Hudson's landmark contribution to ovarian cancer surgery.

Abstract

In this journal in 1968 Christopher Hudson, a Resident Assistant Physician Accoucheur at St Bartholomew's Hospital, London, described a pioneering approach to surgical resection of ovarian cancer (OC) from the pelvis (Hudson J Obstet Gynaecol Br Cwlth 1968;75:1155–60). Hudson's ‘radical oophorectomy’ was intended to remove an ‘ovarian tumour fixed in the pelvis intact with the whole of the peritoneum from surrounding structures still attached’. It was applicable to cancers confined to the pelvis or with early omental involvement, but not in the presence of more widespread disease, including bulky para-aortic lymph nodes. The principle steps included entry into the presacral space to mobilise the rectum, and dissection of the bladder from the upper vagina, allowing the vagina to be transected to gain entry to the rectovaginal space. The pelvic tumour with peritoneum of the entire pouch of Douglas and bladder peritoneum, if necessary, could then be removed as a ‘false’ capsule (Figure 1). Subsequently, Hudson reported on 25 women (23 with cancer) undergoing the procedure between 1965 and 1972 (Hudson Gynecol Oncol 1973;1:370–8). Non-gynaecological organs including bladder, small bowel, rectosigmoid colon, ureter and appendix might require surgical procedures. When possible the rectum was preserved but three rectosigmoid re-anastomoses were performed and one sigmoid colostomy. Complications included two rectovaginal fistulae and one death from haemorrhage 4 weeks after surgery. Twelve women received postoperative chemotherapy and seven received radiotherapy, with 16 alive at the time of the report. Although in 1934 Meigs in Boston wrote that ‘removal of as much tumour as possible’ was beneficial for survival (Meigs Tumors of the Female Pelvic Organs, New York: Macmillan Company, 1934), it took several decades to establish that maximal surgery to no visible disease was the most important prognostic factor for survival in OC. The principles of Hudson's procedure form the foundation for complete resection of OC from the pelvis today. Metastatic disease in the upper abdomen became the biggest barrier to resection for gynaecological oncologists, but with the development of techniques of upper abdominal surgery, including peritonectomies described by Paul Sugarbaker (Ann Surg 1995;221:29–42), together with improvements in perioperative management, this has now been overcome. Hudson wrote ‘only time will tell whether this can influence the salvage in this disease’. He would be gratified to know that clearance of the pelvis as part of removing all visible cancer has a major role to play in survival of women with advanced OC today. Rightly, there is increasing concern that survival for women with OC in the UK lags behind many other countries, a fact stressed by the Chief Medical Officer of England in her most recent Annual Report, as she recommended that training of gynaecological oncologists include the necessary surgery to reduce mortality (Department of Health 2015). Christopher Hudson went on to become Professor of Obstetrics and Gynaecology at the University of Sydney, Australia. In 1980 he delivered the Victor Bonney Lecture at the Royal College of Obstetricians and Gynaecologists. The College can be proud of Hudson, and women with OC can be thankful for his contribution to the field. Thanks go to the pioneers of ovarian cancer treatment, past and present, including Professor Robert Bristow who previously highlighted the contribution of Hudson (Bristow et al. J Am Coll Surg 2003;197:565–74). None declared. Completed disclosure of interests form available to view online as supporting information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.