Intra-abdominal carcinomatosis after prophylactic oophorectomy in women of hereditary breast ovarian cancer syndrome kindreds associated with BRCA1 and BRCA2 mutations

Prophylactic oophorectomy in women at increased cancer risk

PURPOSE OF REVIEW

Bilateral prophylactic salpingo-oophorectomy is widely used for cancer risk reduction in women with BRCA1/2 mutations. Bilateral prophylactic salpingo-oophorectomy significantly reduces breast cancer risk by approximately 50% and ovarian cancer risk by 80-95% but may be accompanied by menopausal symptoms, impaired quality of life and accelerated bone loss. Therefore, decisions regarding the timing of bilateral prophylactic salpingo-oophorectomy and the use of post-bilateral prophylactic salpingo-oophorectomy hormone replacement therapy must be carefully considered.

RECENT FINDINGS

Over the last year, studies have further examined issues related to quality of life associated with bilateral prophylactic salpingo-oophorectomy and have demonstrated that hormone replacement therapy following bilateral prophylactic salpingo-oophorectomy in unaffected women does not negate the breast cancer risk reduction that bilateral prophylactic salpingo-oophorectomy provides. Studies have provided additional information on the residual risk of cancer following bilateral prophylactic salpingo-oophorectomy, have demonstrated its benefit in Lynch syndrome and have suggested a short-term mortality benefit following bilateral prophylactic salpingo-oophorectomy in BRCA1/2 mutation carriers.

SUMMARY

We review the recent studies regarding bilateral prophylactic salpingo-oophorectomy and their implications for the clinical management of women who are at increased cancer risk.

[Hereditary breast and ovarian cancer: primary and secondary prevention for BRCA1 and BRCA2 mutation carriers]

Ten years after the identification of the breast and ovarian cancer predisposition genes, BRCA1 and BRCA2, an emerging literature has explored the efficacy of strategies for primary as well as secondary prevention of breast and ovarian cancer in BRCA1 and BRCA2 mutations carriers. The integration of magnetic resonance imaging for breast cancer screening in BRCA carriers has achieved a higher sensibility of the screening, and an early detection of breast cancer. However, we don't have yet enough level of evidence that magnetic resonance imaging could reduce mortality in BRCA carriers. Because of the limitations of screening for ovarian cancer, bilateral prophylactic salpingo-oophorectomy has been established as one of the most effective strategies to prevent ovarian cancer in BRCA1 and BRCA2 mutation carriers. This strategy also has a favorable effect on the reduction of risk of breast cancer if is performed before the age of 50. The management of this patients must be individualized and multidisciplinary.

Molecular biomarkers for cancer detection in blood and bodily fluids

Cancer is a major and increasing public health problem worldwide. Traditionally, the diagnosis and staging of cancer, as well as the evaluation of response to therapy have been primarily based on morphology, with relatively few cancer biomarkers currently in use. Conventional biomarker studies have been focused on single genes or discrete pathways, but this approach has had limited success because of the complex and heterogeneous nature of many cancers. The completion of the human genome project and the development of new technologies have greatly facilitated the identification of biomarkers for assessment of cancer risk, early detection of primary cancers, monitoring cancer treatment, and detection of recurrence. This article reviews the various approaches used for development of such markers and describes markers of potential clinical interest in major types of cancer. Finally, we discuss the reasons why so few cancer biomarkers are currently available for clinical use.

Clinical management of BRCA1 and BRCA2 mutation carriers

The cancer susceptibility genes BRCA1 and BRCA2 appear to be responsible for virtually all hereditary breast ovarian families, and a smaller subset of hereditary site-specific breast cancer families. Fortunately, effective strategies have been developed to reduce the risk for the development of breast and ovarian cancer in women with BRCA1/2 mutations, making genetic testing for these mutations an important part of the management at women with a strong family history of these diseases. Here, we review the current evidence for risk reduction strategies and outline future research directions.

Congenital heart disease and pregnancy

Patients with congenital heart disease who wish to become pregnant offer a challenge to obstetricians, cardiologists and anesthetists. Although no large randomized trials exist to support the management of this emerging population, small prospective and retrospective studies provide valuable data on the likely success of pregnancy and the risks involved. Recently, there is emerging consensus on the management of this specialized group of patients, and this article aims to provide the practitioner with an overview of patient needs and the issues to be addressed. All patients with congenital heart disease wishing to consider pregnancy should be referred for specialist assessment prior to conception. Maternal risk, fetal risk and recurrence risk in the fetus should all be addressed. Most women with congenital heart disease can undergo pregnancy without significant risk. However, for some women the risk of maternal death is high, including those with: severe aortic stenosis, impaired left ventricular function, pulmonary hypertension and Marfan syndrome with dilated aortic root. All patients should be offered a detailed 20-week fetal cardiac scan and, in certain cases, prepregnancy genetic counseling. Most patients can deliver vaginally, with cesarean section reserved for obstetric indications or patients in whom straining at delivery could be potentially fatal (i.e., those with Marfan syndrome, aortic aneurysm, severe fixed left heart obstruction, or the acutely unwell mother). Antibiotic prophylaxis should be given routinely in labor to all patients in whom dental prophylaxis is indicated.

Predictors of occult neoplasia in women undergoing risk-reducing salpingo-oophorectomy

OBJECTIVE

The purpose of this study was to define the rate of neoplasia in prophylactic surgical specimens with the use of a careful surgical and pathologic protocol in a prospective study of high-risk women who were undergoing risk-reducing salpingo-oophorectomy. Outcomes of interest were neoplasia that was identified in surgical specimens and clinical outcomes of women who were undergoing risk-reducing salpingo-oophorectomy. We hypothesized that older age and having a BRCA1 mutation would be predictors for tubal or ovarian neoplasia and that a careful surgical and pathologic protocol would lead to a low rate of subsequent primary peritoneal cancer.

STUDY DESIGN

A prospective tissue and research database enrolled patients who underwent risk-reducing salpingo-oophorectomy for prevention of ovarian cancer. Clinical and pathologic data were extracted for those patients after the initiation of a defined surgical and pathologic protocol in 1999.

RESULTS

One hundred thirteen women met the high-risk criteria; 40 of the women (45%) who were tested had a deleterious mutation in BRCA1, and 22 women (25%) had a mutation in BRCA2. Seven women had ovarian or tubal neoplasia (6.2%). One woman had occult endometrial cancer. Age > or =45 years and having a BRCA1 or BRCA2 mutation were significant predictors of occult neoplasia. Two patients with neoplasia that was identified at risk-reducing salpingo-oophorectomy experienced recurrence. Three patients with BRCA1 mutations have subsequent new diagnoses of breast cancer. No patients had primary peritoneal cancer after risk-reducing salpingo-oophorectomy.

CONCLUSION

Age > or =45 years and mutations in BRCA1 or BRCA2 predict occult neoplasia in women who undergo risk-reducing salpingo-oophorectomy. A thorough pathologic and surgical protocol at the time of risk-reducing salpingo-oophorectomy may improve the risk of subsequent primary peritoneal cancer.