Clear cell carcinoma of the fimbria of the fallopian tube in a BRCA1 carrier undergoing prophylactic surgery

Rare non-serous fallopian tube cancers: institutional experience and literature review

INTRODUCTION

We reviewed 63 reports from the literature on rare non-serous tumors of the fallopian tubes and carried out a comparative analysis of clinical manifestations and diagnostic methods. We also report our observations from patients with these tumors.

MATERIALS AND METHODS

Of 157 patients with primary fallopian tube cancer (FTC) treated in our regional oncological hospital between 1970 and 2020, there were nine (6%) cases of rare non-serous cancers, including one case each of choriocarcinoma, carcinosarcoma, and neuroendocrine tumor, and two cases each of non-keratinizing squamous cell carcinoma, mucinous adenocarcinoma, and clear cell adenocarcinoma.

RESULTS

For carcinosarcoma and squamous cell, clear cell, and transitional cell carcinomas, clinical history, patient age, and clinical manifestations were similar to the main group of FTCs. Choriocarcinoma differed significantly from other cancers of the fallopian tubes in terms of patient age and clinical course. Mucinous adenocarcinoma, mesothelioma, and borderline tumors, with rare exceptions, were almost always asymptomatic and were found only incidentally during surgery. Choriocarcinoma and carcinosarcoma had an aggressive course, while squamous cell, transitional cell, clear cell, and mucinous carcinomas were less aggressive. Since most rare non-serous tumors have a similar disease course to typical FTCs and there is a lack of appropriate treatment protocols for rare tumors, treatment options developed for ovarian tumors and FTC are justified for these tumors.

CONCLUSION

Rare non-serous malignant fallopian tube tumors are very similar to serous and endometrioid FTC in terms of clinical manifestations and diagnosis.

The fallopian tube: from back stage to center stage

The recognition that a significant fraction of what historically has been classified as ovarian cancer is, in fact, a malignancy that arises in the fallopian tube mucosa comprises a paradigm shift in our understanding of these neoplasms. New etiologic and management opportunities have been created by this insight, both for women at increased genetic risk of ovarian cancer by virtue of being BRCA1/2 mutation carriers and, perhaps, for women in the general population as well.

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.

Intercepting pelvic cancer in the distal fallopian tube: theories and realities

The pathogenesis of high-grade serous carcinoma of the ovary has come into sharper focus as closer attention has been paid to the earlier phases of this disease. The study of patients with BRCA mutation has been of particular value, in as much as the examination of prophylactic salpingo-oophorectomies will reveal an early cancer in approximately 5% of individuals. Recently studies have shown that about 80% of these early carcinomas originate in the distal fallopian tube. This review summarizes the recent data supporting the distal fallopian tube as an important site for serous carcinogenesis, stressing both the presence of a novel precursor (the p53 signature) and the application of this model to all women irrespective of BRCA status. The challenges and unmet needs unmasked by this paradigm shift in ovarian cancer research are discussed.

Incidental carcinomas in prophylactic specimens in BRCA1 and BRCA2 germ-line mutation carriers, with emphasis on fallopian tube lesions: report of 6 cases and review of the literature

The identification of germ-line mutations in 2 genes (BRCA1 and BRCA2) responsible for the majority of hereditary ovarian cancers has led an increasing number of women carriers of these mutations to undergo prophylactic oophorectomy (PO) to reduce their risk of subsequent ovarian carcinoma. A large number of unexpected, clinically occult neoplasms are thus being discovered. Up to December 2004, the Medical Genetics Service of the National Cancer Institute in Milan, Italy, has tested 756 probands from breast and/or ovarian cancer families for BRCA1 and BRCA2 germ-line mutations. Molecular screening of family members led to the identification of 344 female carriers of BRCA1 (239) or BRCA2 (105) germ-line mutations. Of the 186 potentially eligible women (37 of whom had tested positive for BRCA1 and 13 for BRCA2 mutation), 50 (26.8%) chose to undergo PO. Six clinically occult primary gynecologic malignancies (2 stage IIIC serous carcinomas of the ovary, 3 in situ serous carcinomas of the fallopian tube, and 1 stage IIB invasive serous carcinoma of the fallopian tube) and 1 occult ovarian metastasis from breast carcinoma were identified in the PO specimens of 7 women (all BRCA1 mutated). Four of the patients with occult primary gynecologic cancers are alive without disease 129, 87, 38, and 7 months after PO, respectively. One of the 2 patients with primary ovarian cancer and the single patient with tubal invasive carcinoma are alive with recurrent disease 83 and 20 months after PO, respectively. In addition, one of the patients whose PO specimen did not show any malignancy presented with stage IIIC tubal carcinoma 77 months after PO. The relatively high number of tubal neoplasms found at PO in this group of patients underlines the linkage between mutation and the risk of developing tubal cancer, and stresses the need to include removal of the entire tubes at the time of PO and of thoroughly evaluating the specimens at the microscopic level. The upstaging of all 3 invasive carcinomas after staging surgery, and the late recurrence and persistence of 2 of them despite treatment indicate that small size of the tumors should not preclude therapy.

Role of prophylactic hysterectomy in patients at high risk for hereditary cancers

BACKGROUND

Current surgical recommendations for ovarian cancer prophylaxis in women at high risk of developing ovarian cancer include bilateral salpingo-oophorectomy (risk-reducing salpingo-oophorectomy (RRSO)). The role of hysterectomy is unclear. We sought to determine outcomes following prophylactic surgery in high-risk women.

METHODS

We surveyed unaffected members of the Gilda Radner Familial Ovarian Cancer Registry who had undergone oophorectomy from 1981 to 2002. Data were collected and analyzed for statistical significance by the Fisher's Exact Test.

RESULTS

Two hundred eighty women were surveyed, and 154 (55%) responded; 97% were Caucasian and 14% reported being Jewish. The median age of the respondents was 51 years (range 29-79); median age at oophorectomy was 41 years (range 15-68). Fifty-eight patients (38%) reported a laparoscopic procedure. One hundred five patients (68%) had a simultaneous hysterectomy, and 4 (3%) had a prior hysterectomy. Forty-four patients (29%) underwent BSO only. Of these 44 patients, 40 (91%) did not require a subsequent hysterectomy. Of the 4 who did, 2 were for leiomyomas, one for menorrhagia and the other was unknown. While not statistically significant, of the 3 patients who developed a subsequent gynecologic malignancy, all had undergone a hysterectomy. There was a statistically significant difference in whether or not the uterus was removed as part of the procedure by time period, whereby women treated prior to 1990 had a higher likelihood of having a hysterectomy (P = 0.03).

CONCLUSION

The women in our study did not require hysterectomy for prevention of malignancy. We conclude that one should screen for benign gynecological indications for hysterectomy when planning a prophylactic BSO for prevention of ovarian cancer. Other potential risk factors for endometrial cancer, including the role of UPSC in HBOC, remain to be elucidated.

Immunohistochemical detection of glucose transporter GLUT1 in benign and malignant fallopian tube epithelia, with comparison to ovarian carcinomas

CONTEXT

Enhanced expression of GLUT1, a facilitative glucose transporter found on red blood cells, blood-brain barrier, and perineurium, has been described in a large spectrum of epithelial malignancies.

OBJECTIVE

We present an immunohistochemical survey of GLUT1 expression in benign and malignant fallopian tube epithelia, and compare serous carcinomas of the fallopian tube and ovary.

DESIGN

One hundred two routinely fixed and processed archival specimens (36 benign fallopian tubes, 29 primary tubal adenocarcinomas, and 37 primary ovarian adenocarcinomas) were immunostained with rabbit anti-GLUT1 and developed with streptavidin-biotin/diaminobenzidine. Only distinct membrane staining was scored positively (1+ to 3+).

RESULTS

Benign tubes (n = 36) were either negatively stained (58.3%) or displayed rare weak staining (0.5+ to 1+, rarely 2+; 41.7%); of the latter, 4 specimens showed chronic salpingitis, and 6 showed hyperplasia (epithelial tufting and stratification). A case of florid hyperplasia with atypia in a BRCA1-positive patient was GLUT1 negative. Twenty-three (79.3%) of 29 tubal carcinomas were positively stained. Staining ranged from focal/scattered foci (n = 15) to multifocal/extensive (n = 8). Of the 6 nonstaining tubal carcinomas, 3 were undifferentiated. Nineteen tubal carcinoma sections showed residual benign epithelium, which was consistently nonstaining. Very frequently, GLUT1 staining intensified in cells furthest from stroma/ stromal capillaries and/or bordering necrotic zones. On average, GLUT1 staining in primary fallopian tube cancers was less extensive than in primary ovarian adenocarcinomas.

CONCLUSIONS

GLUT1 immunostaining of fallopian tube adenocarcinomas was substantially stronger and more extensive than staining of benign tubal epithelium, consistent with previously described findings in carcinomas versus benign tissues from many primary sites. The frequent localization of GLUT1 positivity to regions most distal from stroma/stromal capillaries is consistent with known activation of GLUT1 expression by hypoxia-sensing cellular pathways and may constitute a survival advantage under hypoxic conditions present in malignancy. The difference in extent of GLUT1 staining between primary tubal and primary ovarian serous adenocarcinomas is discussed.

Additional salpingectomy after previous prophylactic oophorectomy in high-risk women: sense or nonsense?

OBJECTIVES

Since BRCA1/2 germ line mutation carriers are also at a higher risk of developing fallopian tube carcinoma, resection of the fallopian tubes is currently included at the time of risk reducing surgery. In this study, we comment on the need of additional bilateral prophylactic salpingectomy (BPS) following previous bilateral prophylactic oophorectomy (BPO) in women at high risk of ovarian cancer.

METHODS

Retrospectively, the medical files of 42 high-risk women, who had undergone BPO only, were reviewed.

RESULTS

In our center, risk-reducing surgery consisted of BPO only for 42 women. Twenty-seven women received an informative letter in which counseling for additional BPS was offered. In total, 15 women opted for additional BPS. Surgery was performed with a mean interval of 65 months (range 6-101) in 10 BRCA1 carriers, one BRCA2 carrier, one BRCA1 and 2 carrier, and three women with non-informative test results. The procedure was readily done by laparoscopy in 13 women and two needed a laparotomy. No post-operative complications had occurred. Histopathological examination revealed no malignancy.

CONCLUSIONS

We believe that additional risk reduction of cancer necessitates BPS in BRCA1/2 carriers after previous BPO. BPS after previous BPO was easily performed. Today, physicians should include resection of the fallopian tube at prophylactic surgery in high-risk women and should consider additional BPS in women who have undergone BPO only.

Intraperitoneal serous adenocarcinoma: a critical appraisal of three hypotheses on its cause

OBJECTIVE

Serous ovarian, Fallopian tube, and peritoneal adenocarcinomas are remarkably similar, both in their morphology, as well as in their clinical behavior. Despite extensive clinical and fundamental research, controversy still exists on the origin of serous female adnexal tumors. Difficulties in identification of site of origin at late stage the of disease at detection, when ovary, Fallopian tube, and the abdominal cavity are usually all involved, in addition to their macroscopic and microscopic resemblance, are major causes of this debate. In 3 hypotheses, 3 possible tissues of origin are proposed: the ovarian surface epithelium, the Fallopian tube epithelium, and the secondary Mullerian system.

STUDY DESIGN

We searched for all peer-reviewed articles and reviews that examined "serous ovarian carcinoma," "Fallopian tube carcinoma," "Mullerian system," "ovarian surface epithelium," "tubal epithelium," and "peritoneal." We included only articles that could give information on the origin of serous carcinomas. Additional articles were added by examining references of overview articles in relevant fields.

RESULTS

Discussed are the experimental data underlying these hypotheses.

CONCLUSION

An attempt is made to integrate the 3 hypotheses into a comprehensive model of serous intraperitoneal adenocarcinogenesis. It can be concluded that the Fallopian tubes play a major role in the development of female serous cancer.

Atypical epithelial proliferation in fallopian tubes in prophylactic salpingo-oophorectomy specimens from BRCA1 and BRCA2 germline mutation carriers

Although growing numbers of tubal carcinomas in carriers of BRCA1 and BRCA2 germline mutations have been reported, very little is known about the nature and frequency of their possible precursor lesions. The aim of this study is to investigate the occurrence of atypical proliferative tubal lesions in grossly normal fallopian tubes from 26 women with BRCA1 and BRCA2 germline mutations who underwent prophylactic salpingo-oophorectomy and whose ovaries were histologically negative for carcinoma. Fallopian tubes from 49 women who had undergone hysterectomy with salpingo-oophorectomy for uterine leiomyoma served as controls. In the 22 BRCA1-mutated women, there were two in situ carcinomas and two atypical hyperplasias of the tubal epithelium. The tubes of the BRCA2-mutated women and of the 49 control women did not show any atypical proliferation. The frequency of proliferative lesions of the tubal epithelium, including in situ carcinoma, appears to be increased in BRCA1 mutation carriers. Removal and thorough examination of the fallopian tubes at the time of surgical prophylaxis for ovarian cancer is therefore recommended.

BRCA1 mutations in South African breast and/or ovarian cancer families: evidence of a novel founder mutation in Afrikaner families

Germ-line mutations within BRCA1 are responsible for different proportions of inherited susceptibility to breast/ovarian cancer, and the spectrum of mutations within this gene is often unique to certain populations. At this time, there have been no reports regarding the role of BRCA1 in South African breast and/or ovarian cancer families. We therefore screened 90 South African breast/ovarian cancer families for BRCA1 mutations by means of PCR-based mutation detection assays. Eighteen families (20%) were identified with BRCA1 disease-causing mutations. Four Ashkenazi Jewish families were identified with the 185delAG mutation, whereas 2 Afrikaner and 1 Ashkenazi Jewish family were found to harbor the 5382insC mutation. Five of the families (5.56%), all of whom are Afrikaners, were found to carry the novel E881X mutation. Genotype analyses show that these patients share a common ancestor. Genealogic studies have identified 3 possible founding couples for this mutation, all of whom arrived in the Cape from France in the late 1600s. Of the remaining mutations detected, 3 have not been reported previously and include the S451X, 1493delC (detected twice) and 4957insC mutations.

Clinical outcome of prophylactic oophorectomy in BRCA1/BRCA2 mutation carriers and events during follow-up

A retrospective study was performed to assess the histopathologic findings in high-risk women undergoing bilateral prophylactic (salpingo)-oophorectomy. The medical files of BRCA1 or BRCA2 mutation carriers and members of a hereditary breast/ovarian cancer (HBOC) family, who had undergone prophylactic surgery, were reviewed. In all, 38 women underwent a bilateral oophorectomy (26 BRCA1, three BRCA2 and nine HBOC, respectively). A total of 90 women underwent bilateral salpingo-oophorectomy (58 BRCA1, six BRCA2, one BRCA1 and 2, 25 HBOC, respectively). At the time of salpingo-oophorectomy, five of 58 BRCA1 carriers (8.6%) were diagnosed with an occult carcinoma: two fallopian tube carcinomas, two ovarian carcinomas and one case was defined as a fallopian tube/ovarian carcinoma. No occult carcinomas were found in the other groups. Of the 38 patients, who underwent a bilateral oophorectomy (mean follow-up 45 months), three of 26 BRCA1 mutation carriers (3.4 in 100 women-years) developed peritoneal papillary serous carcinoma (PPSC) during follow-up. So far, no PPSC have occurred in the 90 women, who underwent a salpingo-oophorectomy (mean follow-up 12 months), including 58 BRCA1 carriers (0 in 60 in women-years). These results contribute to the thesis that BRCA1 germline mutation carriers are not only at risk for ovarian cancer, but also for fallopian tube carcinoma and peritoneal papillary serous carcinoma. Our data suggest that PPSC risk among BRCA2 carriers is lower than among BRCA1 carriers.

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.

Challenges in the early diagnosis and staging of Fallopian-tube carcinomas associated with BRCA mutations

The histopathologic diagnosis of fallopian-tube carcinoma has been traditionally made at an advanced stage. More recently, predictive genetic BRCA testing is leading to the recognition in prophylactic oophorectomy specimens of clinically occult tubal carcinomas that are frequently in situ or small early-stage invasive carcinomas. These early lesions present a challenge in diagnosis and staging because the available criteria for the histopathologic diagnosis and staging of tubal carcinoma were derived from the clinicopathologic experience derived from the usual high-stage tubal carcinomas. The detection of early-stage tubal carcinomas requires that all tubal tissue be submitted for histologic examination. The diagnostic criteria for tubal in situ carcinoma have been defined, although the natural history of this lesion is unclear. Similarly defined criteria for a diagnosis of tubal dysplasia are lacking. Any early, invasive tubal carcinoma should be staged using a refined staging system suitable for early stage and fimbrial carcinomas. The adoption of these methods should increase our knowledge of early-stage tubal carcinoma and may add to our understanding of the development of ovarian-epithelial neoplasia.

DNA array-based method for detection of large rearrangements in the BRCA1 gene

In most families with multiple cases of breast and ovarian cancer, the cancer appears to be associated with germline alterations in BRCA1 or BRCA2. However, somatic mutations in BRCA1 and BRCA2 in sporadic breast and ovarian tumors are rare, even though loss of heterozygosity in BRCA1 and BRCA2 loci in these tumors appears frequently. This may be attributed to mutation detection assays that detect alterations in the coding regions and splice site junctions, but that miss large gene rearrangements. To look specifically for mutations such as large gene rearrangements that span several kilobases (kb) of genomic DNA, we have developed a fluorescence DNA microarray assay. This assay rapidly and simultaneously screens for such rearrangements along the entire gene. In our screen of 15 malignant ovarian tumors, we found one sample with a novel 3-kb deletion encompassing exon 17 of BRCA1 that leads to a frameshift mutation. This deletion was not detected in the corresponding constitutive DNA. Our results indicate that, whereas somatic mutations in BRCA1 appear to be rare in ovarian cancers, the search for large gene rearrangements should be included in any BRCA1 mutational analysis. Furthermore, the method described in this report has the potential to screen clinical tumor samples for genomic rearrangements simultaneously in a large number of cancer-associated genes.

Current management of fallopian tube carcinoma

The management of fallopian tube carcinoma is similar to that of ovarian carcinoma. Surgery should consist of bilateral salpingo-oophorectomy, total abdominal hysterectomy, comprehensive surgical staging also including a systematic pelvic and para-aortic lymphadenectomy, and aggressive debulking in patients with advanced tumour. Patients with apparently early stage low-risk fallopian tube carcinoma, not submitted to complete surgical staging, as well as those with early stage high-risk disease should receive adjuvant single-agent carboplatin. Patients with advanced disease should undergo paclitaxel- plus carboplatin-based chemotherapy. Second-line treatment for persistent/recurrent disease should be mainly based on the platinum-free interval, whereas secondary cytoreduction should be considered only for highly selected patients with localized, late relapse.

Unexpected gynecologic neoplasms in patients with proven or suspected BRCA-1 or -2 mutations: implications for gross examination, cytology, and clinical follow-up

Identification of inheritable mutations associated with the development of malignancy has led to prophylactic surgeries to remove tissues at risk. We report seven unrelated patients with family histories of breast and/or ovarian cancer, five of whom underwent prophylactic salpingo-oophorectomy with hysterectomy. Four had proven BRCA-1 or -2 mutations. Malignant cells were found unexpectedly in the peritoneal washings of two patients, leading to the discovery of early-stage fallopian tube carcinoma. After changing the sampling technique at our institution, two more cases of unexpected fallopian tube carcinoma in situ were discovered. Another patient had a significant family history and underwent hysterectomy for uterine fibroids, leading to the discovery of fallopian tube carcinoma. Another patient with BRCA-1 mutation had unexpected widespread primary peritoneal papillary serous adenocarcinoma. The final patient had a borderline malignant clear cell adenofibroma. These cases underscore the importance of peritoneal cytology and thorough sampling in the management of patients undergoing hysterectomy with a family history of breast/ovarian cancer and/or known BRCA-1/BRCA-2 mutations. As prophylactic surgeries are becoming more common secondary to advances in molecular diagnostics, pathologists need to be aware that surgical specimens from these patients may require more rigorous examination to uncover early neoplastic changes.

Dysplastic changes in prophylactically removed Fallopian tubes of women predisposed to developing ovarian cancer

The aim of this study was to investigate the occurrence of (pre)neoplastic lesions in overtly normal Fallopian tubes from women predisposed to developing ovarian carcinoma. The presence of (pre)neoplastic lesions was scored in histological specimens from 12 women with a genetically determined predisposition for ovarian cancer, of whom seven tested positive for a germline BRCA1 mutation. A control group included 13 women. Immunohistochemistry was used to determine the expression of p21, p27, p53, cyclin A, cyclin D1, bcl-2, Ki67, HER-2/neu, and the oestrogen and progesterone receptors. Loss of heterozygosity (LOH) analysis on the BRCA1 locus was also assessed on dysplastic tissue by PCR studies. Of the 12 women with a predisposition for ovarian cancer, six showed dysplasia, including one case of severe dysplasia. Five harboured hyperplastic lesions and in one woman no histological aberrations were found in the Fallopian tube. No hyperplastic, dysplastic or neoplastic lesions were detected in the Fallopian tubes of control subjects. In the cases studied, morphologically normal tubal epithelium contained a higher proportion of Ki67-expressing cells (p=0.005) and lower fractions of cells expressing p21 (p<0.0001) and p27 (p=0.006) than in the control group. Even higher fractions of proliferating cells were found in dysplastic areas (p=0.07) and accumulation of p53 was observed in the severely dysplastic lesion. Expression patterns of other proteins studied, including the hormone receptors, were similar in cases and controls. One subject, a germline BRCA1 mutation carrier, showed loss of the wild-type BRCA1 allele in the severely dysplastic lesion. In conclusion, the Fallopian tubes of women predisposed to developing ovarian cancer frequently harbour dysplastic changes, accompanied by changes in cell-cycle and apoptosis-related proteins, indicating an increased risk of developing tubal cancer.

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.

A genetic epidemiological study of carcinoma of the fallopian tube

OBJECTIVE

The goal of this work was to evaluate the importance of genetic factors in the etiology of fallopian tube cancer.

METHODS

All pathologically confirmed cases of fallopian tube cancer diagnosed in Ontario from 1990 to 1998 were identified from the records of the Ontario Cancer Registry. Living patients were approached to provide information about their family history and to provide a blood sample for testing for mutations in BRCA1 and BRCA2.

RESULTS

A modest increase in the risk of ovarian cancer (relative risk (RR) = 2.2; 95% confidence interval (CI) = 0.4, 6.3) and of early-onset breast cancer (RR = 2.4; 95% CI = 0.6, 6.1) was observed in the first-degree relatives of the fallopian cancer cases. Five of the forty-four cases were positive for a mutation in BRCA1 (11%) and two were positive for a BRCA2 mutation (5%). Five of eighteen women diagnosed at or before age 55 were positive (28%). Two of the seven mutation carriers had a strong family history of breast and ovarian cancer, and three carriers had a modest family history. Three of the forty-four cases were Jewish, and of these, two carried a founder mutation characteristic of this population.

CONCLUSIONS

Fallopian tube carcinoma should be considered to be a clinical component of the hereditary breast-ovarian cancer syndrome, and may be associated with BRCA1 and BRCA2 mutations. Genetic evaluation should be offered to women who present with fallopian tube carcinoma. It is important to consider the risk of fallopian tube carcinoma when prophylactic oophorectomy is performed in high-risk women.