The post-reproductive Fallopian tube: better removed?

Development of Hydrosalpinx After Prior Vaginal Hysterectomy and Bilateral Salpingectomy

Hydrosalpinx is defined as the obstruction and fluid distension of the fallopian tube. It is most often seen in the setting of pelvic inflammatory disease, but preserved fallopian tubes or tubal segments after hysterectomy can also develop hydrosalpinx. This case report highlights an instance of painful hydrosalpinx after vaginal hysterectomy and advocates for the complete removal of fallopian tubes as the standard of care at the time of hysterectomy of any route. In this case, a 40-year-old female, G4P3104, with a history of vaginal hysterectomy and prophylactic bilateral salpingectomy for abnormal uterine bleeding and symptomatic uterine leiomyoma two years prior, presented with one month of left lower quadrant pain. She was found to have an anechoic, tubular structure adjacent to the left ovary on transvaginal ultrasound. At the time of diagnostic laparoscopy, a 10x4 centimeter (cm) dilated hydrosalpinx was found and removed. Pathology confirmed the hydrosalpinx, and the patient's pain resolved after the surgery. Given our findings of painful hydrosalpinx following incomplete bilateral salpingectomy at the time of vaginal hysterectomy, attempts at the removal of the entire fallopian tube including the fimbriae are strongly recommended to prevent the morbidity of repeated surgery.

Disordered hypothalamus-pituitary-ovary axis in heterotopic extraovarian sex cord-stromal proliferation: a case report of fallopian tube serous adenofibroma

BACKGROUND

Fallopian tube serous adenofibromas are uncommon tumors of the female genital tract, only dozens of cases have ever been reported. Earlier study indicated that they might be derived from embryonic remnants of the Müllerian duct. Clinical presentation of these tumors is usually asymptomatic. Small cysts of 0.5-3 cm in diameter are mostly incidentally found at the fimbriae end, with coarse papillary excrescences lined by epithelial cells and connective tissue stroma without nuclear pleomorphism or mitosis.

CASE PRESENTATION

A 23-year-old woman with normal secondary sexual characters and 46, XX karyotype, presented to the gynecology clinic complaining of irregular menstrual cycles. Laboratory studies reported unique discrepancy of hormone levels; anti-Müllerian hormone (AMH): 6.05 ng/mL (The normal range of AMH is 1.70-5.63 ng/mL in women aged under 35 years old), follicle stimulating hormone (FSH): 31.9 mIU/mL (reference range: 3.85-8.78, follicular phase; 4.54-22.51, ovulatory phase; 1.79-5.12, luteal phase; 16.74-113.59, menopause), and luteinizing hormone (LH): 52.0 mIU/mL (reference range: 2.12-10.89, follicular phase; 19.18-103.03, ovulatory phase; 1.20-12.86, luteal phase; 10.87-58.64, menopause), mimicking gonadotropin-resistant ovary syndrome. The ultrasound reported a right adnexal cyst of 10.4 × 7.87 × 6.7 cm. Laparoscopic evaluation was performed; pathology revealed serous adenofibroma of the fallopian tube with ovarian stroma contents. Heterotopic extraovarian sex cord-stromal proliferations was most probable. The patient's hormone levels returned to the reproductive status two weeks after surgery; FSH: 7.9 mIU/mL, LH: 3.59 mIU/mL,and AMH: 4.32 ng/mL. The patient's menstrual cycles have resumed to normal for over two years after removal of the fallopian tube cyst.

CONCLUSIONS

This case of fallopian tube serous adenofibromas presented a discrepancy of serum AMH and FSH mimicking gonadotropin-resistant ovary syndrome. The clinical picture derived from heterotopic extraovarian sex cord-stromal proliferation indicated a disordered hypothalamus-pituitary-ovary axis.

Contraceptives and cancer risks in BRCA1/2 pathogenic variant carriers: a systematic review and meta-analysis

BACKGROUND

Increasing numbers of BReast CAncer (BRCA) 1 or 2 pathogenic variant (PV) carriers, who have an inherited predisposition to breast and ovarian cancer, are being identified. Among these women, data regarding the effects of contraception on cancer risks are unclear and various guidelines provide various recommendations.

OBJECTIVE AND RATIONALE

We aim to optimize counselling regarding contraception for BRCA1/2-PV carriers. Therefore, we performed a systematic review and meta-analysis. We investigated the risk ratio for developing breast cancer or ovarian cancer in BRCA1/2-PV carriers who have used any form of contraception versus non-users. Second, we analysed breast and ovarian cancer risk among BRCA1/2-PV carriers as influenced by the duration of contraceptive use and by the time since last use. In addition, we provide an overview of all relevant international guidelines regarding contraceptive use for BRCA1/2-PV carriers.

SEARCH METHODS

A systematic search in the Medline database and Cochrane library identified studies describing breast and/or ovarian cancer risk in BRCA1/2-PV carriers as modified by contraception until June 2021. The search included medical subject headings, keywords and synonyms related to BRCA and contraceptives (any kind). PRISMA guidance was followed. Risk Of Bias In Non-randomized Studies of Interventions and Grading of Recommendations, Assessment, Development and Evaluations assessments were performed. Random-effects meta-analyses were used to estimate pooled effects for breast and ovarian cancer risk separately. Subgroup analyses were conducted for BRCA1 versus BRCA2 and for the various contraceptive methods.

OUTCOMES

Results of the breast cancer risk with oral contraceptive pill (OCP) analysis depended on the outcome measure. Meta-analyses of seven studies with 7525 women revealed a hazard ratio (HR) of 1.55 (95% CI: 1.36-1.76) and of four studies including 9106 women resulted in an odds ratio (OR) of 1.06 (95% CI: 0.90-1.25), heterogeneity (I2) 0% and 52%, respectively. Breast cancer risk was still increased in ever-users compared with never-users >10 years after last OCP use. In contrast, ovarian cancer risk was decreased among OCP users: HR 0.62 (95% CI: 0.52-0.74) based on two studies including 10 981 women (I2: 0%), and OR 0.49 (95% CI: 0.38-0.63) based on eight studies including 10 390 women (I2: 64%). The protective effect vanished after cessation of use. Tubal ligation also protects against ovarian cancer: one study including 3319 women (I2: 0%): HR: 0.44 (95% CI: 0.26-0.74) and three studies with 7691 women (I2: 44%): OR: 0.74 (95% CI: 0.53-1.03). Data regarding other contraceptives were unavailable. No differences were observed between BRCA1 and BRCA2-PV carriers. The quality of evidence was either low or very low.

WIDER IMPLICATIONS

The OCP potentially increases breast cancer risk, while ovarian cancer risk decreases with either the OCP and tubal ligation in BRCA1/2-PV carriers. Counselling of BRCA1/2-PV carriers should be personalized; the genetic and non-genetic factors (like prior risk-reducing surgeries, prior breast cancer and age) and patients' preferences (reversibility, ease of use, reliability and effect on menstrual cycle) should be balanced. To further optimize counselling for high-risk women, future research should focus on other (commonly used) contraceptive methods and cancer risks in this specific population, and on the potential impact of changing formulations over time.

Fallopian tubal histogenesis of ovarian endometriosis-A study of folate receptor-alpha expression

Background

Ovary is a common organ site involved by endometriosis. We previously found that fallopian tube may contribute to the histogenesis of ovarian endometriosis. The finding was novel and requires further studies. We addressed this issue by examining a differentially expressed gene folate receptor alpha (FOLR1) and its protein (FRA) in this study.

Results

A total of 144 tissue samples were studied. These included 32-paired tubal-endometrial-ovarian endometriosis samples (n = 96), 18 samples of ovarian endometriosis without corresponding fallopian tube or endometrium, and 30 ovarian tissue samples with ovarian surface epithelia but without endometriosis. Multiple comparisons among groups of ovarian endometriosis, normal fallopian tube and benign endometrium were performed. FOLR1 was highly expressed in the epithelia of fallopian tube and ovarian endometriosis, with paired endometrial samples showing a significantly lower level of expression. Similar differential studies for FRA protein were performed through Western blot and immunohistochemistry (IHC). The expression of folate receptor alpha at both mRNA and protein levels in the tissues (fallopian tube or ovarian endometriosis vs. the endometrium) were significantly different (p < 0.001). All ovarian surface mesothelial epithelia showed negative expression of FRA by IHC.

Conclusion

The results further support that the fallopian tube may contribute to the development of ovarian endometriosis. Understanding the tubal contribution to ovarian endometriosis should ultimately contribute to ongoing investigative efforts aimed at identifying alternative ways to prevent and treat endometriosis. High level of FRA expression in the fallopian tube and endometriosis might be considered as potential tissue sites for targeted therapy.

Estrogen and Progesterone Receptor Immunoexpression in Fallopian Tubes among Postmenopausal Women Based on Time since the Last Menstrual Period

Existing data on the expression of estrogen receptor (ERα) and progesterone receptor (PR) in fallopian tubes in postmenopausal women are mostly inconclusive. Therefore, we assessed ERα and PR immunoexpression in the oviducts of these women. One hundred postmenopausal women were divided into three groups based on time elapsed since the last menstrual period: (A) 1–5 years, (B) 6–10 years, and (C) ≥11 years. In all groups, both in the glandular epithelium and stroma of the ampulla and isthmus of the oviduct, immunolocalization of ERα and PR were noted. The glandular epithelium of the ampulla showed a higher percentage of PR-positive cells than the isthmus in each group. Regarding ERα, there were no significant differences. In the glandular epithelium in both the ampulla and isthmus, the percentage of ERα- and PR-positive cells was significantly higher than that in the stroma in each study group and higher in the A group than in the C group. In conclusion, in postmenopausal women, time elapsed since the last menstrual period in the fallopian tubes was positively correlated with the following: (1) the epithelium showed vacuolation of cytoplasm with greater frequency, (2) the proportion of ciliated cells decreased, and (3) the percentage of ERα- and PR-positive cells also decreased. The obtained results indicate a significant decrease in ERα and PR expression depending on the time that has elapsed since the last menstruation, which is undoubtedly related to the loss of the reproductive function of the patients.

Opportunistic Salpingectomy at the Time of Urogynecologic Surgery: Why, in Whom, and How?

OBJECTIVES

This review aims to (1) describe evidence supporting the fallopian tube as a site of high-grade serous carcinoma, (2) review literature regarding salpingectomy in high- and average-risk women, and (3) discuss feasibility and safety of salpingectomy in urogynecologic surgery.

METHODS

PubMed and university library resources were used to retrieve relevant English-language publications via keyword search, including "ovarian cancer," "salpingectomy," "risk," "safety," "hysterectomy," "trends," "technique," and "urogynecology." Each publication was reviewed in detail and references incorporated, where relevant.

RESULTS

Evidence supports the fimbriated portion of the fallopian tube as a site of high-grade serous carcinoma in both hereditary and sporadic cases. Routine opportunistic salpingectomy in average-risk women may reduce ovarian cancer risk by 42% to 65% and prevent future surgery for benign tubal disease. Opportunistic salpingectomy is cost-effective for sterilization and cost-saving during hysterectomy. For genetically predisposed women, salpingo-oophorectomy remains the recommended strategy for ovarian cancer risk reduction. Despite being feasible, safe, and cost-effective, concomitant salpingectomy is least commonly performed during vaginal hysterectomy compared with other hysterectomy routes. Salpingectomy rates during vaginal hysterectomy are influenced by geographic factors, surgeon experience, and adhesive disease.

CONCLUSIONS

Opportunistic salpingectomy holds promise as a risk-reducing intervention for ovarian cancer. The American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology recommend that physicians counsel average-risk women regarding opportunistic salpingectomy when planning pelvic surgery. Randomized controlled trials are needed to evaluate long-term implications of salpingectomy. Urogynecologic surgeons should discuss salpingectomy as part of surgical informed consent. Vaginal salpingectomy should be incorporated into residency and fellowship training programs.

Laparoscopic “Core-Pulling” Salpingectomy: A Novel and Minimally Invasive Modified Salpingectomy

The present study aimed to evaluate the feasibility, safety, and efficacy of laparoscopic “core-pulling” salpingectomy for tubal pregnancy. Laparoscopic core-pulling salpingectomy is a novel and minimally invasive salpingectomy variant, whose technical details are described here. In this retrospective study, 154 patients with tubal pregnancy underwent laparoscopic salpingectomy. In total, 76 and 78 patients underwent laparoscopic core-pulling salpingectomy (LCPS) and conventional multiport laparoscopic salpingectomy (MPLS), respectively. Then, clinical characteristics, intraoperative findings, and operative outcomes were compared between the 2 groups. Surgery was successful in all 154 patients, and no significant differences were found between the LCPS and MPLS groups in clinical characteristics, intraoperative findings, and operative outcomes. These findings indicated that LCPS is feasible and constitute a practical alternative to conventional salpingectomy.

In vivo modeling of metastatic human high-grade serous ovarian cancer in mice

Metastasis is responsible for 90% of human cancer mortality, yet it remains a challenge to model human cancer metastasis in vivo. Here we describe mouse models of high-grade serous ovarian cancer, also known as high-grade serous carcinoma (HGSC), the most common and deadliest human ovarian cancer type. Mice genetically engineered to harbor Dicer1 and Pten inactivation and mutant p53 robustly replicate the peritoneal metastases of human HGSC with complete penetrance. Arising from the fallopian tube, tumors spread to the ovary and metastasize throughout the pelvic and peritoneal cavities, invariably inducing hemorrhagic ascites. Widespread and abundant peritoneal metastases ultimately cause mouse deaths (100%). Besides the phenotypic and histopathological similarities, mouse HGSCs also display marked chromosomal instability, impaired DNA repair, and chemosensitivity. Faithfully recapitulating the clinical metastases as well as molecular and genomic features of human HGSC, this murine model will be valuable for elucidating the mechanisms underlying the development and progression of metastatic ovarian cancer and also for evaluating potential therapies.

Rarely does an experimental model fully replicate the clinical metastases of a human malignancy. Faithfully representing the clinical metastases of human high-grade serous ovarian cancer with complete penetrance, coupled with histopathological, molecular, and genomic similarities, these mouse models, particularly one harboring mutant p53, will be vital to elucidating the underlying pathogenesis of human ovarian cancer. In-depth understanding of the development and progression of ovarian cancer is crucial to medical advances in the early detection, effective treatment, and prevention of ovarian cancer. Also, these robust mouse models, as well as cell lines established from the mouse primary and metastatic tumors, will serve as useful preclinical tools to evaluate therapeutic target genes and new therapies in ovarian cancer.

Horizons of nanotechnology applications in female specific cancers

Female-specific cancers are the most common cancers in women worldwide. Early detection methods remain unavailable for most of these cancers, signifying that most of them are diagnosed at later stages. Furthermore, current treatment options for most female-specific cancers are surgery, radiation and chemotherapy. Although important milestones in molecularly targeted approaches have been achieved lately, current therapeutic strategies for female-specific cancers remain limited, ineffective and plagued by the emergence of chemoresistance, which aggravates prognosis. Recently, the application of nanotechnology to the medical field has allowed the development of novel nano-based approaches for the management and treatment of cancers, including female-specific cancers. These approaches promise to improve patient survival rates by reducing side effects, enabling selective delivery of drugs to tumor tissues and enhancing the uptake of therapeutic compounds, thus increasing anti-tumor activity. In this review, we focus on the application of nano-based technologies to the design of novel and innovative diagnostic and therapeutic strategies in the context of female-specific cancers, highlighting their potential uses and limitations.

Effects of hysterectomy with simultaneous bilateral salpingectomy on the subsequent pelvic mass

Objectives

To analyze the clinicopathological characteristics of subsequent pelvic masses after hysterectomy for benign diseases, and to compare the masses following hysterectomy with or without simultaneous bilateral salpingectomy.

Methods

This study retrospectively analyzed patients undergone reoperation for pelvic mass subsequently to previous hysterectomy for benign disease from January 2012 to December 2016 in Peking Union Medical College Hospital.

Results

A total of 247 patients were enrolled in this study, of which 80.16% (n = 198) received simple hysterectomy, and 5.67% (n = 14) underwent hysterectomy with bilateral salpingectomy. The clinicopathological data of patients undergone simple hysterectomy or simultaneous bilateral salpingectomy was compared. In the former group, we found that 68.18% (n = 135) of the pelvic massed were benign, and the remaining 31.82% (n = 63) were malignant. In latter group, 57.10% (n = 8) were benign (8%) and 42.90% (n = 6) were malignant. Univariate analysis showed that the age of surgery for pelvic masses in patients undergoing hysterectomy with simultaneous bilateral salpingectomy was significantly younger than that in patients without salpingectomy (median, 44.5 vs 50 years, P < 0.0001), and the time interval between hysterectomy and onset of pelvic masses was also significantly shorter (median, 2 vs 5 years, P < 0.0001). And the probability of pelvic encapsulated effusion was significantly higher for the salpingectomy group. Multivariate analysis showed that there was no significant difference of the age of resection of pelvic mass, the time interval hysterectomy and pelvic mass onset, and the probability of pelvic encapsulated effusion between the two groups.

Conclusions

The results showed that the incidence of secondary benign pelvic masses may be reduced when hysterectomy was performed with simultaneous bilateral salpingectomy. However, there was no statistical difference in the clinical characteristics and pathological types of pelvic masses between patients received hysterectomy with or without salpingectomy.

Hydrosalpinx in patients with hysterectomy without salpingo-oophorectomy referred for pelvic magnetic resonance imaging

OBJECTIVE

Women with ovarian-sparing hysterectomy before 2007 are more likely to have retained Fallopian tube remnants which can become fluid-filled, distended masses, potentially mistaken for a cystic adnexal neoplasm on imaging. Here we assess the prevalence and appearance of hydrosalpinx in women with ovarian-sparing hysterectomy prior to 2007 referred for pelvic MRI.

METHODS

A total of 3044 consecutive pelvic MRI exams performed over a two-year period (2003-2004) were selected from our radiology database and retrospectively reviewed. Examinations performed on male patients (N = 858), duplicate examinations on the same patient (N = 675) and examinations performed for MR guided biopsy (N = 1) were excluded from the study. From the remaining female pelvic MRI examinations (N = 1510), patients with hysterectomy without oophorectomy were identified. The frequency of hydrosalpinx in this population was then determined visually by two experienced radiologists and kappa analysis was then performed to assess for interobserver agreement.

RESULTS

Of the 3044 pelvic MRI examinations, 1510 were performed on females and 76 (5%) of these women had ovarian-sparing hysterectomy. Of these 76 women, 14 patients (18%) had hydrosalpinx (kappa = 0.8) of which 11 were unilateral and 3 bilateral. A total of 9 of the 14 cases positive for hydrosalpinx in patients with ovarian-sparing hysterectomy were referred to MRI for evaluation of cystic adnexal masses detected on other modalities.

CONCLUSION

Hydrosalpinx should be considered in the differential diagnosis of cystic adnexal lesions in women with prior hysterectomy and retained ovaries.

Cell Origins of High-Grade Serous Ovarian Cancer

High-grade serous ovarian cancer, also known as high-grade serous carcinoma (HGSC), is the most common and deadliest type of ovarian cancer. HGSC appears to arise from the ovary, fallopian tube, or peritoneum. As most HGSC cases present with widespread peritoneal metastases, it is often not clear where HGSC truly originates. Traditionally, the ovarian surface epithelium (OSE) was long believed to be the origin of HGSC. Since the late 1990s, the fallopian tube epithelium has emerged as a potential primary origin of HGSC. Particularly, serous tubal intraepithelial carcinoma (STIC), a noninvasive tumor lesion formed preferentially in the distal fallopian tube epithelium, was proposed as a precursor for HGSC. It was hypothesized that STIC lesions would progress, over time, to malignant and metastatic HGSC, arising from the fallopian tube or after implanting on the ovary or peritoneum. Many clinical studies and several mouse models support the fallopian tube STIC origin of HGSC. Current evidence indicates that STIC may serve as a precursor for HGSC in high-risk women carrying germline BRCA1 or 2 mutations. Yet not all STIC lesions appear to progress to clinical HGSCs, nor would all HGSCs arise from STIC lesions, even in high-risk women. Moreover, the clinical importance of STIC remains less clear in women in the general population, in which 85–90% of all HGSCs arise. Recently, increasing attention has been brought to the possibility that many potential precursor or premalignant lesions, though composed of microscopically—and genetically—cancerous cells, do not advance to malignant tumors or lethal malignancies. Hence, rigorous causal evidence would be crucial to establish that STIC is a bona fide premalignant lesion for metastatic HGSC. While not all STICs may transform into malignant tumors, these lesions are clearly associated with increased risk for HGSC. Identification of the molecular characteristics of STICs that predict their malignant potential and clinical behavior would bolster the clinical importance of STIC. Also, as STIC lesions alone cannot account for all HGSCs, other potential cellular origins of HGSC need to be investigated. The fallopian tube stroma in mice, for instance, has been shown to be capable of giving rise to metastatic HGSC, which faithfully recapitulates the clinical behavior and molecular aspect of human HGSC. Elucidating the precise cell(s) of origin of HGSC will be critical for improving the early detection and prevention of ovarian cancer, ultimately reducing ovarian cancer mortality.

LAVH superior to TVH when concomitant salpingo-oophorectomy is intended in prolapse hysterectomy: a comparative cohort study

PURPOSE

This comparative cohort study evaluated the influence of surgical route for prolapse hysterectomy (vaginal or laparoscopically assisted) on the achievement of intended elective salpingo-oophorectomy, which was a procedural goal planned with the patient before primary vaginal native-tissue prolapse surgery.

METHODS

Consecutive patients who underwent total vaginal hysterectomy (TVH; n = 163) or laparoscopically assisted vaginal hysterectomy (LAVH; n = 144) and vaginal native-tissue repair for pelvic organ prolapse at Jena University Hospital were enrolled.

RESULTS

Peri- and postoperative parameters, including Clavien-Dindo (CD) classification of surgical complications, were compared between groups using Student's t test, Fisher's exact test, and multivariable regression. Patient characteristics were similar, except that grade IV prolapse was more common in the LAVH group (p < 0.001). The following parameters differed between the TVH and LAVH groups: concomitant salpingectomy (1.2% vs. 34%) and salpingo-oophorectomy (45% vs. 66%), non-performance of intended salpingo-oophorectomy (36% vs. 0% OR 0.006, 95% CI < 0.001-0.083), adhesiolysis (0% vs. 44%), CD II-III complications (51% vs. 14.6% p < 0.001), operating time (153 ± 61 vs. 142 ± 27 min), and postoperative in-patient days (9.02 ± 4.9 vs. 4.99 ± 0.96; all p < 0.001).

CONCLUSIONS

LAVH enabled the safe performance of planned concomitant salpingo-oophorectomy in all cases. To achieve the procedural goal in such cases, laparoscopic assistance in prolapse hysterectomy should be considered.

Opportunistic Salpingectomy at the Time of Benign Laparoscopic Hysterectomy: Assessment of Possible Complications and Histopathological p53-Signatures

Introduction

The aim of this study is to assess the prevalence of tubal histopathological abnormalities (serous tubal intraepithelial carcinoma STIC and p53 signatures) and the prevalence of perioperative and postoperative complications related to opportunistic laparoscopic salpingectomy in a low risk population.

Materials and Methods

In this observational prospective cohort, prophylactic bilateral salpingectomy during benign laparoscopic hysterectomy was systematically performed in 100 consecutive women. Peri- and postoperative complications were registered. Duration of salpingectomy and post-salpingectomy blood loss were also measured. Histopathological and immunohistochemical analysis with anti-p53 antibody were performed on the whole fallopian tubes according to a specific and validated protocol.

Results

Laparoscopic salpingectomy was always possible without any peri- or postoperative complication attributable to the salpingectomy itself. The mean duration was 428 seconds (354 – 596) and the blood loss was 9 cm ³ (2 – 15). Using histopathological and immunohistochemical assessment with anti-p53 antibody on 199 fallopian tubes (99 bilateral salpingectomies and one unilateral salpingectomy because of previous salpingectomy for ectopic pregnancy), there was a prevalence of 5.52% (11/199) of p53 signatures. No STIC were observed and no associated cancer.

Conclusions

Laparoscopic salpingectomy is both feasible and innocuous during benign hysterectomy. Meticulous histopathologic examination of the tubes may reveal specific abnormalities.

Risk-reducing Surgery in Women at Low Lifetime Risk of Developing Ovarian Carcinoma: Opportunistic Salpingectomy

Lack of success in ovarian cancer control through screening or advances in treatment in the general population has prompted exploration in new avenues of prevention. "Opportunistic" salpingectomy describes a surgical procedure or risk-reducing intent in women at low-risk/general population risk for developing ovarian cancer who are undergoing pelvic/abdominal surgery for other indications. This chapter reviews the uptake, safety, and anticipated impact of this prevention initiative.

Tuboperitoneal fistula, ectopic pregnancy, and remnants of fallopian tube: a confocal microtomography analysis and 3D reconstruction of human fallopian tube pathologies

Objective: The aim of this study was to provide a three-dimensional (3D) microscopic reconstruction of morphological modifications of the fallopian tube (FT) following surgical sterilization (including tuboperitoneal fistula) and ectopic pregnancy (EP) using confocal microtomography (micro-CT). Methods: Six specimens of FT from elective and emergency surgeries were selected: three remnants of the FT (RFT) from surgical sterilization, including one presenting tuboperitoneal fistula, and three FTs with EP. The specimens were fixed in formalin and stained with Lugol solution. Micro-CT studies were conducted on the specimens using protocols adapted from biological studies. Results: Three RFTs from surgical sterilization and three FTs affected by EPs were successfully scanned using micro-CT. There was good contrast impregnation, allowing tissue segmentation and analysis of different sections of the FTs. Three FT specimens from EP exhibited considerable distortion of the tubal anatomy, mainly from the blood clot in the tubal abortion. Three RFT specimens exhibited some features observed in traditional microscopy, such as tubal distension and loss of normal anatomical characteristics of a normal FT, and indicated the presence of a tuboperitoneal fistula in one of the three specimens. Conclusion: Micro-CT can identify morphological characteristics of FT pathologies previously described in a microscopic scale, with tissue contrast and the possibility of 3D reconstruction. Micro-CT is also useful in guiding traditional sectioning of specimens for histopathological studies.

Ovarian reserve following cesarean section with salpingectomy vs tubal ligation: a randomized trial

BACKGROUND

Epithelial ovarian cancer is assumed to derive from the fallopian tube. Salpingectomy has been previously demonstrated to reduce the risk of ovarian cancer, and may be used as a means of sterilization.

OBJECTIVE

We aimed to compare short-term ovarian reserve and operative complications in cases of salpingectomy and tubal ligation during cesarean section.

STUDY DESIGN

Study patients who underwent elective cesarean section at our institution and requested sterilization were randomized to bilateral salpingectomy or tubal ligation. Prior to surgery, blood samples were obtained for antimüllerian hormone. Surgical course was noted, including overall time, complications, and postoperative hemoglobin. Repeat antimüllerian hormone samples were obtained from patients 6-8 weeks following surgery.

RESULTS

In all, 46 patients were recruited for participation, of whom 33 completed a follow-up visit, and for whom repeat antimüllerian hormone levels were available. Patients in the salpingectomy group were slightly older (37.0 ± 3.9 vs 34.3 ± 4.1 years, P = .02). No differences were noted in patient parity, body mass index, or gestational age between the groups. Pregnancy and postdelivery antimüllerian hormone levels were not significantly different between the groups, with an average increase of 0.58 ± 0.98 vs 0.39 ± 0.41 ng/mL in the salpingectomy and tubal ligation groups, respectively (P = .45). Surgeries including salpingectomy were longer by an average 13 minutes (66.0 ± 20.5 vs 52.3 ± 15.8 minutes, P = .01). No difference was demonstrated between the groups regarding surgical complications and postoperative hemoglobin decrease.

CONCLUSION

Sterilization by salpingectomy appears to be as safe as tubal ligation regarding operative complications and subsequent ovarian reserve. As salpingectomy offers the advantage of cancer risk reduction, it may be offered in the settings of elective preplanned surgeries.

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.

The Effect of Salpingectomy on Ovarian Reserve and Ovarian Function

BACKGROUND

The effect of salpingectomy on ovarian reserve and ovarian function is still a controversial issue, and more investigations are needed.

OBJECTIVE

The aim of this study was to determine the effect of salpingectomy on ovarian reserve and ovarian function.

STUDY STRATEGY

PubMed, Embase, Medline, Web of Knowledge, and the Cochrane trial register were searched.

SELECTION CRITERIA

Studies must have similar study method and be published in English; clear data can be extracted from full test.

DATA COLLECTION AND ANALYSIS

Data were collected and analyzed by Review Manager 5.3.

MAIN RESULTS

A total of 13 studies were eligible. The level of anti-müllerian hormone is lower, and early follicular phase follicle-stimulating hormone is higher in salpingectomy groups. The level of early follicular phase estradiol and the ovarian volume of salpingectomy groups are the same as control. The total dose of follicle-stimulating hormone needed during in vitro fertilization and embryo transfer (IVF-ET) treatment cycles, the number of collected oocytes, and the clinical pregnancy rate are similar in salpingectomy and control groups.

CONCLUSIONS

Salpingectomy does not appear to affect ovarian function, ovarian response to gonadotropin stimulation, or outcome of IVF-ET in the short run. It may, however, impair ovarian reserve in the long run.

Incidental (Prophylactic) Salpingectomy at Benign Gynecologic Surgery and Cesarean Section: a Survey of Practice in Austria

Introduction: Most serous ovarian cancers are now thought to originate in the fallopian tubes. This has raised the issue of performing incidental salpingectomy (also called elective, opportunistic, prophylactic or risk-reducing salpingectomy) at the time of benign gynecologic surgery or cesarean section. We conducted an online survey to ascertain the policies regarding incidental salpingectomy in Austria in late 2014. Material and Methods: All 75 departments of obstetrics and gynecology in public hospitals in Austria were surveyed for their policies regarding incidental salpingectomy at benign gynecologic surgery or cesarean section. Results: Sixty-six of 75 surveyed departments completed the questionnaire, resulting in a response rate of 88 %. Overall, 46 of 66 (70 %) units reported offering or recommending incidental salpingectomy at benign gynecologic surgery, 12 units (18 %) did not, and eight units (12 %) did not have a consistent policy. Salpingectomy was the preferred method for surgical sterilization, including sterilization at the time of cesarean section (71 % and 64 % of units, respectively). Conclusions: Incidental (elective, opportunistic, prophylactic, risk-reducing) salpingectomy is now widely offered at benign gynecologic surgery and cesarean section in Austria. Evidence for the role of the fallopian tubes in the origin of serous pelvic cancer has led to changes in clinical practice.

Preventive Salpingectomy and Ovarian Reserve: Experimental Study

The levels of anti-Müllerian hormone, follicle-stimulating hormone, and testosterone were studied in rats after removal of the uterine horns, oviducts, or combined surgery. The effects of preventive salpingectomy on ovarian reserve were studied. After preventive salpingectomy, the level of anti-Müllerian hormone was low throughout the experiment, follicle-stimulating hormone increased only by the end of observation (on day 40), and testosterone level decreased only on day 10. Hysterectomy alone caused no changes in the concentrations of the studied hormones on day 10 after surgery. Salpingectomy alone reduced the concentrations of anti-Müllerian hormone and testosterone and did not change the level of follicle-stimulating hormone during this period.

Adnexal masses requiring reoperation in women with previous hysterectomy with or without adnexectomy

OBJECTIVES

To characterize the etiologies of adnexal masses requiring reoperation in women with prior hysterectomy and to compare incidence and pathology of these masses based upon whether total, partial or no adnexectomy was performed at time of hysterectomy. In addition, the average time interval between hysterectomy and reoperation for a pelvic mass is ascertained.

STUDY DESIGN

A single-institution, retrospective review spanning 10 years. Using pertinent ICD-9 and CPT codes, women with a history of hysterectomy who underwent a subsequent surgery for an adnexal or pelvic mass were identified.

RESULTS

Over ten years, 250 women returned for gynecologic surgery due to a pelvic mass after prior hysterectomy. Most had undergone hysterectomy only (76%). 64.8% of these women had masses of ovarian origin, 12.4% were tubal in origin, 20% of masses involved both the ovary and tube and a small proportion arose from non-gynecologic processes. 18% of these women had a malignancy; 80% were ovarian and 6.7% originated from the fallopian tube. Patients having had a prior hysterectomy and bilateral salpingectomy returned soonest (p<0.0001) and patients with malignant masses returned after the longest time intervals (HR 0.41, p<0.0001).

CONCLUSIONS

The majority of adnexal masses requiring reoperation after hysterectomy are gynecologic in origin, benign, and arise from the ovary. Women returning with malignant masses after hysterectomy present after longer time intervals.

Feasibility and safety of outpatient total laparoscopic hysterectomy

Background and Objective:

Ambulatory total laparoscopic hysterectomy (TLH) could lead to significant cost savings, but some fear the effects of what could be premature postsurgical discharge. We sought to estimate the feasibility and safety of TLH as an outpatient procedure for benign gynecologic conditions.

Methods:

We report a prospective, consecutive case series of 128 outpatient TLHs performed for benign gynecologic conditions in a tertiary care center.

Results:

Of the 295 women scheduled for a TLH, 151 (51%) were attempted as an outpatient procedure. A total of 128 women (85%) were actually discharged home the day of their surgery. The most common reasons for admission the same day were urinary retention (19%) and nausea (15%). Indications for hysterectomy were mainly leiomyomas (62%), menorrhagia (24%), and pelvic pain (9%). Endometriosis and adhesions were found in 23% and 25% of the cases, respectively. Mean estimated blood loss was 56 mL and mean uterus weight was 215 g, with the heaviest uterus weighing 841 g. Unplanned consultation and readmission were infrequent, occurring in 3.1% and 0.8% of cases, respectively, in the first 72 hours. At 3 months, unplanned consultation, complication, and readmission had occurred in a similar proportion of inpatient and outpatient TLHs (17.2%, 12.5%, and 4.7% versus 18.1%, 12.7%, and 5.4%, respectively). In a logistic regression model, uterus weight, presence of adhesions or endometriosis, and duration of the operation were not associated with adverse outcomes.

Conclusion:

Same-day discharge is a feasible and safe option for carefully selected patients who undergo an uncomplicated TLH, even in the presence of leiomyomas, severe adhesions, or endometriosis.

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.

Paradigm Shift in the Management Strategy for Epithelial Ovarian Cancer

The hypothesis on the pathogenesis of epithelial ovarian cancer continues to evolve. Although epithelial ovarian cancer had been assumed to arise from the coelomic epithelium of the ovarian surface, it is now becoming clearer that the majority of serous carcinomas arise from epithelium of the distal fallopian tube, whereas clear cell and endometrioid cancers arise from endometriosis. Molecular and genomic characteristics of epithelial ovarian cancer have been extensively investigated. Our understanding of pathogenesis of the various histologic types of ovarian cancer have begun to inform changes to the strategies for management of epithelial ovarian cancer, which represent a paradigm shift not only for treatment but also for prevention, which previously had not been considered achievable. In this article, we will discuss novel attempts at the prevention of high-grade serous ovarian cancer and treatment strategies for two distinct entities in epithelial ovarian cancer: low-grade serous and clear cell ovarian carcinomas, which are relatively rare and resistant to conventional chemotherapy.

The role of reproductive hormones in epithelial ovarian carcinogenesis

Epithelial ovarian cancer comprises ∼85% of all ovarian cancer cases. Despite acceptance regarding the influence of reproductive hormones on ovarian cancer risk and considerable advances in the understanding of epithelial ovarian carcinogenesis on a molecular level, complete understanding of the biologic processes underlying malignant transformation of ovarian surface epithelium is lacking. Various hypotheses have been proposed over the past several decades to explain the etiology of the disease. The role of reproductive hormones in epithelial ovarian carcinogenesis remains a key topic of research. Primary questions in the field of ovarian cancer biology center on its developmental cell of origin, the positive and negative effects of each class of hormones on ovarian cancer initiation and progression, and the role of the immune system in the ovarian cancer microenvironment. The development of the female reproductive tract is dictated by the hormonal milieu during embryogenesis. Intensive research efforts have revealed that ovarian cancer is a heterogenous disease that may develop from multiple extra-ovarian tissues, including both Müllerian (fallopian tubes, endometrium) and non-Müllerian structures (gastrointestinal tissue), contributing to its heterogeneity and distinct histologic subtypes. The mechanism underlying ovarian localization, however, remains unclear. Here, we discuss the role of reproductive hormones in influencing the immune system and tipping the balance against or in favor of developing ovarian cancer. We comment on animal models that are critical for experimentally validating existing hypotheses in key areas of endocrine research and useful for preclinical drug development. Finally, we address emerging therapeutic trends directed against ovarian cancer.

Identifying post-menopausal women at elevated risk for epithelial ovarian cancer

OBJECTIVE

We developed and validated a hybrid risk classifier combining serum markers and epidemiologic risk factors to identify post-menopausal women at elevated risk for invasive fallopian tube, primary peritoneal, and ovarian epithelial carcinoma.

METHODS

To select epidemiologic risk factors for use in the classifier, Cox proportional hazards analyses were conducted using 74,786 Women's Health Initiative (WHI) Observational Study (OS) participants. To construct a combination classifier, 210 WHI OS cases and 536 matched controls with serum marker measurements were analyzed; validation employed 143 cases and 725 matched controls from the WHI Clinical Trial (CT) with similar data.

RESULTS

Analyses identified a combination risk classifier composed of two elevated-risk groups: 1) women with CA125 or HE4 exceeding a 98% specificity threshold; and 2) women with intact fallopian tubes, prior use of menopausal hormone therapy for at least two years, and either a first degree relative with breast or ovarian cancer or a personal history of breast cancer. In the WHI OS population, it classified 13% of women as elevated risk, identifying 30% of ovarian cancers diagnosed up to 7.8years post-enrollment (Hazard Ratio [HR]=2.6, p<0.001). In the WHI CT validation population, it classified 8% of women as elevated risk, identifying 31% of cancers diagnosed within 7years of enrollment (HR=4.6, p<0.001).

CONCLUSION

CA125 and HE4 contributed significantly to a risk prediction classifier combining serum markers with epidemiologic risk factors. The hybrid risk classifier may be useful to identify post-menopausal women who would benefit from timely surgical intervention to prevent epithelial ovarian cancer.

Opportunistic bilateral salpingectomy during gynaecological surgery for benign disease: A survey of current Australian practice

BACKGROUND

Recent evidence supports the fallopian tube as the site of origin for many pelvic serous cancers (PSC) including epithelial ovarian cancers (EOC). As a result, a change in practice with opportunistic bilateral salpingectomy (OBS) at the time of hysterectomy has been advocated as a preventative strategy for PSC in a low-risk population.

AIMS

The aim of this study was to assess current clinical practice in Australia with respect to OBS during gynaecological surgery for benign indications.

MATERIALS AND METHODS

An anonymous online survey was sent to all active Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) Fellows in Australia. Data regarding clinician demographics and the proportion of clinicians offering OBS were collected. Reasons for and against offering or discussing OBS were sought. A descriptive analysis was performed.

RESULTS

The response rate was 26% (280/1490) with 70% of respondents offering or discussing OBS to women undergoing gynaecological surgery for benign indications, usually at the time of abdominal (96%) or laparoscopic (76%) hysterectomy. The main reason for offering or discussing OBS was current evidence to suggest the fallopian tubes as the site of origin for most EOC. Main reasons for not offering OBS were insufficient evidence to benefit the woman (36%) or being unaware of recent evidence (33%).

CONCLUSIONS

The survey responses indicate that OBS is frequently discussed or offered in Australia, usually at the time of hysterectomy. Given the lack of robust evidence to suggest a benefit at a population-based level, a national registry is recommended to monitor outcomes.

The ovary is an alternative site of origin for high-grade serous ovarian cancer in mice

Although named "ovarian cancer," it has been unclear whether the cancer actually arises from the ovary, especially for high-grade serous carcinoma (HGSC), also known as high-grade serous ovarian cancer, the most common and deadliest ovarian cancer. In addition, the tumor suppressor p53 is the most frequently mutated gene in HGSC. However, whether mutated p53 can cause HGSC remains unknown. In this study, we bred a p53 mutation, p53(R172H), into conditional Dicer-Pten double-knockout (DKO) mice, a mouse model duplicating human HGSC, to generate triple-mutant (TKO) mice. Like DKO mice, these TKO mice develop metastatic HGSCs originating from the fallopian tube. Unlike DKO mice, however, even after fallopian tubes are removed in TKO mice, ovaries alone can develop metastatic HGSCs, indicating that a p53 mutation can drive HGSC arising from the ovary. To confirm this, we generated p53(R172H)-Pten double-mutant mice, one of the genetic control lines for TKO mice. As anticipated, these double-mutant mice also develop metastatic HGSCs from the ovary, verifying the HGSC-forming ability of ovaries with a p53 mutation. Our study therefore shows that ovaries harboring a p53 mutation, as well as fallopian tubes, can be a distinct tissue source of high-grade serous ovarian cancer in mice.

Society of Gynecologic Oncology recommendations for the prevention of ovarian cancer

Mortality from ovarian cancer may be dramatically reduced with the implementation of attainable prevention strategies. The new understanding of the cells of origin and the molecular etiology of ovarian cancer warrants a strong recommendation to the public and health care providers. This document discusses potential prevention strategies, which include 1) oral contraceptive use, 2) tubal sterilization, 3) risk-reducing salpingo-oophorectomy in women at high hereditary risk of breast and ovarian cancer, 4) genetic counseling and testing for women with ovarian cancer and other high-risk families, and 5) salpingectomy after childbearing is complete (at the time of elective pelvic surgeries, at the time of hysterectomy, and as an alternative to tubal ligation). The Society of Gynecologic Oncology has determined that recent scientific breakthroughs warrant a new summary of the progress toward the prevention of ovarian cancer. This review is intended to emphasize the importance of the fallopian tubes as a potential source of high-grade serous cancer in women with and without known genetic mutations in addition to the use of oral contraceptive pills to reduce the risk of ovarian cancer.

[Prophylactic salpingectomy or salpingo-oophorectomy as an ovarian cancer prevention?]

A recent hypothesis has stated that many ovarian cancers (especially high-grade serous histotype) could arise from the distal part of the fallopian tube. On one hand we know that risk-reducing salpingo-oophorectomy is the most effective prevention for ovarian cancer among BRCA mutation carriers. On the other, oophorectomy increases the relative risk for cardiovascular, osteoporotic psychosexual and cognitive dysfunctions in premenopausal women. This raises the question whether bilateral salpingectomy could be an effective strategy in the prevention of ovarian cancer in case of hereditary predisposition and in the general population. Here we discuss origin of ovarian cancer in the light of the latest molecular studies and the relative risks and benefits of a strategy of exclusive salpingectomy in comparison with the classical adnexectomy.

Oophorectomy versus salpingo-oophorectomy in Turner syndrome patients with Y-chromosome material: clinical experience and current practice patterns assessment

BACKGROUND/PURPOSE

Gonadectomy is recommended in Turner syndrome (TS) patients with Y-chromosome material due to high risk of tumor in the dysgenetic gonads. No recommendations exist on whether concurrent salpingectomy should be performed.

METHODS

A retrospective chart review of surgical procedure and histopathology in TS patients with Y-chromosome enrolled in a TS database was undertaken at Cincinnati Children's Hospital Medical Center. An electronic survey was sent to members of the International Pediatric Endosurgery Group to assess prevalent practice patterns and attitudes on gonadectomy and concurrent salpingectomy in this population.

RESULTS

In March 2011, 12/158 (8%) TS girls (mean age 6.6 years) enrolled in the database had TS with Y-chromosome. Gonadoblastoma was identified in 4/12 (33%) patients and 2/4 had malignant transformation to dysgerminoma and teratoma. Approach to gonadectomy was varied and 3/12 had concurrent salpingectomy. Fifty-four laparoscopic surgeons responded to the survey with no clear consensus on whether salpingectomy should be concurrently performed.

CONCLUSIONS

TS patients with Y-chromosome have an increased risk of gonadal tumor development and gonadectomy is recommended. While there is no consensus among pediatric laparoscopic surgeons on concurrent salpingectomy, it is reasonable to consider this combination procedure.

Tubal origin of ovarian endometriosis

Endometriosis is a puzzling and debilitating disease that affects millions of women around the world. Ovary is the most common organ site involved by endometriosis. Despite various hypotheses about its cell of origin, uncertainty remains. On the basis of our clinicopathologic observations, we hypothesize that fallopian tube may contribute the histogenesis of ovarian endometriosis. To examine if the hypothesis, tubal origin of ovarian endometriosis, has scientific supporting evidence, we identified a set of novel genes, which are either highly expressed in the normal fallopian tube or in the endometrium through a gene differential array study. Among many differentially expressed genes, FMO3 and DMBT1 were selected as the initial biomarkers to test the hypothesis. These biomarkers were then validated in ovarian sections with foci of endometriosis by comparing their expression levels in the fallopian tube and the endometrium within the same patients with real-time PCR, western blot and immunohistochemistry analysis. FMO3 was highly expressed in the tubal epithelia while low in the paired endometrium. In contrast, DMBT1 was high in the endometrium but low in the fallopian tube. In 32 ovarian endometriosis cases analyzed by real-time PCR, 18 (56%) showed a high level of FMO3 and a low level of DMBT1 expression. However, 14 (44%) endometriosis cases showed a reversed expression pattern with these two markers. Results were similarly seen in the methods of western blot and immunohistochemistry. The findings suggest that approximately 60% of the ovarian endometriosis we studied may be derived from the fallopian tube, whereas about 40% of the cases may be of endometrial origin. The fallopian tube epithelia may represent one of the tissue sources contributing to ovarian endometriosis. Such novel findings, which require confirmation, may have a significant clinical impact in searching for alternative ways of prevention and treatment of endometriosis.

Early preinvasive lesions in ovarian cancer

Faced with the catastrophic prognosis for ovarian cancer due to the fact that it is most often diagnosed late at the peritoneal carcinomatosis stage, screening and early detection could probably reduce the mortality rate. A better understanding of the molecular characteristics of the different ovarian cancer subtypes and their specific molecular signatures is indispensable prior to development of new screening strategies. We discuss here the early natural history of ovarian cancer and its origins.

Physician opinions regarding elective bilateral salpingectomy with hysterectomy and for sterilization

STUDY OBJECTIVE

To gather opinions about the benefits and concerns of performing bilateral salpingectomy without oophorectomy during hysterectomy for benign indications and as a sterilization procedure.

DESIGN

Survey study (Canadian Task Force classification III).

SETTING

Practicing physicians in US institutions that have obstetrics and gynecology residency programs listed on the FREIDA website were surveyed electronically.

INTERVENTION

A validated, standardized questionnaire designed to gather opinions about bilateral salpingectomy performed during hysterectomy or for sterilization was administered via SurveyMonkey to practitioners of obstetrics and gynecology.

MEASUREMENTS AND MAIN RESULTS

Results were compiled and presented as percentages of total responders. A total of 234 surveys were returned. Fifty-four percent of physicians perform bilateral salpingectomy during hysterectomy, most commonly to reduce the risks of cancer (75%) and repeat operation (49.1%). Of the 45.5% of physicians who do not perform bilateral salpingectomy during hysterectomy, most (69.4%) believe there is no benefit. Fifty-eight percent of practitioners believe that bilateral salpingectomy is the most effective method of sterilization after age 35 years but choose this method only in patients in whom one sterilization procedure has failed or because of tubal disease. Only 7.2% of surgeons prefer it as an interval sterilization procedure.

CONCLUSION

Most practitioners believe that bilateral salpingectomy is beneficial. Most also believe that bilateral salpingectomy is the most effective sterilization procedure; however, only 7.2% use this method as an interval procedure. More data are needed to evaluate the prophylactic effect of bilateral salpingectomy against postoperative sequelae.