PROPHYLACTIC SALPINGECTOMY

DR SUJOY DASGUPTAMBBS (Gold Medalist, Hons)

MS (Obst & Gynae- Gold Medalist)DNB (Obst & Gynae)

Fellow- Reproductive Endocrinology & Infertility, ACOG (USA)

OVARIAN

CANCER

Surgery

Chemotherapy

Targeted Therapy

ImmunoTherapy

Viral Therapy

Gene Therapy

•Docetaxel•Trabectedin•Liposomal Doxorubicin•Nanotherapy

•Oncolytic Measles • AdV-tk

•Veliparib•Bevacizumab

•Therapeutic Vaccine- FANG vaccine, TroVax•Adaptor T cell Transfer

• Monoclonal Ab- Demcizumab•Antibody-Drug Conjugate- Ipilimumab, urelumab

RESULTS

Cure?????

National Institute of Health, SEER Stat Fact Sheets: Ovary Cancer

Advanced Epithelial Ovarian Cancer- 75%

Prevention

Screening

Precancerous Stage

• Cervix• Colon• Breast

BSO Specimens in BRCA Mutations• Colgan TJ, Murphy J, Cole DE, Narod S, Rosen B. Am J Surg

Pathol.2001;25:1283–9. • Piek JM, van Diest PJ, Zweemer RP, et al.  J Pathol. 2001;195:451–6.

TP53 Ki67

Serous Tubal Intraepithelial Carcinoma (STIC)

In hereditary “ovarian” cancer the precursors are in the fallopian tube (tubal intraepithelial carcinoma or TIC)

Further Studies in BSO SpecimensBRCA Mutation Status STIC in histopathology1-5

BRCA Carriers 60-100%BRCA Non-Carriers 30-60%

1. Kamran MW, Vaughan D, et al. Eur J Obstet Gynecol Reprod Biol 2013;170:251–4.

2. Erickson BK, Conner MG, Landen CN Jr. Am J Obstet Gynecol 2013;209:409–14.

3. Kurman RJ, Shih I. Am J Surg Pathol 2010;34:433–43.4. Crum CP. Mol Oncol 2009;3:165–70.5. Kindelberger DW, Lee Y, et al. Am J Surg Pathol 2007;31:161–9.

Seih, Salvador, et al. Int J Epidemiology. 2013

Potential to develop endometrioid/ clear cell

carcinomas

Retrograde menstruation

(Inflammation, Endometriosis)

Infection

Irritants (Talc)

Fallopian tube as conduitOvarian Cancer- a Misnomer!!!

Potential to develop endometrioid/ clear cell

carcinomas

Tubal ligation (or salpingectomy)

blocks passage

Retrograde menstruation

(Inflammation, Endometriosis)

Infection

Irritants (Talc)

Development of high-grade serous

carcinomas

Salpingectomy removes at-risk

tissue

Fallopian tube as conduit Fallopian tube as sourceOvarian Cancer- a Misnomer!!!

Potential to develop endometrioid/ clear cell

carcinomas

Tubal ligation (or salpingectomy)

blocks passage

Retrograde menstruation

(Inflammation, Endometriosis)

Infection

Irritants (Talc)

Development of high-grade serous

carcinomas

Salpingectomy removes at-risk

tissue

Fallopian tube as conduit Fallopian tube as sourceOvarian Cancer- a Misnomer!!!

Prophylactic Salpingectomy

Research vs Practice

SOGC, 2010

Change 1

Change 2

ACOG Recommendations (2015)

1. The surgeon and patient should discuss the potential benefits of the removal of the fallopian tubes during a hysterectomy in women at population risk of ovarian cancer who are not having an oophorectomy.

2. When counselling women about laparoscopic sterilization methods, clinicians can communicate that bilateral salpingectomy can be considered a method that provides effective contraception.

3. Prophylactic salpingectomy may offer clinicians the opportunity to prevent ovarian cancer in their patients.

4. Randomized controlled trials are needed to support the validity of this approach to reduce the incidence of ovarian cancer.

Procedure

Route• Decision for salpingectomy-

should not alter route for hysterectomy (ACOG Committee Opinion, Number 620, Jan 2015)

How much to remove•Remove completely from fimbrial end up to utero-tubal junction•Cauterize/ remove any fimbrial attachment on the ovary•Preserve blood supply to ovary through hilum

Short Term Results

No differences in• Length of hospital stay • Surgical Complications• Blood transfusion• Re-admission to hospital

Operating Time

Minimal additional time*

*McAlpine JN, Hanley GE, Woo MM, et al. Am J Obstet Gynecol 2014;210:471.e1–471.e11

Hysterectomy + 16 Min

Sterilization + 10 Min

Ovarian Function?

BRCA Mutation

1. Screening- Breast, Ovary2. Life-style modification-

Pregnancy, Lactation, Tubal Ligation

3. Chemoprevention- COC, Tamoxifen

4. Prophylactic Surgery-• Mastectomy• Bilateral Salpingo-

Oohorectomy(BSO)

High Risk Women

• Recommend risk-reducing salpingo-oophorectomy, ideally between 35 and 40 years, and upon completion of child bearing, or individualized based on early age of onset of ovarian cancer in the family, after family is completed

• Salpingectomy (BSOR) in place of Salpingo-oophorectomy

(BSO)???

• Bilateral salpingectomy with ovarian retention (BSOR), may have a public health benefit for women undergoing benign gynecologic surgery, especially in those for whom BSO is recommended but who are reluctant to have their ovaries removed due to hormonal implications.

• Salpingectomy alone is not the standard of care and is discouraged outside a clinical trial. The concern for risk-reducing salpingectomy alone is that women are still at risk for developing ovarian cancer.

Solution???

• Two step procedure Salpingectomy alone (BSOR)-

in early age followed by Oophorectomy- after

menopause

We do not know

• Necessary cause of Ovarian Cancer?

• Why ovarian mass dominates over tubal mass?

• How tubal cancer cells seeds into ovary/ peritoneum?

Future

• Still many missed opportunities

• ?Other surgical procedures • Long term effects • Overall impact on survival• Cost-effectiveness

Indian Scenario

• Restricted access to health care system

• A substantial portion of Indian women opt for tubal ligation

• Total tubectomy is seldom performed

• Hysterectomy with BSOR ?

Final thought

• Prophylactic salpingectomy should be routine during hysterecomy for benign gynaecological conditions

• Should be discussed as permanent contraceptive measures for women seeking tubal ligation

• Absolutely safe• Puts ray of hope in prevention of ovarian cancer• Women positive for BRCA1 or BRCA2 who

have not completed child-bearing?

Ideal trialRCT

(High-Risk Women)BSOR

f/b delayed oophorecto

my

BSO as single surgery

RCT (High-Risk & Average-Risk

Women)Hysterecto

my with BSOR

Hysterectomy alone

Bertrand Russel

Thank You