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Salpingectomy for Ovarian Cancer Prevention

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Salpingectomy for Ovarian Cancer Prevention The American College of Obstetricians and Gynecologists WOMEN’S HEALTH CARE PHYSICIANS COMMITTEE OPINION Number 620 • January 2015 Committee on Gynecologic Practice This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Salpingectomy for Ovarian Cancer Prevention ABSTRACT: Ovarian cancer has the highest mortality rate out of all types of gynecologic cancer and is the fifth leading cause of cancer deaths among women. Current attempts at screening for ovarian cancer have been unsuccessful and are associated with false-positive test results that lead to unnecessary surgery and surgical complications. Prophylactic salpingectomy may offer clinicians the opportunity to prevent ovarian cancer in their patients. Randomized controlled trials are needed to support the validity of this approach to reduce the incidence of ovarian cancer. The approach to hysterectomy or sterilization should not be influenced by the theoretical benefit of salpingectomy. Surgeons should continue to observe and practice minimally invasive techniques. Based on the current understanding of ovarian carcino- and are associated with false-positive test results that lead genesis and the safety of salpingectomy, the American to unnecessary surgery and surgical complications (1– College of Obstetricians and Gynecologists supports the 4). Prophylactic salpingectomy may offer clinicians the following recommendations and conclusions: opportunity to prevent ovarian cancer in their patients. The most compelling theory of epithelial ovarian • The surgeon and patient should discuss the potential carcinogenesis suggests that serous, endometrioid, and benefits of the removal of the fallopian tubes during a clear cell carcinomas are derived from the fallopian tube hysterectomy in women at population risk of ovarian and the endometrium and not directly from the ovary cancer who are not having an oophorectomy. (5–9). This is in contrast to the traditional view of ovar- • When counseling women about laparoscopic ster- ian carcinogenesis in which ovarian surface epithelium ilization methods, clinicians can communicate that (mesothelium) undergoes metaplastic changes leading bilateral salpingectomy can be considered a method to the different histologic types of epithelial ovarian can- that provides effective contraception. cer. In women with a genetic predisposition for ovarian • Prophylactic salpingectomy may offer clinicians cancer, lesions have been found in the fallopian tubes the opportunity to prevent ovarian cancer in their that closely resemble ovarian high-grade serous carci- patients. nomas or serous tubal intraepithelial carcinomas. These lesions are thought to be the primary source of ovarian • Randomized controlled trials are needed to support carcinoma that secondarily involves the ovary. Genetics the validity of this approach to reduce the incidence studies show that these tubal lesions express a common of ovarian cancer. TP53 mutation, as do high-grade serous, high-grade Ovarian cancer has the highest mortality rate out endometrioid, and undifferentiated carcinomas. In addi- of all types of gynecologic cancer and is the fifth leading tion, gene expression of high-grade serous carcinomas cause of cancer deaths among women (1). The overall is more closely related to the fallopian tube morphology survival rate for women with epithelial ovarian cancer than the ovarian surface epithelium. High-grade serous has improved marginally in the past 50 years. The more carcinomas express a müllerian marker (PAX8) but not aggressive epithelial ovarian carcinomas represent 75% a mesothelial marker (calretinin). This research signifi- of all cases of ovarian cancer and are responsible for cantly affects two groups of women: 1) those at high risk 90% of deaths due to ovarian cancer. Current attempts for hereditary ovarian cancer and 2) those at popula- at screening for ovarian cancer have been unsuccessful tion risk (no genetic predisposition for ovarian cancer) VOL. 125, NO. 1, JANUARY 2015 OBSTETRICS & GYNECOLOGY 279 undergoing routine pelvic surgery. This Committee salpingectomy eliminates tubal reversal as an option for Opinion addresses women at population risk undergoing those women who experience regret and seek fertility routine pelvic surgery for benign disease. options later. Tubal ligation has a protective effect specifically Complete salpingectomy is preferred over fimbriec- against endometrioid and clear cell carcinomas of the tomy (20); however, if complete salpingectomy cannot ovary, which supports the theory that these tumors may be performed, then removing as much of the fallopian be due to retrograde menses of endometrial cells (10). tubes as possible, excluding the interstitial portion, still By performing salpingectomy when patients undergo may have value (21). Studies of risk-reducing surgery for an operation during which the fallopian tubes could be patients with BRCA mutations demonstrated that 1–5% removed in addition to the primary surgical procedure of those women had early tubal malignancy; in most of (eg, hysterectomy), the risk of ovarian cancer may be these cases of malignancy, an early intraepithelial com- further reduced. Randomized controlled trials are needed ponent was located in the fimbriated end of the fallopian to support the validity of this approach to reduce the inci- tube (21, 22). Earlier benign lesions (serous tubal intraepi- dence of ovarian cancer. thelial lesions and tubal intraepithelial lesions in transi- Salpingectomy at the time of hysterectomy or as a tion) and a concept of surrogate precursor, called secretory means of tubal sterilization appears to be safe, without cell outgrowths, have been implicated in the development an increase in complications, such as the need for blood of tubal dysplasia and tubal carcinomas (20). Serous tubal transfusions and readmissions, compared with hysterec- intraepithelial lesions and tubal intraepithelial lesions in tomy alone or tubal ligation (1). Additionally, ovarian transition are most frequently located in the fimbriated function does not appear to be affected by salpingectomy end of the uterine tube, whereas secretory cell outgrowths at the time of hysterectomy based on surrogate serum are distributed throughout the tube. markers or response to in vitro fertilization (11–14). The pathologic specimen processing in low-risk The surgeon and patient should discuss the poten- women should include representative sections of the fal- tial benefits of the removal of the fallopian tubes during lopian tube, any suspicious lesions, and an entire section- a hysterectomy in women at population risk of ovarian ing of the fimbriae (20). Salpingectomy should remove cancer who are not having an oophorectomy. Counseling the tube completely from its fimbriated end and up to women who are undergoing routine pelvic surgery about the uterotubal junction; the interstitial portions of the the risks and benefits of salpingectomy should include an tubes do not need to be removed. Any fimbrial attach- informed consent discussion about the role of oopho- ments on the ovary should be cauterized or removed. rectomy and bilateral salpingo-oophorectomy (BSO). In addition, salpingectomy should be performed with Bilateral salpingo-oophorectomy that causes surgical meticulous attention. Care should be taken not to inter- menopause reduces the risk of ovarian cancer but may rupt blood supply to the ovary through the infundibulo- increase the risk of cardiovascular disease, osteoporosis, pelvic ligament because the collateral vasculature from and cognitive impairment (15). In the Nurses’ Health the tubal mesosalpinx is occluded during the tubal Study, all-cause mortality and cancer mortality increased removal. Preservation of the utero-ovarian ligament is in women who received a BSO (16). The risk of ovarian recommended. cancer after hysterectomy with ovarian conservation Initiatives to increase salpingectomy have been shown is 0.1–0.75% (17). Death from ovarian cancer after to be successful (1). Based on one physician survey, tubo-ovarian conservation in the Nurses’ Health Study most surgeons (54%) perform salpingectomy with hys- was 0.03% (16). The benefits of ovarian conservation terectomy, whereas a minority (7.2%) perform salpin- decrease with age, and there is little benefit after age gectomy for sterilization (23). Other than a significant 65 years (18). Given current theories of ovarian carci- increase in operative time for salpingectomy with hysterec- nogenesis, ovarian conservation and salpingectomy may tomy (16 minutes) and with sterilization (10 minutes), no represent a better option than BSO for ovarian cancer significant differences in operative times or complication risk reduction for most women undergoing other pelvic rates for salpingectomy have been identified (1). surgeries for benign disease. When counseling women The approach to hysterectomy or sterilization should about laparoscopic sterilization methods, clinicians can not be influenced by the theoretical benefit of salpingec- communicate that bilateral salpingectomy can be con- tomy. Surgeons should continue to observe and practice sidered a method that provides effective contraception. minimally invasive techniques. A vaginal hysterectomy Although there is no information about the effectiveness should not be changed to a laparoscopic hysterectomy of complete salpingectomy
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