Yes, I did. "Did you notice anything on the internal wall of the cyst?" Obviously I had seen nothing. "Well," he said, "there is a very small focus of well differentiated, microinvasive adenocarcinoma on the internal wall of the cyst near the ovary itself." Immediately I realized that I had been so sure of the benignity of the tumor, that I must not have lifted it completely out of the fluid that had filled it and the bowl that contained it, and the one area I must not have gotten a good look at and feel of was where the cyst arose from the ovary itself.

I was heartsick. I asked if I could review the tissue as soon as I completed my duties at the office, and the pathologist said he would wait for me. At about 5:30 p.m., I went to his office to look at the slides. There were multiple sections, all of which we re-examined, most of them showing only a benign serous epithelium lining the cyst wall - until the last two slides. And there it was. A very small, less than 5 millimeters long, area of malignant cells with a few tiny nests of these ugly little bastards infiltrating about two or three millimeters into the tissue underlying the internal cyst lining. No doubt about it. It was cancer, albeit just a little.

Last year, my wife was diagnosed with breast cancer. It, too, was very small, though not nearly so small as this. Over the course of my professional life, I have confirmed a diagnosis of cancer hundreds of times. I have given a diagnosis of possible cancer perhaps a thousand times or more. Getting this diagnosis yourself, or hearing it applied to someone you love is like getting kicked, very hard, in the stomach. I felt the same way when I looked at Mary's slide.

I went immediately to the hospital to tell Mary the bad news. While I am almost certain that Mary has been cured, I plan to go back and do a hysterectomy and remove the other ovary as I should have done that day.
After I told Mary and her husband that I had been wrong in my preliminary surgical diagnosis, I told her that she could go home the next day. On Thanksgiving morning, the nurses removed half her skin staples and I asked her to come in on Friday to let me remove the rest. I knew that it was going to take more than a few hours for what I had told her to soak in.

Friday morning, Mary came to the office with her husband to remove the remaining skin staples. As she was about to leave, she still seemed shellshocked, and I was worried that she might be having a lot of guilt about her abortion and blaming this for the diagnosis of cancer. I asked if there was anything she wanted to ask or tell me. Mary began to cry. "Doctor, I haven't been able to sleep. I keep thinking maybe this is God's punishment for having that abortion, or those abortions--for killing my babies."

"Mary", I said, "if this is God's punishment, it is being administered in a very odd way. Have you thought about what might have happened if you hadn't had this abortion? You would have continued your pregnancy. You would have assumed that your belly was enlarging because you were going to have a baby. Given the rate at which this tumor was growing, there is a very good chance that sometime before you delivered, the tumor might have ruptured, spilling cancer cells all into your abdomen. Blood flow to the pelvic organs is drastically increased during pregnancy. There is also a high probability that the tumor cells would have spread throughout your body by the time you delivered. Ovarian cancer, when we find it very early, as we did yours, is very curable - sometimes, just by removing the ovary. I think that even though I screwed up and didn't do the procedure that I would have done had I had the diagnosis at the operating table, that it is highly probable that you are cured. Mary, I think someone was watching over you that day you came in for the abortion. Otherwise, you might have been dead this time next year, and your new baby half an orphan."

Mary looked a little startled at all that, then she grabbed me and hugged hard, though not hard enough to break a rib. "I love you, doctor Harrison." And I am sure that at that moment, she did.

Of course, I don't know what the future will bring for Mary. Even more surgery after we do the hysterectomy and remove the other ovary? Perhaps chemotherapy? Probably not. I do know that her future is much, much brighter than it would have been had she decided not to abort, or had elective abortion not been an obtainable option for her. And I gave thanks for all that this past Thursday.

I hope that we are still able to celebrate the reproductive freedom of families and couples and women like Mary even if George Bush is re-elected president in 2004. But right now the future for Reproductive Freedom in this country does not look nearly so bright as Mary's future.

William F. Harrison, M.D.

Addendum
I wrote this just before I did the follow up hysterectomy, removal of the other ovary and extensive pelvic and abdominal washings, all of which returned as free of malignancy, for "Mary" shortly after Thanksgiving in 2003. I saw her for her six week post op exam a few weeks later when I asked her to return for an evaluation every three months for the next two years to be followed then every six months for the next three years. I had intended to send it off to several publications after I had seen her a time or two for follow-ups. But I was injured in late Feb, 2004, and didn't return to practice until Sept. 8th, last year. By the time I returned to practice, I had little memory of the events of the previous three months before my injury, but as the weeks passed, my memory of those lost weeks began to return, and I finally thought to ask for Mary's chart. I noticed that she had paid nothing on her bill and she had neither returned to see us, nor had she been contacted. I immediately called her and requested that she return for an evaluation. She said, "Dr. Harrison, I owe you over $3,000 and have no way to pay that debt. That's the reason I haven't been back to see you." I asked her if she had gotten a bill from us. She answered that she had received one bill shortly after her second surgery. I told her about my injury shortly after her last visit to my office, and that this was the reason I had not been pestering her about a follow-up visit. Speaking in language I knew she would understand, I said that she owed me nothing. I told her that I felt the reason I had received the remarkable recovery I had made from my injury was all because of her. I told her that I think the reason God had brought me back to life, was to take care of her, to follow her for the next few years and make sure she didn't have a recurrence of her cancer. I saw her on Thursday after I returned from the NAF meeting in Montreal. On that visit I told her that she had saved my life. And she beamed and hugged me as though she believed it.

Who's to say it's not true?


William F Harrison, MD, FACOG

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