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    Surgical options for reducing risk in BRCA mutation carriers


    Outcome of occult neoplasia at RRSO

    Pooling results from the largest studies, more than 150 occult cancers of the Fallopian tube or ovary diagnosed at the time of RRSO have been described. More than 70% of these occult cancers were tubal primaries. Occult cancers were more common in BRCA1 mutation carriers and in women older than 50.32,33 In the event that occult cancer is found in the final cytology or pathology report, patients should be referred to a gynecologic oncologist for a thorough discussion of optimal management and the role of additional surgery.

    Recent data from 2 large series of women with unexpected adnexal neoplasia highlight some of the challenges and controversies in the management of occult cancers.15,34 Among these asymptomatic women with occult invasive cancers despite normal preoperative screening, 40%–60% of women had stage II or greater disease and recurrence rates were 17%–47% even after treatment with adjuvant chemotherapy.

    Women with STIC had a better prognosis, although recurrence/subsequent primary peritoneal carcinoma has been reported in several cases 3–6 years after RRSO. The role of comprehensive staging and adjuvant chemotherapy is less established in women with STIC, although they appear to be beneficial in women with STIC and positive cytology.35

    Cancer surveillance post-RRSO

    The risk of a subsequent primary peritoneal cancer following RRSO is 1%–4%.6,12 Current practice guidelines for optimal cancer surveillance in BRCA mutation carriers following RRSO are vague and based largely upon expert opinion.

    The Society of Gynecologic Oncology and the National Cancer Care Network endorse pelvic exams for ongoing monitoring of menopausal symptoms, consideration of short-term HRT, and related medical issues. (Semi)-annual CA 125 monitoring is recommended; however, the evidence is insufficient to demonstrate that surveillance facilitates earlier detection of subsequent primary peritoneal cancer or provides a survival benefit, given its rare occurrence.36,37


    Ilana Cass, MD
    Dr. Cass is an Assistant Professor of Obstetrics and Gynecology, UCLA/Cedars-Sinai Medical Center, Los Angeles, Calif.


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