Occult Tubal Carcinoma After Risk-Reducing Salpingo-oophorectomy

Abstract

OBJECTIVE: To perform a systematic review of the literature to estimate the prevalence and outcomes of occult tubal carcinoma in BRCA mutation carriers and high-risk patients undergoing risk-reducing salpingo-oophorectomy. DATA SOURCE: A search was done using OVID MEDLINE, EMBASE, and ClinicalTrials.gov between 1946 and March 2019 with keywords and MeSH terms selected by an expert medical librarian and coauthors. METHODS OF STUDY SELECTION: Two independent reviewers performed study selection with an initial screen on abstracts and a second on full articles. Articles were rejected if they were irrelevant to the study question, pertained to a different population or did not report occult tubal neoplasia. Quality was assessed using methodologic index for nonrandomized studies criteria. TABULATION, INTEGRATION, AND RESULTS: Data were extracted and recorded in an Excel database. Forest plots for the prevalence of occult carcinoma were done using STATA. Among 2,402 studies assessed, 27 met the inclusion criteria for qualitative and quantitative analysis. A total of 6,283 patients underwent risk-reducing salpingo-oophorectomy between 2002 and 2019: 2,894 cases were BRCA1, 1,579 BRCA2, and 1,810 high-risk based on family history. Among these, 75 patients were diagnosed with occult tubal carcinoma at the time of surgery. The pooled prevalence was 1.2% (I2=7.1%, P=.363) occurring at a median age of 53.2 years (range 42.4–67). In a subanalysis of 18 studies reporting follow-up data, 10 recurrences (18.7%, 95% CI 7.5–53%) and 24 cases of post–risk-reducing salpingo-oophorectomy peritoneal cancer (0.54%, 95% CI 0.4–1.9%) were reported after a median follow-up of 52.5 months. BRCA1, older age, and previous breast cancer were more often associated with occult malignancy. CONCLUSION: Occult tubal carcinomas found at risk-reducing salpingo-oophorectomy in high-risk patients and BRCA mutation carriers have significant potential for recurrence despite the frequent administration of postoperative chemotherapy.

Uptake Rate of Risk-Reducing Salpingo-Oophorectomy and Surgical Outcomes of Female Germline BRCA1/2 Mutation Carriers: A Retrospective Cohort Study

“…In literature, the occult ovarian/tubal cancer rate in BRCA1/2 mutation carriers undergoing RRSO has been reported to be 0.6%–17%. 15 16 17 18 19 Therefore, it is recommended that BRCA1/2 mutation carriers, especially those who completed childbearing, undergo RRSO soon after genetic testing to prevent the development of ovarian/tubal cancer and microscopic cancer progression. Nevertheless, neglecting cancer screening after RRSO should be avoided, as the risks of developing primary peritoneal cancer and breast cancer still remain.…”

Ovarian cancer arising from the proximal fallopian tube in a patient with a BRCA2 mutation

“…Much of this evidence is based on the discovery of occult carcinoma and pre-cancerous lesions in the fallopian tube at the time of RRBSO. A systematic review of 24 studies including a total of 6283 patients (4473 BRCA1/2 carriers) found 75 patients with occult tubal carcinoma at time of RRBSO in addition to 93 patients with STIC/STIL ( Piedimonte et al, 2020 ). Table 1 (adapted from Piedimonte et al (2020) ) details the histologic findings and location of occult carcinomas from studies included in the systematic review.…”

“…A systematic review of 24 studies including a total of 6283 patients (4473 BRCA1/2 carriers) found 75 patients with occult tubal carcinoma at time of RRBSO in addition to 93 patients with STIC/STIL ( Piedimonte et al, 2020 ). Table 1 (adapted from Piedimonte et al (2020) ) details the histologic findings and location of occult carcinomas from studies included in the systematic review. Although not all of the original studies describe the location of the lesion within the tube, of those that did, 52 cases were located within the fimbriated end of the fallopian tube.…”

“…Rapid uptake of RRBSO following the cloning of BRCA1/2 in the 1990s afforded pathologists the surgical specimens that led to the paradoxical observation that most ovarian cancers begin in the fallopian tube and not the ovary ( Callahan et al, 2007 , Finch et al, 2006 , Piedimonte et al, 2020 , Reade et al, 2014 , Walker et al, 2015 ). Studies evaluating occult cancers and precursor lesions at time of RRBSO including serous tubal intraepithelial lesions (STIL) and serious tubal intraepithelial carcinoma (STIC) lesions demonstrate that the majority of cases arise in the distal end of the fallopian tube, usually the fimbria or ampulla ( Callahan et al, 2007 , Finch et al, 2006 , Piedimonte et al, 2020 ).…”

Role of Routine Peritoneal Biopsies During Risk Reducing Salpingo-Oophorectomy (RRSO)

“…Even if you take biopsies from all recommended sites (paracolic gutters left and right, ovarian fossa left and right, pouch of Douglas and the peritoneal fold of the prevesical pouch), it will still be less than 1 % of the peritoneum [8]. Furthermore, Piedimonte et al [23] mentioned recent data in colorectal cancer indicating seeding of metastases through disseminated cancer cells while the carcinoma is still undetectable (less than 0.01 m 3 ). Therefore, as shown in our study, the routine sampling of peritoneal biopsies during RRSO does not appear to provide any additional information or additional oncological benefit.…”