Prophylactic salpingectomy

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Prophylactic salpingectomy is a preventative surgical technique performed on patients who are at higher risk of having ovarian cancer, such as individuals who may have pathogenic variants of the BRCA1 or BRCA2 gene. [1] Originally salpingectomy was used in cases of ectopic pregnancies. [2] As a preventative surgery however, it involves the removal of the fallopian tubes. By not removing the ovaries this procedure is advantageous to individuals who are still of child bearing age. It also reduces risks such as cardiovascular disease and osteoporosis which are associated with removal of the ovaries. [1]

Contents

Indications

In 2013 in America alone there were 22,000 cases of ovarian cancer diagnosed and reported. Of these 10% were due to an inherited disorder. [3] It is also the fifth most common cancer related cause of death in women. [4] The BRCA1 and BRCA2 genes are the most common inherited genetic mutations which lead to ovarian cancer. [3] As such a preventative surgery such a prophylactic salpingectomy is thought to decrease this risk of getting cancer. Recent research has shown that ovarian cancer may not originate in the ovaries themselves but start in the fallopian tubes. [5] It is therefore thought that in women who are of child bearing age the more common salpingo-oophorectomy may not be the correct surgery of choice. [1]

Gene MutationRisk of Developing Ovarian Cancer by age of 70 (%)
No Mutation1.4
BRCA139-46
BRCA210-27

[3]

A bilateral prophylactic salpingectomy with ovarian conservation was proposed as a “middle-ground" method of primary prevention, with the benefit of removing potential tissue of origin without the risks of surgical menopause. This method has been proposed for clinical trials in high-risk patients, but results are not currently available. [6]

Potential indications for Prophylactic Salpingectomy:

In 2013, the SGO released a clinical practice statement recommending that a bilateral salpingectomy should be considered “at the time of abdominal or pelvic surgery, hysterectomy, or in lieu of tubal ligation”. The American College of Obstetricians and Gynecologists (ACOG) recommended that the procedure should be considered for population-risk patients: those without increased risk based on personal or family history, but they were clear that the approach to pelvic surgery, hysterectomy, or sterilization should not change simply to increase the chances of completing bilateral salpingectomy. The proposed plan of the British Columbia Ovarian Cancer Research Group program, involved performing opportunistic salpingectomy with benign hysterectomy or in lieu of bilateral tubal ligation for permanent contraception. It is suggested that this approach would yield a 20-40 percent population risk reduction for ovarian cancer over the next 20 years. However, overall 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. [7]

Clinical Trials and Evidence

There are currently 2 ongoing clinical trials regarding prophylactic salpingectomy;

1) A study focusing on prophylactic salpingectomy with delayed oophorectomy (PSDO) in reducing risk of ovarian cancer. PSDO will result in the patient not immediately going through the menopause after the surgery, this will only happen once the ovaries are removed. Study is estimated to be complete in August 2018.

2) Another study looking at BRCA-positive women who are reluctant to undergo prophylactic surgery – this refusal increase risk of developing serious pelvic carcinoma. This study looks at the removal of the fimbriae structures of the ovaries. Results for this study are expected in October 2017.

[Both of these studies have been completed. Who can add the results of these studies (and others) to this article?]

BRCA1/2 mutation carriers are recommended salpingectomy at around the age of 40 to decrease their risk of ovarian cancer. Salpingectomy is most effective if performed before the natural menopause occurs, it was also found that there is no increased complication risks when salpingectomy is done at the same time as hysterectomy. [8]

A Nationwide study [9] found statistically lower risk of ovarian cancer among women with previous salpingectomy when compared to the unexposed population. Bilateral salpingectomy is associated with a 50% decrease in ovarian cancer risk compared to unilateral salpingectomy (the removal of both or one fallopian tubes). Most protective effect was seen in women who had a bilateral salpingectomy. High-Grade Serous Carcinoma (HGSC) is usually driven by BRCA gene mutations – it was hypothesised that a decrease risk of ovarian cancer observed among women with salpingectomy reflects the effect of the removed tubal epithelium (fallopian tube).[ citation needed ]

Those at risk are recommended sapling-oophorectomy at around the age of 40/after child-bearing to reduce ovarian cancer risk, and also reduces breast cancer too. Removal of healthy ovaries is also associated with negative health effects due to oestrogen deficiency, leaving the ovaries intact within the reproductive system is balanced with the remaining breast cancer risk. This was the first population based study describing the association between removing fallopian tubes and decreasing risk of ovarian cancer. [9]

Risks of Procedure

Surgical risks

Due to the mean age of the procedure being 36 years, age-related complications play a minimal factor during and after surgery. Older patients have the additional risk of coexisting age-related medical conditions, which would possibly cause complications in surgery. Surgery causes extra stress which requires an increased functional demand of the patient – geriatric patients may not be able to meet this, so for the average prophylactic salpingectomy recipient this is not significant. [10]

It has also been proven that the procedure does not increase normal surgical/post operative risks. It does, however, carry the same standard risks as a normal surgery. Complications associated with the surgical procedure include; reaction to anaesthesia, excessive bleeding, injury to other organs, and infection. [11]

One study also confirmed after reviewing 21,000 procedures, that there was no increased risk in hysterectomy plus bilateral salpingectomy compared to hysterectomy alone. This may indicate that there are no surgical risks related to salpingectomy alone. They also found that prophylactic salpingectomy did not increase length of stay or the likelihood of readmission or blood transfusion. This is a reassuring and highly interesting result as both of these complications were voiced as surgical concerns at the time prophylactic salpingectomy was first proposed. [12]

Long-term effects

There is no significant increased risk in future hospital admissions after a prophylactic salpingectomy. Each year over 225,000 women experience ovarian cancer, and as there are currently no effective screening tests, prophylactic salpingectomy reduces this risk effectively for those where it is appropriate, as the procedure is often only done to those with 50% or higher risk of ovarian cancer in their lifetime.[ citation needed ]

However, some groups have found that unilateral salpingectomy seemed to impair ovarian function. Less blood flow to the ovary and a reduced antral follicle count was seen shortly after surgery. It is hypothesised that this will ameliorate as time goes on, but for now it is known as a short-term effect. [13]

In vitro fertilisation after salpingectomy

A study in 1998 showed that salpingectomy had no detrimental effect on ovarian response after in vitro fertilisation (IVF) treatment, which is very reassuring for those wanting to undergo the procedure to prevent cancer or cysts if they want to have children in the future. IVF treatment and the outcome of IVF remains consistent in two cohorts of patients – one with salpingectomy and the other without. In patients with hydrosalpinx, it is highly beneficial to have prophylactic salpingectomy before conceiving due to potential difficulties in achieving pregnancy. [14]

Effects on testosterone

Medical experience with bilateral salpingectomy over the past 5–10 years gave us confidence that the surgical removal of the tubes would not result in the negative consequences of oophorectomy such as impaired sexuality and osteoporosis due to reduced testosterone levels. [15]

Similar Procedures

Delayed oophorectomy

Early salpingectomy with delayed oophorectomy allows for the postponement of premature surgical menopause and is therefore associated with an improved quality of life. [1]

Emergency salpingectomy

Laparotomy with salpingectomy is the recommended treatment for ectopic pregnancy. [16]

Bilateral salpingo-oophorectomy

Currently, the only intervention proven to reduce ovarian cancer risk is bilateral salpingo-oophorectomy (BSO) at age 35–40 for BRCA1 carriers or age 40–45 for BRCA2, which has been shown to decrease incidence by 80-96%. During BSO both ovaries and both fallopian tubes are removed in one operation. However, only 60-70% of BRCA mutation carriers undergo BSO currently, which is related to the generation of premature surgical menopause in the patient and the associated risks of oestrogen deficiency, urogenital atrophy, osteoporosis, and cardiovascular disease. [1]

See also

Related Research Articles

<span class="mw-page-title-main">Tubal ligation</span> Surgical clipping,removal or blocking of the fallopian tubes

Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.

Oophorectomy, historically also called ovariotomy, is the surgical removal of an ovary or ovaries. The surgery is also called ovariectomy, but this term is mostly used in reference to non-human animals, e.g. the surgical removal of ovaries from laboratory animals. Removal of the ovaries of females is the biological equivalent of castration of males; the term castration is only occasionally used in the medical literature to refer to oophorectomy of women. In veterinary medicine, the removal of ovaries and uterus is called ovariohysterectomy (spaying) and is a form of sterilization.

<span class="mw-page-title-main">Ovarian cancer</span> Cancer originating in or on the ovary

Ovarian cancer is a cancerous tumor of an ovary. It may originate from the ovary itself or more commonly from communicating nearby structures such as fallopian tubes or the inner lining of the abdomen. The ovary is made up of three different cell types including epithelial cells, germ cells, and stromal cells. When these cells become abnormal, they have the ability to divide and form tumors. These cells can also invade or spread to other parts of the body. When this process begins, there may be no or only vague symptoms. Symptoms become more noticeable as the cancer progresses. These symptoms may include bloating, vaginal bleeding, pelvic pain, abdominal swelling, constipation, and loss of appetite, among others. Common areas to which the cancer may spread include the lining of the abdomen, lymph nodes, lungs, and liver.

Gender-affirming surgery for female-to-male transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.

<span class="mw-page-title-main">Salpingectomy</span> Surgical removal of fallopian tube

Salpingectomy refers to the surgical removal of a fallopian tube. This may be done to treat an ectopic pregnancy or cancer, to prevent cancer, or as a form of contraception.

In medicine, salpingo-oophorectomy is the removal of an ovary and its fallopian tube. This procedure is most frequently associated with prophylactic surgery in response to the discovery of a BRCA mutation, particularly those of the normally tumor suppressing BRCA1 gene, which can increase the risk of a woman developing ovarian cancer to as high as 65%.

Gynecologic oncology is a specialized field of medicine that focuses on cancers of the female reproductive system, including ovarian cancer, uterine cancer, vaginal cancer, cervical cancer, and vulvar cancer. As specialists, they have extensive training in the diagnosis and treatment of these cancers.

<span class="mw-page-title-main">Hereditary breast–ovarian cancer syndrome</span> Medical condition

Hereditary breast–ovarian cancer syndromes (HBOC) are cancer syndromes that produce higher than normal levels of breast cancer, ovarian cancer and additional cancers in genetically related families. It accounts for 90% of the hereditary cancers. The hereditary factors may be proven or suspected to cause the pattern of breast and ovarian cancer occurrences in the family. The name HBOC may be misleading because it implies that this genetic susceptibility to cancer is mainly in women. In reality, both sexes have the same rates of gene mutations and HBOC can predispose to other cancers including prostate cancer and pancreatic cancer. For this reason, the term "King syndrome" has recently come into use. The new name references Mary-Claire King who identified the genes BRCA1 and BRCA2.

Gynecologic cancer is a type of cancer that affects the female reproductive system, including ovarian cancer, uterine cancer, vaginal cancer, cervical cancer, and vulvar cancer.

Primary fallopian tube cancer (PFTC), often just tubal cancer, is a malignant neoplasm that originates from the fallopian tube.

A borderline tumor, sometimes called low malignant potential (LMP) tumor, is a distinct but yet heterogeneous group of tumors defined by their histopathology as atypical epithelial proliferation without stromal invasion. It generally refers to such tumors in the ovary but borderline tumors may rarely occur at other locations as well.

<i>BRCA</i> mutation Medical condition

A BRCA mutation is a mutation in either of the BRCA1 and BRCA2 genes, which are tumour suppressor genes. Hundreds of different types of mutations in these genes have been identified, some of which have been determined to be harmful, while others have no proven impact. Harmful mutations in these genes may produce a hereditary breast–ovarian cancer syndrome in affected persons. Only 5–10% of breast cancer cases in women are attributed to BRCA1 and BRCA2 mutations, but the impact on women with the gene mutation is more profound. Women with harmful mutations in either BRCA1 or BRCA2 have a risk of breast cancer that is about five times the normal risk, and a risk of ovarian cancer that is about ten to thirty times normal. The risk of breast and ovarian cancer is higher for women with a high-risk BRCA1 mutation than with a BRCA2 mutation. Having a high-risk mutation does not guarantee that the woman will develop any type of cancer, or imply that any cancer that appears was actually caused by the mutation, rather than some other factor.

A preventive mastectomy or prophylactic mastectomy or risk-reducing mastectomy (RRM) is an elective operation to remove the breasts so that the risk of breast cancer is reduced.

Ovarian remnant syndrome is a condition that occurs when ovarian tissue is left behind following oophorectomy, causing development of a pelvic mass, pelvic pain, and occasionally dyspareunia. Ovarian remnant syndrome (ORS) is characterized by the presence of residual ovarian tissue after a woman has had surgery to remove one ovary or both ovaries (oophorectomy).

<span class="mw-page-title-main">High-grade serous carcinoma</span> Medical condition

High-grade serous carcinoma (HGSC) is a type of tumour that arises from the serous epithelial layer in the abdominopelvic cavity and is mainly found in the ovary. HGSCs make up the majority of ovarian cancer cases and have the lowest survival rates. HGSC is distinct from low-grade serous carcinoma (LGSC) which arises from ovarian tissue, is less aggressive and is present in stage I ovarian cancer where tumours are localised to the ovary.

Ovarian germ cell tumors (OGCTs) are heterogeneous tumors that are derived from the primitive germ cells of the embryonic gonad, which accounts for about 2.6% of all ovarian malignancies. There are four main types of OGCTs, namely dysgerminomas, yolk sac tumor, teratoma, and choriocarcinoma.

Prophylactic surgery, is a form of surgery whose purpose is to minimize or prevent the risk of developing cancer in an organ or gland that has yet to develop cancer and is known to be at high risk of developing cancer. This form of preventive healthcare may include surgeries such as mastectomies, oophorectomies, colectomies and surgical corrections, such as the surgical correction of cryptorchidism or undescended testis. Another less common definition of prophylactic surgery also includes the prevention of other diseases, outcomes or even future appearance.

<span class="mw-page-title-main">Breast and ovarian cancer</span>

Breast and ovarian cancer does not necessarily imply that both cancers occur at the same time, but rather that getting one cancer would lead to the development of the other within a few years. Women with a history of breast cancer have a higher chance of developing ovarian cancer, vice versa.

<span class="mw-page-title-main">SEE-FIM Protocol</span> Pathology protocol to assess cancer risk

The SEE-FIM protocol is a pathology dissection protocol for Sectioning and Extensively Examining the Fimbria (SEE-FIM). This protocol is intended to provide for the optimal microscopic examination of the distal fallopian tube (fimbria) to identify either cancerous or precancerous conditions in this organ.

References

  1. 1 2 3 4 5 Kwon, Janice S.; Tinker, Anna; Pansegrau, Gary; McAlpine, Jessica; Housty, Melissa; McCullum, Mary; Gilks, C. Blake (January 2013). "Prophylactic Salpingectomy and Delayed Oophorectomy as an Alternative for BRCA Mutation Carriers". Obstetrics & Gynecology. 121 (1): 14–24. doi: 10.1097/aog.0b013e3182783c2f . PMID   23232752. S2CID   41081248.
  2. ↑ Strandell, A.; Lindhard, A.; Waldenström, U.; Thorburn, J. (2001-06-01). "Prophylactic salpingectomy does not impair the ovarian response in IVF treatment". Human Reproduction (Oxford, England). 16 (6): 1135–1139. doi: 10.1093/humrep/16.6.1135 . ISSN   0268-1161. PMID   11387282.
  3. 1 2 3 4 Holman, Laura L.; Friedman, Sue; Daniels, Molly S.; Sun, Charlotte C.; Lu, Karen H. (2014). "Acceptability of prophylactic salpingectomy with delayed oophorectomy as risk-reducing surgery among BRCA mutation carriers". Gynecologic Oncology. 133 (2): 283–286. doi:10.1016/j.ygyno.2014.02.030. PMC   4035022 . PMID   24582866.
  4. 1 2 Yoon, Sang-Hee; Kim, Soo-Nyung; Shim, Seung-Hyuk; Kang, Soon-Beum; Lee, Sun-Joo (2016). "Bilateral salpingectomy can reduce the risk of ovarian cancer in the general population: A meta-analysis". European Journal of Cancer. 55: 38–46. doi:10.1016/j.ejca.2015.12.003. PMID   26773418.
  5. ↑ Venturella, Roberta; Morelli, Michele; Lico, Daniela; Cello, Annalisa Di; Rocca, Morena; Sacchinelli, Angela; Mocciaro, Rita; D'Alessandro, Pietro; Maiorana, Antonio (2015). "Wide excision of soft tissues adjacent to the ovary and fallopian tube does not impair the ovarian reserve in women undergoing prophylactic bilateral salpingectomy: results from a randomized, controlled trial". Fertility and Sterility. 104 (5): 1332–1339. doi: 10.1016/j.fertnstert.2015.08.004 . PMID   26335129.
  6. ↑ Greene, Mark H.; Mai, Phuong L.; Schwartz, Peter E. (January 2011). "Does bilateral salpingectomy with ovarian retention warrant consideration as a temporary bridge to risk-reducing bilateral oophorectomy in BRCA1/2 mutation carriers?". American Journal of Obstetrics and Gynecology. 204 (1): 19.e1–19.e6. doi:10.1016/j.ajog.2010.05.038. PMC   3138129 . PMID   20619389.
  7. ↑ Kwon, Janice S.; McAlpine, Jessica N.; Hanley, Gillian E.; Finlayson, Sarah J.; Cohen, Trevor; Miller, Dianne M.; Gilks, C. Blake; Huntsman, David G. (2015). "Costs and Benefits of Opportunistic Salpingectomy as an Ovarian Cancer Prevention Strategy". Obstetrics & Gynecology. 125 (2): 338–345. doi:10.1097/aog.0000000000000630. PMID   25568991. S2CID   13536852.
  8. ↑ Schenberg, Tess; Mitchell, Gillian (2014-01-01). "Prophylactic bilateral salpingectomy as a prevention strategy in women at high-risk of ovarian cancer: a mini-review". Frontiers in Oncology. 4: 21. doi: 10.3389/fonc.2014.00021 . PMC   3918654 . PMID   24575389.
  9. 1 2 Falconer, Henrik; Yin, Li; Grönberg, Henrik; Altman, Daniel (2015-02-01). "Ovarian Cancer Risk After Salpingectomy: A Nationwide Population-Based Study". Journal of the National Cancer Institute. 107 (2): dju410. doi: 10.1093/jnci/dju410 . ISSN   0027-8874. PMID   25628372.
  10. ↑ Turrentine, F.E.; Wang, H.; Simpson, V.B.; Jones, R.S. (2008). "Surgical Risk Factors, Morbidity, and Mortality in Elderly Patients". Critical Reviews in Oncology/Hematology. 68: S13. doi:10.1016/s1040-8428(08)70016-7.
  11. ↑ "The Cochrane Library: Cochrane Database of Systematic Reviews". Cochrane Database of Systematic Reviews. 1996. doi:10.1002/14651858. hdl: 2328/35732 .
  12. ↑ McAlpine, Jessica N.; Hanley, Gillian E.; Woo, Michelle M.M.; Tone, Alicia A.; Rozenberg, Nirit; Swenerton, Kenneth D.; Gilks, C. Blake; Finlayson, Sarah J.; Huntsman, David G.; Miller, Dianne M.; Ovarian Cancer Research Program of British Columbia (2014). "Opportunistic salpingectomy: uptake, risks, and complications of a regional initiative for ovarian cancer prevention". American Journal of Obstetrics and Gynecology. 210 (5): 471.e1–471.e11. doi: 10.1016/j.ajog.2014.01.003 . PMID   24412119.
  13. ↑ Chan, C. C. W.; Ng, E. H. Y.; Li, C. F.; Ho, P. C. (2003-10-01). "Impaired ovarian blood flow and reduced antral follicle count following laparoscopic salpingectomy for ectopic pregnancy". Human Reproduction. 18 (10): 2175–2180. doi: 10.1093/humrep/deg411 . ISSN   0268-1161. PMID   14507841.
  14. ↑ Lass, Amir; Ellenbogen, Adrian; Croucher, Carolyn; Trew, Geoff; Margara, Raul; Becattini, Carolina; Winston, Robert M. L (1998-12-01). "Effect of salpingectomy on ovarian response to superovulation in an in vitro fertilization–embryo transfer program". Fertility and Sterility. 70 (6): 1035–1038. doi: 10.1016/S0015-0282(98)00357-4 . PMID   9848291.
  15. ↑ Castelo-Branco, C.; Palacios, S.; Combalia, J.; Ferrer, M.; Traveria, G. (2009-12-01). "Risk of hypoactive sexual desire disorder and associated factors in a cohort of oophorectomized women". Climacteric. 12 (6): 525–532. doi:10.3109/13697130903075345. ISSN   1473-0804. PMID   19905904. S2CID   24700993.
  16. ↑ Dickens, B.M.; Faúndes, A.; Cook, R.J. (2003). "Ectopic pregnancy and emergency care: ethical and legal issues". International Journal of Gynecology & Obstetrics. 82 (1): 121–126. doi:10.1016/s0020-7292(03)00175-9. PMID   12834958. S2CID   24304388.
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