Laparoscopic management of women with a family history of ovarian cancer

Pathologic findings at risk-reducing salpingo-oophorectomy: primary results from Gynecologic Oncology Group Trial GOG-0199

PURPOSE

Risk-reducing salpingo-oophorectomy (RRSO) lowers mortality from ovarian/tubal and breast cancers among BRCA1/2 mutation carriers. Uncertainties persist regarding potential benefits of RRSO among high-risk noncarriers, optimal surgical age, and anatomic origin of clinically occult cancers detected at surgery. To address these topics, we analyzed surgical treatment arm results from Gynecologic Oncology Group Protocol-0199 (GOG-0199), the National Ovarian Cancer Prevention and Early Detection Study.

PARTICIPANTS AND METHODS

This analysis included asymptomatic high-risk women age ≥ 30 years who elected RRSO at enrollment. Women provided risk factor data and underwent preoperative cancer antigen 125 (CA-125) serum testing and transvaginal ultrasound (TVU). RRSO specimens were processed according to a standardized tissue processing protocol and underwent central pathology panel review. Research-based BRCA1/2 mutation testing was performed when a participant's mutation status was unknown at enrollment. Relationships between participant characteristics and diagnostic findings were assessed using univariable statistics and multivariable logistic regression.

RESULTS

Invasive or intraepithelial ovarian/tubal/peritoneal neoplasms were detected in 25 (2.6%) of 966 RRSOs (BRCA1 mutation carriers, 4.6%; BRCA2 carriers, 3.5%; and noncarriers, 0.5%; P < .001). In multivariable models, positive BRCA1/2 mutation status (P = .0056), postmenopausal status (P = .0023), and abnormal CA-125 levels and/or TVU examinations (P < .001) were associated with detection of clinically occult neoplasms at RRSO. For 387 women with negative BRCA1/2 mutation testing and normal CA-125 levels, findings at RRSO were benign.

CONCLUSION

Clinically occult cancer was detected among 2.6% of high-risk women undergoing RRSO. BRCA1/2 mutation, postmenopausal status, and abnormal preoperative CA-125 and/or TVU were associated with cancer detection at RRSO. These data can inform management decisions among women at high risk of ovarian/tubal cancer.

Perioperative outcomes using LigaSure™ compared to conventional bipolar instruments in laparoscopic salpingo-oophorectomy: a randomized controlled trial

BACKGROUND

The aim of this study was to compare the effects of LigaSure™ versus conventional bipolar techniques on operating time and blood loss during laparoscopic salpingo-oophorectomy in a randomized controlled trial.

METHODS

In three teaching hospitals, 100 women undergoing a laparoscopic salpingo-oophorectomy were randomized for LigaSure or conventional bipolar instruments. Primary outcome was operating time (from initial skin incision to removal of the specimen). Secondary outcome measures were total operating time (from initial skin incision to skin closure), time to dissect the ovarian and infundibulopelvic ligaments, intraoperative blood loss, and subjective judgment of the instrument used.

RESULTS

There were no differences in operating time and total operating time using LigaSure versus conventional bipolar instruments: 41.0 vs. 39.2 min (p = 0.78; 95 % CI = -10.9 to 14.5) and 54.6 vs. 58.6 min (p = 0.46; 95 % CI = -14.8 to 6.8), respectively. The mean blood loss using LigaSure versus conventional bipolar instruments was 38 vs. 33 mL (p = 0.73; 95 % CI = -22.7 to 32.2). Various subjective efficacy and instrument handling parameters of the two instruments varied among participating centers.

CONCLUSION

There were no significant differences in operating time and blood loss with the use of LigaSure compared to conventional bipolar instruments during laparoscopic salpingo-oophorectomy, even after correction for potential confounders.

Hereditary ovarian carcinoma: heterogeneity, molecular genetics, pathology, and management

Hereditary ovarian cancer accounts for at least 5% of the estimated 22,000 new cases of this disease during 2009. During this same time, over 15,000 will die from malignancy ascribed to ovarian origin. The bulk of these hereditary cases fits the hereditary breast-ovarian cancer syndrome, while virtually all of the remainder will be consonant with the Lynch syndrome, disorders which are autosomal dominantly inherited. Advances in molecular genetics have led to the identification of BRCA1 and BRCA2 gene mutations which predispose to the hereditary breast-ovarian cancer syndrome, and mutations in mismatch repair genes, the most common of which are MSH2 and MLH1, which predispose to Lynch syndrome. These discoveries enable relatively certain diagnosis, limited only by their variable penetrance, so that identification of mutation carriers through a comprehensive cancer family history might be possible. This paper reviews the subject of hereditary ovarian cancer, with particular attention to its molecular genetic basis, its pathology, and its phenotypic/genotypic heterogeneity.

Uptake and timing of bilateral prophylactic salpingo-oophorectomy among BRCA1 and BRCA2 mutation carriers

PURPOSE

To evaluate prophylactic salpingo-oophorectomy uptake and timing among BRCA1/2 mutation carriers in a cancer risk assessment program.

METHODS

Clinical records of female BRCA1/2 mutation carriers who received cancer genetic counseling between 1996 and 2003 were reviewed to determine the completion and the timing of prophylactic salpingo-oophorectomy. Logistic regression models evaluated associations between subject characteristics and surgery. Survival analysis methods were used to estimate the distribution of time to surgery.

RESULTS

Among 88 women, 70% underwent prophylactic salpingo-oophorectomy. Prophylactic salpingo-oophorectomy was associated with older age, white race, having children, and a family history of ovarian cancer. Many women waited more than 12 months to undergo surgery and some delayed by several years. Younger age and not having children were associated with delays to surgery.

CONCLUSION

Prophylactic salpingo-ooporectomy is an acceptable risk reduction measure for many BRCA1/2 mutation carriers. Some women make this decision many years after genetic testing. Continued discussion of the risks and benefits of risk reduction options may facilitate the uptake of recommended risk reduction interventions among BRCA mutation carriers.

TIMP-3 and Phosphatidylinositol 3-kinase Genes Were Found to Be Related to the Progression of Colon Cancer in a Comparison of Pneumoperitoneum and Laparotomy in a Murine Model

PURPOSE

Laparoscopic surgery has been performed on a wide variety of patients because the clinical benefits of a perioperative recovery result in a better short-time outcome than an open colectomy. However, no basic and molecular-biological examinations have yet to elucidate the mechanisms of such an improved outcome.

METHOD

To examine the gene expression profiles of mice inoculated with colon cancer cells, the tumors, the livers and the lungs of mice were analyzed using a microarray.

RESULTS

In the laparotomy and control group, we observed a significant enhancement of tumor growth in comparison to the laparoscopic group. When analyzing the genes that became more remarkably upregulated or downregulated in the laparoscopic group in comparison to those in the laparotomy or control group, we focused our attention on the TIMP-3 gene and PI3-kinase gene expression. The downregulation of TIMP-3 and the upregulation of PI3-kinase were observed. To confirm the downstream signal of the PI3-kinase gene, we examined the expression of Skp-2 gene and p27 protein. We observed the expression level of the Skp-2 to be upregulated, while the expression level of p27 protein decreased.

CONCLUSIONS

The surgical procedures of a laparotomy induced a downregulation of TIMP-3 and an upregulation of PI3-kinase, which together resulted in an enhancement of cancer cell growth thus leading to an increased invasion activity and cell cycle in comparison to treatment using a laparoscopic approach.

Total laparoscopic hysterectomy for oncological indications with outcomes stratified by age

OBJECTIVE

We hypothesize that there is no difference in surgical outcomes of patients undergoing total laparoscopic hysterectomy (TLH) for various oncological indications when stratified by age categories.

METHODS

Data were analyzed by ANOVA and chi-square test with significance of P < 0.05, stratified by age (young: <50 years, middle: 50-64, senior age 65+).

RESULTS

There were 208 patients, age 26-86 years: 85 young, 82 middle, and 41 senior women. Preoperative diagnoses included 13 cases of cervical dysplasia, 10 cervical or upper vaginal carcinoma, 60 endometrial neoplasias, 22 prophylaxes of familial ovarian carcinoma, 95 with complex pelvic mass, and 8 with early ovarian carcinoma. Mean body mass index (BMI) was 27.2 kg/m(2) for all groups. Parity increased with age (1.0, 1.3, and 2.0; P = 0.001). Surgical duration was longer for young than middle or senior (168, 147, and 140 min, P = 0.0095). All groups had a similar mean blood loss (133 cc, ns) and similar mean length of hospital stay (1.8 days, ns). Overall complication rate was 7.7% with no variance by age: one seroma, one hematoma, one diverticulitis, one incisional hernia, one vaginal nonhealing, one adhesive bowel obstruction, and five urologic complications (two bladder, three ureteral; four treated with catheter or stent, one reimplant. Reoperation was required in 2.8%.

CONCLUSIONS

Null hypothesis accepted: TLH appears feasible and safe for oncological practice indications throughout the life span. This pilot data can facilitate guidelines for a randomized controlled trial of TLH with TAH and laparoscopic assisted vaginal hysterectomy (LAVH).

Laparoscopic training and practice in gynecologic oncology among Society of Gynecologic Oncologists members and fellows-in-training

OBJECTIVE

To determine the proportion of Society of Gynecologic Oncologists (SGO) members performing laparoscopic procedures and to determine SGO members' and fellows' opinions regarding indications for and the adequacy of training in laparoscopy.

METHODS

Surveys were mailed to SGO members and fellows-in-training in December 2002. Anonymous responses were collected by mail or through a Web site. The survey was mailed twice and was estimated to take 5 min to complete. The data were analyzed using frequency distributions and nonparametric tests.

RESULTS

Three hundred thirty-six SGO members (45%) and fifty-seven fellows (49%) responded. Among SGO members, 272 (84%) currently performed laparoscopic surgeries. Reasons cited for performing laparoscopy were decreased length of hospital stay (74%), improved patient quality of life (57%), patient preference (48%), improved cosmesis (46%), and better visualization (18%). Among those who did not perform laparoscopy, 50% cited increased operating time as their main reason. When asked to indicate the laparoscopic procedure most commonly performed in their practice, 69% reported diagnosis of an adnexal mass; 11%, prophylactic bilateral salpingo-oophorectomies; and 10%, laparoscopically assisted vaginal hysterectomy and lymph node staging for uterine cancer. Only 3% of SGO respondents performed more than 50% of their procedures laparoscopically, and all respondents reported converting from laparoscopy to laparotomy less than 25% of the time. Most respondents had limited laparoscopic training during their fellowships: 39% received none, and 46% received limited (less than five procedures per month) training. Nevertheless, 78% of SGO respondents rated their laparoscopic skills as either very good or good. Among fellows, only 25% believed they were receiving very good or good laparoscopic training. Eighty percent of SGO respondents believe that at least six procedures per month were necessary for adequate training, yet only 33% of fellows performed that many procedures.

CONCLUSIONS

Most SGO respondents used laparoscopy for selective indications, and most developed their laparoscopic skills after their fellowship training. SGO respondents believed laparoscopic instruction is an important part of training, but most fellows perceived their laparoscopic training as inadequate.

Selective incorporation of total laparoscopic hysterectomy for adnexal pathology and body mass index

OBJECTIVES

We studied patients undergoing adnexectomy with total laparoscopic hysterectomy (TLH) for ovarian pathology, over a 6-year period.

METHODS

Chart abstraction, analyzed by ANOVA, Fisher's Exact Test with significance at P < 0.05, stratifying by body mass index (BMI, kg/m(2): ideal < 25; overweight 25-29.9; obese 30+).

RESULTS

Of 354 patients undergoing TLH, 90 cases had adnexal pathology: 69 complex masses, 16 BRCA1/2 mutations, 5 unstaged ovarian carcinomas; 48 having ideal BMI, 26 overweight, and 16 obese. Mean age (51 years) and parity (1.2 children) were similar between BMI groups. Thirty-four percent were nulliparous. All 90 underwent TLH, adnexectomy, washings; with 14 appendectomies, 5 lymphadenectomies, 3 node samplings, 6 omentectomies, 8 ureterolyses, and 1 Burch. Mean surgery duration (156 min), blood loss (152cc), and hospital stay (1.9 days) were similar across BMI groups. Mean nodal yield from each lymphadenectomy was 14, and 2.6 from sampling. Mean size of pelvic masses was 8 cm (range 3-19 cm). There were seven cases of ovarian carcinoma: 2 Stage IA, 1 IB, 2 IC, 1 IIC, 1 IIIB; 1 recurrent breast cancer, 16 adenofibromas, 15 endometriomas, 10 dermoids, and 41 serous/mucinous cystadenomas. Mean complication rate was 6.6% (ns): 1 seroma, 1 hematoma, 1 obstructive adhesions, and 3 urological injuries. All urological injuries were within the first third of patients.

CONCLUSIONS

TLH appears feasible for women with adnexal pathology regardless of BMI, in an oncological practice. This pilot data can facilitate guidelines for a randomized controlled trial of TLH with TAH and LAVH, and help surgeons avoid our early complications.

Peritoneal carcinoma in women with genetic susceptibility: implications for Jewish populations

Women from families with multiple cases of breast and ovarian cancer, specifically those who carry cancer-associated mutations of BRCA1 or BRCA2 are at increased life-time risk for peritoneal carcinoma, even after previous surgery to remove the ovaries, fallopian tubes and uterus. Hereditary breast-ovarian cancer (HBOC) syndrome and the associated BRCA1 and BRCA2 mutations are particularly prevalent in women of Jewish lineage, and specific BRCA1 and BRCA2 germline mutations have been linked with peritoneal carcinoma and HBOC syndrome in Jewish populations, especially those of Ashkenazi descent. This review presents the currently available data and looks forward toward further and better understanding of peritoneal carcinoma in women with inherited susceptibility. Over 90% of peritoneal cancer in patients from HBOC syndrome kindreds and associated with BRCA1 and BRCA2 mutations are serous carcinomas, which is equivalent with the proportion of ovarian cancers that are serous carcinomas in similar patients. The best indications are that while many peritoneal carcinomas in genetically susceptible women may arise directly from malignant transformation of the peritoneum, others might represent metastases from primary ovarian or fallopian tube carcinomas. Although the incidence of borderline ovarian tumors may not be increased in HBOC syndrome kindreds and those who carry cancer-associated BRCA1 and BRCA2 mutations, these individuals could be susceptible to malignant transformation of borderline lesions of the ovaries and peritoneum. Moreover, recent reports raise the question of possibly increased risk in Jewish carriers of germline BRCA1 mutations for uterine papillary serous carcinoma, which could be the source of metastasis to the peritoneum in some cases. The penetrance of cancer-associated BRCA1 mutations for ovarian cancer is estimated to be 11%-54%, and for BRCA2 mutations the penetrance for ovarian cancer is 11%-23%. So far, available screening methods appear to be insufficient for early detection of many ovarian cancers. Prophylactic oophorectomy has been found to reduce the risk for ovarian cancer in women from HBOC kindreds and those who carry cancer-associated BRCA1 and BRCA2 mutations, leaving a residual risk for peritoneal carcinomatosis of well less than 5%. Therefore, surgical removal of the ovaries, fallopian tubes and uterus, after child-bearing has been completed and by early in the fifth decade of life, are appropriate prophylactic procedures in women whose genetic susceptibility puts them at increased risk for cancers of mullerian tract origin, including ovarian and fallopian tube carcinomas and possibly serous carcinoma of the uterus. Hysterectomy, as well as salpingo-oophorectomy, removes the gynecologic organs targeted for malignant transformation in genetically susceptible women and simplifies decisions regarding hormone replacement therapy and chemical prophylaxis and treatment of breast cancer. Unless a transabdominal operative approach is otherwise indicated, laparoscopic-assisted transvaginal techniques are well suited for intra-abdominal exploration, cytology, biopsies and prophylactic salpingo-oophorectomy and hysterectomy in women with hereditary susceptibility to gynecologic cancer.

Prophylactic oophorectomy

Because of the lack of effective alternatives and the simplicity of the procedure, prophylactic oophorectomy is viewed as the best available tool for reducing the individual risk of ovarian cancer. The genetics of hereditary ovarian cancer are described in this chapter and a careful risk-versus-benefit assessment is provided with respect to two populations of patients that appear suitable candidates for this procedure. These include patients with increased risk of developing ovarian cancer due to hereditary genetic predisposition, in which the lifetime risk of ovarian cancer may be as high as 16-65%, depending on the penetrance of the germ-line mutation. Additionally, routine salpingo-oophorectomy in patients over 40 years undergoing scheduled gynaecological surgery or colorectal surgery might reduce the overall incidence of ovarian cancer by as much as 5% in the general population.

Hereditary cancers in obstetrics and gynecology

The lack of information regarding the effectiveness of screening strategies, chemoprevention, or surgical prophylaxis, and the uncertainty regarding penetrance and risk modification has led many experts to recommend that genetic testing for BRCA1, BRCA2, and other cancer susceptibility genes be performed only in a research setting. Patients, however, are likely to increasingly request access to genetic testing and deserve up-to-date counseling about recent advancements in our knowledge. The primary care physician should concentrate on identifying women likely to be at high-risk for cancer for further referral, allowing the cancer genetics specialist to track down medical records, clarify the pedigree, discuss genetic testing, and provide access to the appropriate cancer specialist to discuss risk reduction.

Current status of prophylactic surgery for hereditary breast and gynecologic cancers

Given the limitations regarding the impact of screening and the uncertainties concerning chemoprevention for women with significant genetic susceptibilities to breast, endometrial and ovarian cancers, recent research and publications on prophylactic surgery for cancer prevention and improved long-term survival for women at hereditary risk have increasing importance.

Familial ovarian cancer and early ovarian cancer: biologic, pathologic, and clinical features

Women with ovarian cancer have poor overall survival rates, largely because the disease is so often diagnosed at an advanced, less curable stage. Because women with early ovarian cancer experience good survival rates, there is great interest in the study and detection of early disease. Familial ovarian cancer has been relevant to the study of early ovarian cancer in two different ways. First, women from ovarian cancer families often undergo prophylactic oophorectomy to prevent development of this disease. These ovaries have been studied for pathologic or molecular features that might represent early preinvasive disease. Second, screening tests to detect presymptomatic ovarian cancer have selectively targeted this population because of the increased positive predictive value of these tests in this population. A review of the clinical, pathologic, epidemiologic, and molecular biologic aspects of familial ovarian cancer provides a background to facilitate understanding these issues.