Improved quality of risk-reducing salpingo-oophorectomy in Australasian women at high risk of pelvic serous cancer

Objectives

The quality of risk-reducing salpingo-oophorectomy (RRSO) performed in Australasian women was previously reported to be suboptimal. Here we describe the quality of RRSO performed since 2008 in women enrolled in the same cohort and determine whether it has improved.

Design

Prospective cohort study of women at high risk of pelvic serous cancer (PSC) in kConFab. Eligible women had RRSO between 2008 and 2014 and their RRSO surgical and pathology reports were reviewed. “Adequate” surgery and pathology were defined as complete removal and paraffin embedding of all ovarian and extra-uterine fallopian tube tissue, respectively. Associations between clinical factors and “adequate” pathology were assessed using logistic regression. Data were compared with published cohort data on RRSO performed prior to 2008 using Chi square test.

Results

Of 164 contemporary RRSOs performed in 78 centres, 158/159 (99%) had “adequate” surgery and 108/164 (66%) had “adequate” pathology. Surgery performed by a gynaecologic oncologist rather than a general gynaecologist [OR 8.2, 95%CI (3.6–20.4), p < 0.001], surgery without concurrent hysterectomy [OR 2.5, 95%CI (1.1–6.0), p = 0.03], more recent year of surgery [OR 1.4, 95%CI (1.1–1.8), p = 0.02], and clinical notation that indicated high risk [OR 19.4, 95%CI (3.1–385), p = 0.008] were independently associated with “adequate” pathology. Both surgery and pathology were significantly more likely to be “adequate” (p < 0.001) in this contemporary sample.

Conclusion

The quality of RRSOs has significantly improved since our last report. Surgery by a gynaecologic oncologist who informs the pathologist that the woman is at high risk for PSC is associated with optimal RRSO pathology.

The association of serous tubal intraepithelial carcinoma with gynecologic pathologies and its role in pelvic serous cancer

OBJECTIVES

Possible primary sites of pelvic serous cancers are, fallopian tubes, ovaries or peritoneum. Recent studies have revealed that a portion of these tumors originates from serous tubal intraepithelial carcinoma (STIC) at the distal end of fallopian tubes. In this study, the association of STIC with pelvic serous carcinomas and the pathologic parameters that indicate the tubes as the primary site were assessed.

METHODS

In total, 495 pairs of fallopian tubes obtained via total abdominal hysterectomy and bilateral salpingo-oophorectomy between 2011 and 2013 were examined according to SEE-FIM protocol. Hematoxylin and eosin-stained slides were examined by pathologists. Suspicious areas were immunostained with p53 and Ki-67 to diagnose STIC precisely.

RESULTS

Of the 495 cases, 110 cases were malignant. Among 34 cases of non-uterine serous carcinomas, 13 were diagnosed with STIC. STIC was located at the fimbrial end of the fallopian tubes in 12 cases. No STIC was identified in the gynecologic malignancies other than non-uterine serous pelvic carcinomas and benign gynecologic pathologies. Comparison of the ovarian and tubal cancer cases with and without STIC did not reveal a factor that helps to define the primary site. STIC was an important factor associated in a higher portion of the cases with bilateral ovarian cancer.

CONCLUSION

The role of STIC in carcinogenesis continues to be discussed as it is unknown whether STIC is the precursor lesion or just associates with the malignancies. Discovering the accurate precursor lesions and tumor carcinogenesis is essential to prevent these malignancies and to develop early diagnostic methods.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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