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    Surgical options for reducing risk in BRCA mutation carriers


    Optimal RRSO procedure

    The discovery that the Fallopian tube may be the site of origin of many high-grade serous cancers has altered recommendations for RRSO to include removal of as much of the Fallopian tube as possible (Table 1). The tubes should be ligated at the uterine cornua with cautery to optimize destruction of any residual mucosal tubal epithelium.19   

    Although most cancers have been reported in the distal tube, cases of Fallopian tube cancers or STIC involving isolated mid- or contiguous mid- and distal segments of the Fallopian tube have been reported.20 Pelvic washings should be obtained prior to any dissection. Thorough visual assessment of the peritoneal surfaces, upper abdomen, omentum, and diaphragms is necessary.

    Equally important is complete accession by the pathologist of the entire adnexa, using a rigorous protocol. Pathology researchers have advocated a specialized protocol, Sectioning and Extensively Examining the FIMbria (SEE-FIM), which has optimized the detection of occult cancers in the distal Fallopian tube.18 Studies have shown that thorough pathologic evaluation of the adnexa will enhance detection of occult tubal and ovarian cancers from 2.5% to 17%.11,18

    Patients must be counseled extensively regarding the possibility of finding an occult cancer at the time of RRSO. Studies of BRCA mutation carriers show that 4%–8% of women will have an occult cancer at the time of prophylactic surgery, which may necessitate additional surgery for complete staging, and in some cases, adjuvant chemotherapy.10-15 When RRSO is performed laparoscopically, a bag should be used for retrieval to optimize specimen integrity and to minimize the risk of spill or subsequent post-site metastases in the event that there is an occult malignancy.  

    Powell et al have shown that thorough inspection of the peritoneal surfaces with biopsies of any suspicious nodules and pelvic washings are all valuable procedures in detecting ovarian or Fallopian tube cancers. They found no benefit, however, for random peritoneal biopsies or omental sampling because those procedures never resulted in a diagnosis of cancer in the absence of adnexal cancer and can lead to additional surgical morbidity.11

    Frozen section analysis of any suspicious nodules or masses within the adnexa is appropriate to guide intraoperative surgical planning if further surgical staging is feasible. The utility of routine frozen section assessment of normal-appearing adnexa has been questioned because it may compromise the integrity of the tissue for final pathology evaluation.21

    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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