/ /

  • linkedin
  • Increase Font
  • Sharebar

    Prophylactic salpingectomy: The future of ovarian cancer prevention?

     

    The BRCA-positive population

    Studies performed in the late 1990s showed that early serous carcinomas of the fallopian tube were present in 2%–10% of BRCA-positive patients undergoing prophylactic BSO.2 Kindelberger et al studied 55 tubes and ovaries from BRCA-positive women and noted that 41 (75%) had tubal (n = 5), peritoneal
    (n = 6), or ovarian (n = 30) carcinomas and that foci of TIC were identified in 5 of 5, 4 of 6, and 20 of 30 of these cases, respectively.9 Ninety-three percent of TICs involved the fimbriae.

    Many BRCA-positive women are offered prophylactic bilateral mastectomies and BSOs after their diagnosis is confirmed. These women often wait until after their childbearing years to perform the BSO, in hopes that they will have children and also maximize their time before entering surgical menopause. Yet a significant proportion of these women already have TICs present in their tubes at the time of their prophylactic surgeries, and others have already have progression to ovarian cancer.

     At the 24th Annual Ella T. Grasso Ovarian Cancer Symposium, the suggestion of bilateral salpingectomy with ovarian retention (BSOR), and eventual oophorectomy for risk reduction at or near the average age of menopause, were discussed.10,11

    Leblanc et al coined the term “radical fimbriectomy” for BSOR and performed this procedure on a group of 14 BRCA-positive patients.3 Both tubes and the fimbrio-ovarian junction were laparoscopically removed, as well as one-quarter of the ovary itself, while preserving the ovary’s blood supply in the infundibulopelvic ligament. The team then waited 15 minutes to confirm that blood supply to the ovary remained patent despite the partial oophorectomy.

    In their pathology results, they found that 2 of 14 women had p53 signatures in the fimbriated end of the fallopian tube, and 1 of those 2 also had a similar mutation in the small portion of the ovary that was adjacent to that fimbriated end.3 The patients who had this procedure done would require close monitoring in the future, given their BRCA history.

    Although this study was small, the work of this team is novel, and presents a good basis upon which to build future studies.

    The BRCA-negative population

    A change in approach for ovarian cancer prophylaxis for the BRCA-negative population is one that should be both feasible and easy to implement but requires rigorous testing. In this population, tubal involvement is found in at least 15% of ovarian cancers during pathology assessment.2

    Studies have shown that patients who have received a simple bilateral tubal ligation (BTL) or hysterectomy, using the current widely used techniques, have had decreased rates of development of ovarian cancer.12-14

    Some may question whether a total hysterectomy and BSO must be performed to ensure that all segments of the fallopian tube have been removed. In 2010, Cass et al found that a full BSO does not leave behind residual tube, nor does the cornual portion of the tube develop cancer, but some practitioners and patients may continue to worry despite these data.15

    By using the procedure outlined by Leblanc’s team, it should be easy and possible to offer women requesting a bilateral tubal ligation a BSOR, and to incorporate a salpingectomy at the time of hysterectomy for benign disease.

    Future directions

    The question of the best mode for ovarian cancer screening and prevention is a fundamental one that researchers across the world have been working to answer. Research has clearly shown that the fimbriated end of the fallopian tube contains p53 signatures, or precursor lesions that lead to the development of ovarian cancers in both BRCA-positive and BRCA-negative populations.

    This leads to a window of opportunity for gynecologists: offering patients a salpingectomy during benign gynecologic surgeries as one of the few options available for ovarian cancer prophylaxis for the general population. It likewise provides BRCA-positive patients with the possibility of having bilateral salpingectomies with ovarian retention until they approach menopause.

    Questions remain

    Research has not yet determined an exact percentage of BRCA carriers in whom TICs lead to cancer. We do not know the pathways by which tubal ligations reduce the risk of cancer. It is not known at what age it would be best to perform salpingectomy, nor how long may be best to wait before performing subsequent oophorectomy in order to maximize risk reduction.

    On a related note: Would ovarian retention, along with the retention of the estrogen and progesterone the ovary produces, also increase the risk of earlier breast cancers in these women, if they have not yet had prophylactic mastectomies?

    In our opinion, introduction of bilateral salpingectomies at the time of tubal ligation or hysterectomy for benign gynecologic patients is a reasonable option. In the absence of good screening tests, this procedure is the only form of prophylaxis for a cancer that is difficult to detect and often lethal when found.

    Physicians should at least present patients with this option during presterilization and prehysterectomy counseling. Prospective studies will need to be conducted to see if this procedure actually does decrease the risk of ovarian cancer development over time.

     

    References

    1. Lee, Y, Miron A, Drapkin R, et al. A candidate precursor to serous carcinoma that originates in the distal fallopian tube. J Pathol. 2007;211:26–35.

    2. Crum CP, Drapkin R, Kindelberger D, Medeiros F, Miron A, Lee Y. Lessons from BRCA: The tubal fimbria emerges as an origin for pelvic serous cancer. Clin Med Res. 2007;5:35–44.

    3. Leblanc E, Narducci F, Farre I, et al. Radical Fimbriectomy: A reasonable temporary risk-reducing surgery for selected women with a germ line mutation of BRCA 1 or 2 genes? Rationale and preliminary development. Gynecol Oncol. 2011:121:472–476.

    4. Salvador S, Gilks B, Kobel M, Huntsman D, Rosen B, Miller D. The Fallopian Tube: Primary site of most pelvic high-grade serous carcinomas. Int J Gynecol Cancer. 2009;19:58–64.

    5. Fathalla MF. Incessant ovulation—a factor in ovarian neoplasia? Lancet. 1971;2:163.

    6. Cramer DW, Welch WR. Determinants of ovarian cancer risk. II. Inferences regarding pathogenesis. J Natl Cancer Inst. 1983;71(4):717–721.

    7. Drapkin R, Karst AM. The new face of ovarian cancer modeling: Better prospects for detection and treatment. F1000 Med Reports. 2011;3:22.

    8. Crum CP, Drapkin R, Miron A, et al. The distal fallopian tube: A new model of pelvic serous carcinogenesis. Curr Opin Obstet Gynecol. 2007;19:3–9.

    9. Kindelberger DW, Lee Y, Miron A, et al. Intraepithelial carcinoma of the fimbria and pelvic serious carcinoma: Evidence for a causal relationship. Am J Surg Pathol. 2007;31:161–169.

    10. Dietl J, Wischhusen J, Hausler SFM. The post-reproductive Fallopian tube: better removed? Hum Reprod. 2011;46(11):2918–2924.

    11. Greene MH, Mai PL, Schwartz PE. Does bilateral salpingectomy with ovarian retention warrant consideration as a temporary bridge to risk-reducing bilateral oophorectomy in BRCA1/2 mutation carriers? Am J Obstet Gynecol. 2011;204:19.e1-6.

    12. Green A, Purdie D, Bain C, et al. Tubal sterilization, hysterectomy and decreased risk of ovarian cancer. Survey of women’s Health Study group. Int J Cancer. 1997;71(6):948–951.

    13. Hankinson SE, Hunter DJ, Colditz GA, et al. Tubal ligation, hysterectomy, and risk of ovarian cancer. A prospective study. JAMA. 1993;270(23):2813–2818.

    14. Berek JS, Chalas E, Edelson M, et al. Prophylactic and risk-reducing bilateral salpingo-oophorectomy. Obstet Gynecol. 2010;116(3):733–743.

    15. Cass I, Walts A, Karlan BY. Does risk-reducing bilateral salpingo-oophorectomy leave behind residual tube? Gynecol Oncol. 2010;117:27–31.

     

    2 Comments

    You must be signed in to leave a comment. Registering is fast and free!

    All comments must follow the ModernMedicine Network community rules and terms of use, and will be moderated. ModernMedicine reserves the right to use the comments we receive, in whole or in part,in any medium. See also the Terms of Use, Privacy Policy and Community FAQ.

    • Anonymous
      Двухстороннее сальпингэктомия во времия гистерэктомии является профилактикой рака яичника и хронического салпингита.
    • Anonymous
      Двухстороннее сальпингэктомия во времия гистерэктомии является профилактикой рака яичника и хронического салпингита.

    Poll

    Latest Tweets Follow