Risk-reducing salpingectomy as preventative strategy for pelvic serous cancer

Cancer surveillance for transgender and gender diverse patients with Lynch syndrome: a practice resource of the Collaborative Group of the Americas on Inherited Gastrointestinal Cancer

Transgender and gender diverse (TGD) populations with hereditary cancer syndromes face unique obstacles to identifying and obtaining appropriate cancer surveillance and risk-reducing procedures. There is a lack of care provider knowledge about TGD health management. Lynch syndrome (LS) is one of the most common hereditary cancer syndromes, affecting an estimated 1 in 279 individuals. There are no clinical guidelines specific for TGD individuals with LS, highlighting a need to improve the quality of care for this population. There is an urgent need for cancer surveillance recommendations for TGD patients. This commentary provides recommendations for cancer surveillance, risk-reducing strategies, and genetic counseling considerations for TGD patients with LS.

The evolving role of the Women's Health Specialist in cancer prevention and survivorship

IMPORTANCE AND OBJECTIVE

This review provides a framework for primary care physicians, internists, family doctors, NP's, PA's, and oncologists caring for women-henceforth referred to as Women's Health Specialists-to identify and screen patients who may be at high risk for inherited cancer syndromes; an intervention referred to as previvorship care. For women who undergo risk-reducing oophorectomy, survivorship care is critical to optimizing quality of life thereafter. In this paper, we review management of the unique survivorship needs and management options for women at risk for or with a cancer diagnosis, highlighting the importance of interdisciplinary care.

METHODS

To review the available previvorship and survivorship management strategies, a Pub Med search was performed using keywords "survivorship," "genetics," "cancer," "menopause," "hormone therapy," "screening" in addition to review of guidelines, position statements and expert, and committee opinions from the American College of OBGYN, the American Society of Clinical Oncology, The North American Menopause Society, the National Comprehensive Cancer Network , and the American Society for Reproductive Medicine.

DISCUSSION AND CONCLUSION

Women's Health Specialists are in a unique position to identify and screen women who may be at risk for inherited cancer syndromes as well as provide necessary survivorship management following transition from their oncologists' care.

Uptake and timing of risk-reducing salpingo-oophorectomy among patients with BRCA1 and BRCA2 mutations

BACKGROUND

In women with BRCA mutations, risk-reducing bilateral salpingo-oophorectomy has been shown to decrease gynecologic cancer-specific and overall mortality. The National Comprehensive Cancer Network recommends that patients with BRCA mutations undergo risk-reducing bilateral salpingo-oophorectomy between the ages of 35 and 40 years for BRCA1 mutation carriers and between the ages of 40 and 45 years for BRCA2 mutation carriers or after childbearing is complete. Currently, uptake and timing of risk-reducing bilateral salpingo-oophorectomy and reasons for delays in risk-reducing bilateral salpingo-oophorectomy are not well understood.

OBJECTIVE

We sought to evaluate uptake and timing of risk-reducing bilateral salpingo-oophorectomy among women with BRCA1 and BRCA2 mutations concerning the National Comprehensive Cancer Network guidelines and reasons for delays in risk-reducing bilateral salpingo-oophorectomy.

STUDY DESIGN

In this retrospective chart review, we identified women with BRCA1 and BRCA2 mutations who discussed risk-reducing bilateral salpingo-oophorectomy with a provider between 2012 and 2021. Uptake of risk-reducing bilateral salpingo-oophorectomy was documented, and patients were classified as having timely or delay in risk-reducing bilateral salpingo-oophorectomy based on the National Comprehensive Cancer Network guidelines. For those with delay in risk-reducing bilateral salpingo-oophorectomy, reasons cited for delay were collected. Comparative statistical analyses were performed to evaluate characteristics of those with timely vs delayed risk-reducing bilateral salpingo-oophorectomy. A multivariable logistic regression model was used to evaluate the associations among factors related to timing of risk-reducing bilateral salpingo-oophorectomy.

RESULTS

We identified 638 BRCA1 and BRCA2 mutation carriers seen between 2012 and 2021. Of these patients, 306 (48.0%) had undergone risk-reducing bilateral salpingo-oophorectomy and 332 (52.0%) had not. When evaluating the timing of risk-reducing bilateral salpingo-oophorectomy, 136 (21.3%) underwent timely risk-reducing bilateral salpingo-oophorectomy, 239 (37.5%) had delays in risk-reducing bilateral salpingo-oophorectomy, and 263 (41.2%) had not undergone risk-reducing bilateral salpingo-oophorectomy but were younger than the National Comprehensive Cancer Network age guidelines; therefore, they were neither timely nor delayed. Patients with delay in risk-reducing bilateral salpingo-oophorectomy were significantly older at the time of genetic testing than those with timely risk-reducing bilateral salpingo-oophorectomy (mean, 49.8 vs 36.3 years; P<.001). Of the 306 patients who underwent risk-reducing bilateral salpingo-oophorectomy, those with delayed risk-reducing bilateral salpingo-oophorectomy had a significantly shorter interval between BRCA identification and risk-reducing bilateral salpingo-oophorectomy than those with timely risk-reducing bilateral salpingo-oophorectomy (median, 8.7 vs 17.6 months; P<.001). Patients with delay in risk-reducing bilateral salpingo-oophorectomy were more likely to have a personal history of cancer than those with timely risk-reducing bilateral salpingo-oophorectomy (49.8% vs 37.5%; P=.028). Of the 239 women with delay in risk-reducing bilateral salpingo-oophorectomy, 188 (78.7%) had delayed BRCA mutation identification, 29 (12.1%) had menopausal concerns, 17 (7.1%) had ongoing cancer treatment, 12 (5.0%) had coordination with breast surgery, 20 (8.4%) had miscellaneous reasons, and 19 (7.9%) had no reason documented. In the multivariate model, older age at BRCA diagnosis (odds ratio, 0.73; 95% confidence interval, 0.68-0.78; P<.001) was significantly associated with delayed risk-reducing bilateral salpingo-oophorectomy timing; those with BRCA2 mutation type were 7.54 times as likely to have timely risk-reducing bilateral salpingo-oophorectomy than BRCA1 mutation carriers (odds ratio, 7.54; 95% confidence, 3.70-16.42; P<.001).

CONCLUSION

Nearly 38% of BRCA1 and BRCA2 mutation carriers undergo or have yet to undergo risk-reducing bilateral salpingo-oophorectomy over the recommended National Comprehensive Cancer Network age. The most common reason for the delay in risk-reducing bilateral salpingo-oophorectomy was delayed identification of BRCA mutation, noted in 79% of patients with delayed risk-reducing bilateral salpingo-oophorectomy. Timely genetic testing for eligible patients can increase appropriately timed risk-reducing bilateral salpingo-oophorectomy for the prevention of ovarian cancer and reduction of mortality in BRCA mutation carriers.

Short- and long-term outcomes for single-port risk-reducing salpingo-oophorectomy with and without hysterectomy for women at risk for gynecologic cancer

INTRODUCTION

Risk-reducing salpingo-oophorectomy has been established as one of the most effective strategies in risk reduction for ovarian and breast cancers among women at increased genetic risk. However, there are limited data regarding the single-port laparoscopic platform in the field of risk-reducing surgery. Our objective was to describe outcomes after single-port risk-reducing salpingo-oophorectomy with or without hysterectomy for reduction of ovarian, breast, or endometrial cancer risk.

METHODS

A retrospective, single institution (Canadian Task Force Classification II.2) analysis was performed in women at high genetic or familial risk for ovarian/tubal/primary peritoneal cancer or with personal history of breast cancer who underwent single-port laparoscopic risk-reducing salpingo-oophorectomy with or without hysterectomy between October 2009 and December 2015. Data were collected on patient demographics, surgical procedure and characteristics, intra-operative findings, and post-operative outcomes.

RESULTS

In total, 187 single-port laparoscopic surgeries were performed with a median follow-up of 204 (IQR 25-749) days. BRCA1/2, Lynch syndrome, or Cowden syndrome was diagnosed in 64.0% of patients. Additionally, 32.1% had a personal history of breast cancer, and 3.2% reported strong family history of ovarian and/or breast cancer. Single-port risk-reducing salpingo-oophorectomy with hysterectomy was performed in 53.5% of patients. The rate of adverse outcomes, including conversion to multiport laparoscopy or laparotomy (1.6%), intra-operative injury (1.6%), deep vein thrombosis (0.5%), urinary tract infection (2.7%), and/or incisional cellulitis (4.3%) were low. Three patients (1.6%) were diagnosed with malignancy on final pathology. All three patients were BRCA1-positive and their CA125 values were significantly lower than those without malignancy (p=<0.0001).

CONCLUSIONS

Single-port laparoscopy is a safe option for patients undergoing risk-reducing salpingo-oophorectomy with or without hysterectomy. Standardized pre-operative evaluation criteria are needed to determine absolute risk of incidental malignancy, and the risk of identifying a malignancy should be reiterated to patients during pre-operative counseling.

The effects of salpingectomy on the serum level of anti-Müllerian hormone: A single-blind randomized controlled trial

OBJECTIVES

Concerns exist over the effects of salpingectomy on ovarian function. This study aimed to assess the effects of salpingectomy on the serum level of anti-Müllerian hormone.

MATERIALS AND METHODS

This single-blind randomized controlled trial was conducted in 2017-2018 on 86 candidates for hysterectomy. Participants were randomly allocated to undergo either hysterectomy without salpingectomy (control group) or hysterectomy with salpingectomy (intervention group). Serum anti-Müllerian hormone level was measured both before and three months after surgery. Data were analyzed through the Mann-Whitney U test, the Chi-square test, the analysis of covariance, and the linear regression analysis.

RESULTS

The mean value of Serum anti-Müllerian hormone level did not significantly change in the study groups (P>0.05). After removing the effects of confounders, study groups did not significantly differ from each other respecting the posttest mean value of serum anti-Müllerian hormone level (P=0.868).

CONCLUSION

Salpingectomy does not significantly affect serum anti-Müllerian hormone level and ovarian function.

Ovarian cancer screening in the general population

Background Ovarian carcinoma is a poor prognosis cancer mainly due to its late diagnosis. Its incidence is relatively low but mortality is high. The symptomatology is only slightly specific, which complicates diagnostic management. It would therefore be interesting to be able to establish a diagnosis as early as possible in order to improve the prognosis of patients suffering from ovarian cancer. Materials and methods Currently, the combination of an ultrasound examination with a cancer antigen (CA)-125 assay is the most effective diagnostic technique, but not already admitted as a screening method. Therefore, we realized an exhaustive analysis of the most important studies in the last 15 years, in order to find new approaches in ovarian cancer screening. Results The age for initiating screening and its frequency are issues that are not fully resolved. The false positives and morbidity that result from screening are currently notable limitations. Conclusions The latest data do not support effective screening in the general population.

Hysterectomy with opportunistic salpingectomy versus hysterectomy alone

BACKGROUND

Ovarian cancer has the highest mortality rate of all gynaecological malignancies with an overall five-year survival rate of 30% to 40%. In the past two decades it has become apparent and more commonly accepted that a majority of ovarian cancers originate in the fallopian tube epithelium and not from the ovary itself. This paradigm shift introduced new possibilities for ovarian cancer prevention. Salpingectomy during a hysterectomy for benign gynaecological indications (also known as opportunistic salpingectomy) might reduce the overall incidence of ovarian cancer. Aside from efficacy, safety is of utmost importance, especially due to the preventive nature of opportunistic salpingectomy. Most important are safety in the form of surgical adverse events and postoperative hormonal status. Therefore, we compared the benefits and risks of hysterectomy with opportunistic salpingectomy to hysterectomy without opportunistic salpingectomy.

OBJECTIVES

To assess the effect and safety of hysterectomy with opportunistic salpingectomy versus hysterectomy without salpingectomy for ovarian cancer prevention in women undergoing hysterectomy for benign gynaecological indications; outcomes of interest include the incidence of epithelial ovarian cancer, surgery-related adverse events and postoperative ovarian reserve.

SEARCH METHODS

The Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two clinical trial registers were searched in January 2019 together with reference checking and contact with study authors.

SELECTION CRITERIA

We intended to include both randomised controlled trials (RCTs) and non-RCTs that compared ovarian cancer incidence after hysterectomy with opportunistic salpingectomy to hysterectomy without opportunistic salpingectomy in women undergoing hysterectomy for benign gynaecological indications. For assessment of surgical and hormonal safety, we included RCTs that compared hysterectomy with opportunistic salpingectomy to hysterectomy without opportunistic salpingectomy in women undergoing hysterectomy for benign gynaecological indications.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The primary review outcomes were ovarian cancer incidence, intraoperative and short-term postoperative complication rate and postoperative hormonal status. Secondary outcomes were total surgical time, estimated blood loss, conversion rate to open surgery (applicable only to laparoscopic and vaginal approaches), duration of hospital admission, menopause-related symptoms and quality of life.

MAIN RESULTS

We included seven RCTs (350 women analysed). The evidence was of very low to low quality: the main limitations being a low number of included women and surgery-related adverse events, substantial loss to follow-up and a large variety in outcome measures and timing of measurements.No studies reported ovarian cancer incidence after hysterectomy with opportunistic salpingectomy compared to hysterectomy without opportunistic salpingectomy in women undergoing hysterectomy for benign gynaecological indications. For surgery-related adverse events, there were insufficient data to assess whether there was any difference in both intraoperative (odds ratio (OR) 0.66, 95% confidence interval (CI) 0.11 to 3.94; 5 studies, 286 participants; very low-quality evidence) and short-term postoperative (OR 0.13, 95% CI 0.01 to 2.14; 3 studies, 152 participants; very low-quality evidence) complication rates between hysterectomy with opportunistic salpingectomy and hysterectomy without opportunistic salpingectomy because the number of surgery-related adverse events was very low. For postoperative hormonal status, the results were compatible with no difference, or with a reduction in anti-Müllerian hormone (AMH) that would not be clinically relevant (mean difference (MD) -0.94, 95% CI -1.89 to 0.01; I² = 0%; 5 studies, 283 participants; low-quality evidence). A reduction in AMH would be unfavourable, but due to wide CIs, the postoperative change in AMH can still vary from a substantial decrease to even a slight increase.

AUTHORS' CONCLUSIONS

There were no eligible studies reporting on one of our primary outcomes - the incidence of ovarian cancer specifically after hysterectomy with or without opportunistic salpingectomy. However, outside the scope of this review there is a growing body of evidence for the effectiveness of opportunistic salpingectomy itself during other interventions or as a sterilisation technique, strongly suggesting a protective effect. In our meta-analyses, we found insufficient data to assess whether there was any difference in surgical adverse events, with a very low number of events in women undergoing hysterectomy with and without opportunistic salpingectomy. For postoperative hormonal status we found no evidence of a difference between the groups. The maximum difference in time to menopause, calculated from the lower limit of the 95% CI and the natural average AMH decline, would be approximately 20 months, which we consider to be not clinically relevant. However, the results should be interpreted with caution and even more so in very young women for whom a difference in postoperative hormonal status is potentially more clinically relevant. Therefore, there is a need for research on the long-term effects of opportunistic salpingectomy during hysterectomy, particularly in younger women, as results are currently limited to six months postoperatively. This limit is especially important as AMH, the most frequently used marker for ovarian reserve, recovers over the course of several months following an initial sharp decline after surgery. In light of the available evidence, addition of opportunistic salpingectomy should be discussed with each woman undergoing a hysterectomy for benign indication, with provision of a clear overview of benefits and risks.

Persistence of fimbrial tissue on the ovarian surface after salpingectomy

BACKGROUND

Salpingectomy is recommended as a risk-reducing strategy for epithelial tubo-ovarian cancer. The gold standard procedure is complete tubal excision.

OBJECTIVE

The purpose of this study was to assess the presence of residual fimbrial/tubal tissue on ovarian surfaces after salpingectomy.

STUDY DESIGN

Prospective analysis of patients who underwent salpingo-oophorectomy with or without hysterectomy for benign indications, early cervical cancer, or low-risk endometrial cancer at a UK National Health Service Trust. Salpingectomy with or without hysterectomy was performed initially, followed by oophorectomy within the same operation. Separately retrieved tubes and ovaries were sectioned serially and examined completely histologically. The main outcome measure was histologically identified fimbrial/ tubal tissue on ovarian surface. Chi-square/Fisher's exact tests were used to evaluate categoric variables.

RESULTS

Twenty-five consecutive cases (mean age, 54.8 ± 5.0 years) that comprised 41 adnexae (unilateral, 9; bilateral, 16) were analyzed. Seventeen (68.0%), 5 (20.0%), and 3 (12.0%) procedures were performed by consultant gynecologists, subspecialty/specialist trainees, and consultant gynecologic oncologists, respectively. Twelve of 25 procedures (48.0%) were laparoscopic, and 13 of 25 procedures (52.0%) involved laparotomy. Four of 25 patients (16.0%; 95% confidence interval, 4.5-36.1%) or 4 of 41 adnexae (9.8%; 95% confidence interval, 2.7-23.1%) showed residual microscopic fimbrial tissue on the ovarian surface. Tubes/ovaries were free of adhesions in 23 cases. Two cases had dense adnexal adhesions, but neither had residual fimbrial tissue on the ovary. Residual fimbrial tissue was not associated significantly with surgical route or experience (consultant, 3/20 [15%]; trainee, 1/5 [20%]; P=1.0).

CONCLUSION

Residual fimbrial tissue remains on the ovary after salpingectomy in a significant proportion of cases and could impact the level of risk-reduction that is obtained.

Müllerian intra-abdominal carcinomatosis in hereditary breast ovarian cancer syndrome: implications for risk-reducing surgery

More than 40 years ago Lynch et al. described several multigenerational breast cancer family pedigrees which demonstrated autosomal dominant inheritance of a trait(s) that increased risks for both breast and ovarian cancers. Mutation carriers in at least 90 % of these hereditary breast ovarian cancer (HBOC) syndrome families have been linked to cancer-associated mutations in the genes BRCA1 and BRCA2. This review focuses on the contributions of Lynch, colleagues and collaborators and pertinent literature, toward defining the HBOC syndrome, the cancer risks that the inherited adverse mutations convey, the gynecologic tissues and organs from which the malignancy may arise to disseminate throughout the pelvic and abdominal organs and peritoneum and how this information can be used to reduce the risk and morbidities of intra-abdominal carcinomatosis in effected individuals.

Evaluation of ovarian function after hysterectomy with or without salpingectomy: A feasible study

BACKGROUND

Prophylactic salpingectomy for the prevention of ovarian cancer has been recommended strongly. The aim of this study was to compare ovarian function in patients who undergo hysterectomy for benign reasons with or without bilateral salpingectomy.

MATERIALS AND METHODS

This was a clinical-trial study on patients undergone hysterectomy with/without bilateral salpingectomy in Al-Zahra Hospital, in 2015-2016. Demographic information (age, height, and weight) were recorded. Follicle stimulating hormone (FSH) and luteinizing hormone (LH) were measured in 2-5 days of menstrual cycle before operation. Patients were asked to refer in 6 months for follow-up, including FSH and LH re-measurement and also menopausal status examination. Patients were divided into age groups of 39-45, 46-50, and ≥51 and also groups of body mass index including 18.5-24.9, 25-29.9, and 30-34.9.

RESULTS

A total of 37 patients divided into two groups, including 22 patients undergone hysterectomy without salpingectomy (H) and 15 undergone hysterectomy with bilateral salpingectomy (H-bS). The mean age (standard deviation) of Group H was 47.77 (3.03) and Group H-bS was 48.47 (2.03) (P > 0.05). Furthermore, the mean level of FSH and LH before surgery was not significantly different (P > 0.05). The mean level of FSH and LH changes was not significant between H and H-bS groups (P = 0.17), (P = 0.16).

CONCLUSION

Bilateral salpingectomy during hysterectomy did not increase the risk of ovarian dysfunction after 6 months follow-up.

Risk-Reducing Strategies for Ovarian Cancer in BRCA Mutation Carriers: A Balancing Act

OBJECTIVE

The objective of this study was to review the role of bilateral salpingo-oophorectomy in BRCA mutation (mBRCA) carriers and alternative interventions in risk reduction of ovarian cancer (OC).

MATERIALS AND METHODS

A systematic review using PubMed, MEDLINE, EMBASE, and the Cochrane library was conducted to identify studies of different strategies to prevent OC in mBRCA carriers, including bilateral salpingo-oophorectomy, prophylactic salpingectomy with delayed oophorectomy, intensive surveillance, and chemoprevention.

RESULTS

Risk-reducing bilateral salpingo-oophorectomy is an effective intervention, but its associated morbidity is substantial and seems to curtail uptake rates among the target population. Although there is much interest and a strong theoretical basis for salpingectomy with delayed oophorectomy, data on its clinical application are scarce with regard to screening, the use of an algorithmic protocol has recently shown favorable albeit indefinite results in average-risk postmenopausal women. Its incorporation into studies focused on high-risk women might help solidify a future role for screening as a bridge to surgery. The use of oral contraceptives for chemoprevention is well supported by epidemiologic studies. However, there is a lack of evidence for advocating any of the other agents proposed for this purpose, including nonsteroidal anti-inflammatory drugs, vitamin D, and retinoids.

CONCLUSION

Further studies are needed before salpingectomy with delayed oophorectomy or intensive surveillance can be offered as acceptable, less morbid alternatives to upfront oophorectomy for mBRCA carriers. The Oncologist 2017;22:450-459 IMPLICATIONS FOR PRACTICE: Risk-reducing bilateral salpingo-oophorectomy is currently the most effective method for reducing the risk of ovarian cancer in BRCA mutation (mBRCA) carriers. Unfortunately, it is associated with significant short- and long-term morbidity, stemming from reduced circulating estrogen. In recent years, much research has been devoted to evaluating less morbid alternatives, especially multimodal cancer screening and prophylactic salpingectomy with delayed oophorectomy. This review describes the present state of the art, with the aim of informing the counseling provided to mBRCA carriers on this complicated issue and encouraging additional research to facilitate the incorporation of such alternatives into routine practice.

Risk-reducing salpingectomy: Let us be opportunistic

Because there is no screening test for ovarian cancer, effective prevention strategies may be the best way to reduce the mortality of this most lethal gynecologic malignancy. Increasing evidence supports the hypothesis that the fallopian tube is the site of origin for the vast majority of high-grade serous carcinomas. Our growing understanding of the pathogenesis of this disease offers a rare opportunity to explore new preventive measures, such as bilateral salpingectomy, which may provide great benefit without compromising ovarian function. If the tubal paradigm is accurate, then the impact of bilateral salpingectomy could extend to BRCA1 and BRCA2 mutation carriers, high-risk noncarriers, and average-risk women. The authors present a review of the literature on the role of risk-reducing salpingectomy in all women and in high-risk groups, with a focus on morbidity, ovarian function, potential clinical applicability, and epidemiological considerations. Cancer 2017;123:1714-1720. © 2017 American Cancer Society.

Bilateral salpingectomy can reduce the risk of ovarian cancer in the general population: A meta-analysis

BACKGROUND

The results of recent studies have suggested that high-grade serous ovarian cancer predominantly arises within the fallopian tubes. The reduction of ovarian cancer (OC) risk in women with a history of bilateral salpingectomy (BS) has been reported. We performed a meta-analysis to determine the impact of BS in preventing OC in the general population.

METHODS

We searched the PubMed, MEDLINE, and EMBASE databases and CENTRAL in the Cochrane Library for all English-language articles published up to January 2015, using the key words 'ovarian cancer' and 'bilateral salpingectomy.' Odds ratios (ORs) and their 95% confidence intervals (95% CIs) were calculated by standard meta-analysis techniques.

RESULTS

Of the 77 studies retrieved, three were included in this meta-analysis, including one cohort study and two population-based case-control studies with 3509 patients who underwent BS and 5,655,702 controls who did not undergo salpingectomy. Over the combined study period, 29 of the 3509 BS patients developed OC compared with 44,006 of the 5,655,702 without salpingectomy. The meta-analysis results based on the fixed effects model revealed a significant decrease in the risk of OC occurrence in the patients who underwent BS relative to the controls (OR=0.51, 95% CI 0.35-0.75, I(2)=0%). This pattern was also observed in subgroup analysis for the study type.

CONCLUSIONS

Our results suggest that removal of the fallopian tubes is an effective measure to reduce OC risk in the general population. Therefore, prophylactic bilateral salpingectomy should be considered for women who require hysterectomy with benign indications or sterilisation procedures.

The Origin of Epithelial Neoplasms of the Ovary: An Alternative View

Several theories have been proposed to explain the origin of epithelial neoplasms of the ovary. However, most of them did not receive serious consideration until recently when it has been proposed that most ovarian neoplasms arise from the fallopian tube. In this review, we mention the different theories, we discuss in detail the fallopian tube theory, and the reasons why this theory is probably inaccurate. We are also proposing a new theory, the fere ex nihilo, based on the observation of numerous cases, old and new concept, and experimental works with animals. We believe that, most probably, ovarian epithelial neoplasms are related to hormones and the identification of these hormones will allow us not only to diagnose and treat these lethal neoplasms, but also to prevent them.

Opportunistic salpingectomy for ovarian cancer prevention

Recently accumulated evidence has strongly indicated that the fallopian tube is the site of origin for the majority of high-grade serous ovarian or peritoneal carcinomas. As a result, recommendations have been made to change surgical practice in women at general population risk for ovarian cancer and perform bilateral salpingectomy at the time of hysterectomy without oophorectomy and in lieu of tubal ligation, a practice that has been termed opportunistic salpingectomy (OS). Despite suggestions that bilateral salpingectomy may be used as an interim procedure in women with BRCA1/2 mutations, enabling them to delay oophorectomy, there is insufficient evidence to support this practice as a safe alternative and risk-reducing bilateral salpingo-oophorectomy remains the recommended standard of care for high-risk women. While evidence on uptake of OS is sparse, it points toward increasing practice of OS during hysterectomy. The practice of OS for sterilization purposes, although expanding, appears to be less common. Operative and perioperative complications as measured by administered blood transfusions, hospital length of stay and readmissions were not increased with the addition of OS either at time of hysterectomy or for sterilization. Additional operating room time was 16 and 10 min for OS with hysterectomy and OS for sterilization, respectively. Short-term studies of the consequences of OS on ovarian function indicate no difference between women undergoing hysterectomy alone and hysterectomy with OS, but no long-term data exist. There is emerging evidence of effectiveness of excisional sterilization on reducing ovarian cancer rates from Rochester (OR = 0.36 95 % CI 0.13, 1.02), and bilateral salpingectomy from Denmark (OR = 0.58 95 % CI 0.36, 0.95) and Sweden (HR = 0.35, 95 % CI 0.17, 0.73), but these studies suffer from limitations, including that they were performed for pathological rather than prophylactic purposes. Initial cost-effectiveness modeling indicates that OS is cost-effective over a wide range of costs and risk estimates. While preliminary safety, efficacy, and cost-effectiveness data are promising, further research is needed (particularly long-term data on ovarian function) to firmly establish the safety of the procedure. The marginal benefit of OS compared with tubal ligation or hysterectomy alone needs to be established through large prospective studies of OS done for prophylaxis.

Tubal ligation and salpingectomy and the risk of epithelial ovarian cancer and borderline ovarian tumors: a nationwide case-control study

OBJECTIVE

According to the recent theories on the ovarian cancer origin, any protective effect of tubal ligation may vary with histologic subtype of ovarian cancer. Furthermore, bilateral salpingectomy may represent an opportunity for surgical prevention of serous ovarian cancer.

DESIGN

Nationwide register-based case-control study.

SETTING

Denmark during 1982-2011.

POPULATION

Cases were all Danish women diagnosed with epithelial ovarian cancer (n = 13 241) or borderline ovarian tumor (n = 3605) in the study period. Age-matched female population controls were randomly selected by risk set sampling. We required that cases and controls have no previous cancer and that controls have no previous bilateral oophorectomy.

METHODS

Conditional logistic regression was used to estimate odds ratios and 95% confidence intervals, adjusting for potential confounders.

MAIN OUTCOME MEASURES

Epithelial ovarian cancer and borderline ovarian tumors stratified according to histology.

RESULTS

Tubal ligation reduced overall epithelial ovarian cancer risk (odds ratios 0.87; 95% confidence interval 0.78-0.98). We observed significant risk variation according to histology (p = 0.003) with the strongest risk reductions associated with endometrioid cancer (odds ratios 0.66; 95% confidence interval 0.47-0.93) and epithelial ovarian cancer of "other" histology (odds ratios 0.60; 95% confidence interval 0.43-0.83). Tubal ligation was not associated with risk of borderline ovarian tumors. Finally, bilateral salpingectomy reduced epithelial ovarian cancer risk by 42% (odds ratios 0.58; 95% confidence interval 0.36-0.95).

CONCLUSIONS

We confirmed that tubal ligation reduces the risk of epithelial ovarian cancer and particularly endometrioid cancer. To our knowledge, this is the first observational publication to report on salpingectomy and ovarian cancer risk and our promising findings warrant further investigation.

First case of prophylactic salpingectomy with single port access laparoscopy and a new diode laser in a woman with BRCA mutation

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Single port access laparoscopy may be suggested for prophylactic salpingectomy in BRCA carriers.

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Diode laser salpingectomy could preserve ovarian function as it can cut and coagulate with extreme precision and minimal thermal damage.

Acceptability of prophylactic salpingectomy with delayed oophorectomy as risk-reducing surgery among BRCA mutation carriers

OBJECTIVE

Given the emerging evidence for the fimbria as the site of origin for many serous carcinomas in BRCA mutation carriers, consideration is being given in studying prophylactic salpingectomy with delayed oophorectomy (PSDO) as a risk-reducing surgery. We aimed to determine the interest in a study of PSDO among these women.

METHODS

We evaluated the results of an online survey conducted by Facing Our Risk of Cancer Empowered (FORCE), a patient advocacy group, from October 2010 to August 2012. Premenopausal BRCA mutation carriers with no history of ovarian cancer or prior bilateral salpingo-oophorectomy (BSO) were included.

RESULTS

Of the 204 women meeting inclusion criteria, median age was 35 years, 92.5% were white, 25.7% were Jewish, and 16.7% had a history of breast cancer. Overall, 34.3% reported interest in a study of salpingectomy, 35.3% were unsure, and 30.4% were not interested in the study. Women noted the possibility of lowering ovarian cancer risk without menopause as a compelling reason to participate (83.8%). Reasons for not participating in a salpingectomy study included surgical complications (46.6%), potential ovarian damage (42.2%), planning BSO soon (32.4%), and surgical costs (32.8%). Acceptable study risks included the need for two surgeries (77.2%), possibility of not lowering ovarian cancer risk (68%), and disruption of ovarian blood supply (66.5%).

CONCLUSIONS

One-third of BRCA mutation carriers indicated definite interest in a PSDO study. Potential study risks were acceptable to most women. These findings suggest that patient accrual for a clinical trial of prophylactic salpingectomy with delayed oophorectomy is possible.

Prophylactic bilateral salpingectomy as a prevention strategy in women at high-risk of ovarian cancer: a mini-review

Risk-reducing bilateral salpingo-oophorectomy is a proven strategy to reduce the risk of serous ovarian cancer associated with germline BRCA mutations. It is most effective when performed before natural menopause, but it will render a woman prematurely menopausal. The tubal hypothesis of serous ovarian cancer brings with it the possibility of the alternative surgical approach in younger women comprising of risk-reducing bilateral salpingectomy while conserving their ovaries until nearer the age of natural menopause, when a delayed bilateral oophorectomy can be performed. This article will review the evidence behind the tubal hypothesis of serous ovarian cancer and explore the opportunities for translating this into clinical cancer prevention practice.

Ovarian cancer screening--current status, future directions

Evidence of a mortality benefit continues to elude ovarian cancer (OC) screening. Data from the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial which used a screening strategy incorporating CA125 cut-off and transvaginal ultrasound has not shown mortality benefit. The United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) is using the Risk of Ovarian Cancer (ROC) time series algorithm to interpret CA125, which has shown an encouraging sensitivity and specificity however the mortality data will only be available in 2015. The article explores the impact of growing insights into disease aetiology and evolution and biomarker discovery on future screening strategies. A better understanding of the target lesion, improved design of biomarker discovery studies, a focus on detecting low volume disease using cancer specific markers, novel biospecimens such as cervical cytology and targeted imaging and use of time series algorithms for interpreting markers profile suggests that a new era in screening is underway.

Short-term effects of salpingectomy during laparoscopic hysterectomy on ovarian reserve: a pilot randomized controlled trial

OBJECTIVE

To examine the short-term effects of salpingectomy during laparoscopic hysterectomy on ovarian reserve when ovarian preservation is planned in view of determining the feasibility of conducting the study on a larger scale.

DESIGN

Pilot randomized controlled trial.

SETTING

Tertiary care, academic medical center.

PATIENT(S)

Thirty premenopausal women aged 18 to 45 years undergoing laparoscopic hysterectomy with ovarian preservation for benign indications from April 2012 to September 2012.

INTERVENTION(S)

Bilateral salpingectomy (n = 15) versus no salpingectomy (n = 15) at the time of laparoscopic hysterectomy with ovarian preservation.

MAIN OUTCOME MEASURE(S)

Antimüllerian hormone (AMH) measured preoperatively, at 4 to 6 weeks postoperatively, and at 3 months postoperatively, with operative time and estimated blood loss abstracted from the medical records.

RESULT(S)

The mean AMH levels were not statistically significantly different at baseline (2.26 vs. 2.25 ng/ml), 4 to 6 weeks postoperatively (1.03 vs. 1.25 ng/ml), or 3 months postoperatively (1.86 vs. 1.82 ng/ml) among women with salpingectomy versus no salpingectomy, respectively. There was also no statistically significant temporal change in the mean AMH level from baseline to 3 months postoperatively (-0.07 vs. -0.08 ng/ml) between the two groups. No difference in operative time (116 vs. 115 minutes) or estimated blood loss (70 vs. 91 mL) was observed.

CONCLUSION(S)

Salpingectomy at the time of laparoscopic hysterectomy with ovarian preservation is a safe procedure that does not appear to have any short-term deleterious effects on ovarian reserve, as measured by AMH level. Conducting a trial of this nature that is adequately powered with long-term follow-up evaluation would be feasible and is required to definitively confirm these results.

Opportunistic and interventional salpingectomy in women at risk: a strategy for preventing pelvic serous cancer (PSC)

OBJECTIVE

Salpingectomy is proposed as a prophylactic measure to reduce the incidence of tubo-ovarian/pelvic serous cancers. We surveyed the attitudes of obstetrician/gynecologists to incorporating salpingectomy opportunistically into surgery for benign conditions, and electively for young BRCA mutation carriers.

STUDY DESIGN

A questionnaire, designed to assess current standard clinical practice and willingness to perform salpingectomy for female sterilization at abdominal hysterectomy for benign disease (ABH), vaginal benign hysterectomy (VBH) and electively for women with BRCA mutations who wish to postpone oophorectomy was mailed to obstetrician/gynecologists working in Irish hospitals.

RESULTS

In their current practice of interval female sterilization 96% of gynecologists applied clips at laparoscopy and 4% performed salpingectomy, and 73% were willing to consider salpingectomy. Eighty-one percent were willing to consider salpingectomy for sterilization at cesarean section. Gynecologists performing hysterectomy (without oophorectomy) for benign conditions did salpingectomy in 26% at ABH and 5.4% at VBH, and now 90% would consider salpingectomy at ABH and 66% at VBH. Two-thirds of respondents would consider salpingectomy for women at genetic risk of ovarian cancer who want to postpone oophorectomy.

CONCLUSION

Changing general gynecological practice to include more opportunistic salpingectomy has the potential to reduce the incidence of serous cancers. The majority of gynecologists are willing to incorporate more salpingectomies into their surgical practices and consider elective salpingectomy as an interim measure for women with defined genetic risk of pelvic serous cancer.