Peritoneal Lesions in Tubo-Ovarian Serous Neoplasms, Metastases vs Independent Primaries

A REJECTED PAPER BY THE INT JOURNAL OF GYN CANCER, 2023

I have decided to discuss this rejected paper in my website because many of my previous peer reviewed published papers did not have any impact in patient care. The main issues of these studies were: the significance of separating histologic types of high-grade ovarian cancer; the origin of serous tumors in the ovary; how to avoid vaginal metastases in endometrial cancer; histology of the ovary, what is normal vs abnormal; and mucinous tumors developing in abnormal ovaries. The publication of a paper implies spending a significant amount of time to comply with all the rules of the journals, but when a new concept is proposed, then there is an additional main obstacle, which is teaching the reviewers, and this could be an impossible task when someone has a blind believe in authority. Judging by some rejected, and some accepted papers, I believe that writing ideas in a website might have a similar value and effect. A correct thought will always find its way in the universe.

Part 1- Why questioning if a high stage ovarian serous tumor is metastatic or if the multiple lesions represent independent primaries?

Ovarian serous tumors are epithelial neoplasms but do not behave as most epithelial neoplasms. In general, in epithelial neoplasms the size of the primary tumor correlates with the stage of the disease; and the grade of the tumor, and the stage of the disease correlates with the overall survival. Also, most epithelial tumors metastasize first to lymph nodes, or spread to regional tissues. In ovarian serous tumors we do not see similar features, and we will discuss this in detail in subsequent parts. Some of the unusual features of ovarian serous neoplasms have been explained by the way these tumors disseminate, transcelomic. The most accepted theory explaining the transcelomic metastases is the circulation of tumor cells in ascitic fluid in the peritoneal cavity due to obstruction of lymphatic vessels by tumor cells. It is very difficult to accept this theory because of the following observations: 1-Tumor cells are never seen creating a complete obstruction of lymphatic vessels. 2-Ascites is not seen in all cases. 3-This theory applies only to serous tumors. Endometrioid carcinoma, clear cell carcinoma, malignant germ cell tumors, are usually low stage neoplasms. 4-Due to gravity, most metastases should be in the floor of the pelvis or in the posterior peritoneum. Independent primaries would explain the presence of implants and metastases in different areas of the peritoneum.

Reviewers’ comments: None of the three reviewers made any comments regarding the differences of ovarian serous tumors with most epithelial neoplasms, or the issues with the theory of the circulation of cells in the peritoneum. Both issues were discussed in the paper because they are very important to understand multicentricity, but the reviewers either did not read these parts or decided to ignore both.