SGO Clinical Practice Statement: Salpingectomy for Ovarian Cancer Prevention (SGO, November 2013)

Salpingectomy may be appropriate and feasible as a strategy for ovarian cancer risk reduction.

A paradigm shift in our understanding of pelvic serous carcinomas suggests that the site of origin may be the fallopian tube. In BRCA1 and BRCA2 germline mutation carriers, surgical removal of the fallopian tubes and ovaries has been demonstrated to reduce the risk of developing, and dying from, ovarian cancer. Recognizing that occult lesions are as frequently identified in the fallopian tubes, salpingectomy is an essential component to ovarian cancer risk-reducing surgery in high risk women. However, approximately 30 percent of women who are BRCA mutation carriers choose not to undergo risk-reducing salpingo-oophorectomy or to delay this surgery to avoid the quality of life and health risks associated with premature menopause. Physicians of such patients should counsel their women regarding the option of salpingectomy after childbearing followed by oophorectomy at a later date. Concerns for risk-reducing salpingectomy (without oophorectomy) include the fact that women remain at risk for developing ovarian cancer. Moreover, women who opt to delay oophorectomy will not benefit from the 50 percent reduction in breast cancer provided through premenopausal oophorectomy, and these women have significant lifetime breast cancer risk. Whenever surgery is performed in high-risk women, the pathologic processing of specimens should include micro-sectioning the ovaries and tubes, with special attention to the fimbriae.

For women at population risk (average) for ovarian cancer, salpingectomy should be considered (after completion of childbearing) at the time of hysterectomy, in lieu of tubal ligation, and also at the time of other pelvic surgery. The pathologic specimen processing in low risk women should include representative sections of the tube, any suspicious lesions, and entire sectioning of the fimbriae.

In summary, women who have BRCA1 or BRCA2 germline mutations should be counseled regarding bilateral salpingo-oophorectomy, after completion of childbearing, as the best strategy for reducing their risk of developing ovarian cancer. In the event that these women opt to delay or forego risk-reducing bilateral salpingo-oophorectomy, they should be counseled regarding risk-reducing salpingectomy when childbearing is complete followed by oophorectomy in the future, although the safety of this approach has not been studied. Microsectioning of the ovaries and fallopian tubes (especially the fimbriae) is crucial. For women at average risk of ovarian cancer, risk-reducing salpingectomy should also be discussed and considered with patients at the time of abdominal or pelvic surgery, hysterectomy or in lieu of tubal ligation

References:

1. Kurman RJ, Shih IM. The origin and pathogenesis of epithelial ovarian cancer: a proposed unifying theory. Am J SurgPathol 2010;34:433-43.

2. NCCN guidelines: Genetic/Familial High Risk Assessment. Available online, updated 2012. Last accessed 3/2013.

3. Greene MH, Mai PL, Schwartz PE. Does bilateral salpingectomy with ovarian retention warrant consideration as a temporary bridge to risk-reducing bilateral oophorectomy in BRCA1/2 mutation carriers? Am J Obstet Gynecol. 2011 Jan;204(1):19.e1-6.

4. Eisen A, Lubinski J, Klijn J, Moller P, Lynch HT, Offit K, Weber B, Rebbeck T, Neuhausen SL, Ghadirian P, Foulkes WD, Gershoni-Baruch R, Friedman E, Rennert G, Wagner T, Isaacs C, Kim-Sing C, Ainsworth P, Sun P, Narod SA. Breast cancer risk following bilateral oophorectomy in BRCA1 and BRCA2 mutation carriers: an international case-control study. J Clin Oncol. 2005 Oct 20; 23(30):7491-6.