Should salpingectomy be standard of care at time of bilateral tubal ligation?
Two experts take sides on the clinical merits of performing bilateral salpingectomy alone versus removing the tubes in BRCA mutation carriers.
Yes. The procedure’s low morbidity and potential for significant benefit justify removal.
By Denise R. Nebgen, MD, PhD
Dr. Nebgen is an Associate Professor in the Department of Gynecologic Oncology and Reproductive Medicine, and a member of the Clinical Cancer Genetics Program at The University of Texas MD Anderson Cancer Center, Houston.
She has no conflict of interest to disclose with respect to the content of this article.
Ovarian cancer is deadly, with approximately 25,000 cases diagnosed and 12,500 deaths per year in the United States.1 Despite huge international efforts, there are no effective methods of screening for the disease. The lifetime risk of ovarian cancer in women in the general population is 1.5%, compared with a 10% to 46% risk of developing the disease by age 70 among those with BRCA mutation.2
Owing to their elevated risk, many women with BRCA mutations undergo risk-reducing bilateral salpingo-oophorectomy (BSO) at approximately age 40, which reduces their risk of ovarian cancer by 80% or more,3,4 but results in early menopause. Thorough pathologic analysis of specimens from these women has revealed a 4%–17% incidence of occult malignancy, with most of the lesions in the distal portion of the Fallopian tube or fimbria.5,6 Multiple studies have demonstrated a sequence of events known as the tubal carcinogenic pathway that lead to the development of serous tubal intraepithelial carcinomas and invasive ovarian carcinoma in BRCA mutation carriers.5 The Fallopian tube origin of BRCA-associated ovarian cancer, along with the challenges associated with premature menopause following risk-reducing BSO, have led to an interest in performing prophylactic bilateral salpingectomy (BS) with delayed oophorectomy in women with BRCA mutations. Current clinical data demonstrating the efficacy of BS are sparse, but empiric surgical procedures and clinical trials, including one in BRCA women at the authors’ facility, are under way.
Salpingectomy in the general population
The next question that arises is whether routine removal of the Fallopian tubes during surgical procedures is justified in women in the general population who have completed childbearing. We know that bilateral tubal ligation (BTL) reduces ovarian cancer risk by 50% not only in women with BRCA mutations, but also in the general population of women. What we don’t know is the extent to which salpingectomy would further decrease the risk of ovarian cancer. Recent findings show that prophylactic salpingectomy performed in combination with hysterectomy or in place of currently used sterilization procedures does not increase the risk of complications.
The results of a retrospective study that compared BS with BTL alone in 43,931 women in British Columbia were recently published.7 The study’s aim was to assess the uptake and perioperative safety of BS as an ovarian cancer risk reduction strategy in women at low risk of ovarian cancer after the introduction of this concept throughout the province as an educational initiative. The study found that the rate of performance of BS instead of routine BTL increased from 0.5% to 35% over the 4-year period between 2008 and 2011. The operating room time for BS was a mean of 10.2 minutes longer than for BTL alone. The patients in the BS group showed no significant increase in hospital readmissions, blood transfusion, or length of stay compared with the corresponding group, including procedures performed in the peripartum setting.
Perspective on the postpartum setting
Concerns about an increased risk of complications from BS in the postpartum setting due to increased tissue vascularity were addressed in an abstract presented at the American College of Obstetricians and Gynecologists Annual Clinical Meeting in May 2014. Hsieh et al. found no increase in complications in 59 cases of postpartum distal salpingectomy compared with 61 historical controls.8 Vaginal delivery followed by distal salpingectomy resulted in a mean of 5 minutes more operating time and 10 mL more estimated blood loss per case than vaginal delivery followed by modified Pomeroy tubal ligation.
Cesarean delivery with distal salpingectomy resulted in a mean of 17 minutes more operating time but 171 mL less estimated blood loss than cesarean delivery with BTL. Thus, both this study and the Canadian study indicated minimal additional risk with the performance of BS. The risk of regret after permanent sterilization with BS is also a concern; however, in vitro fertilization offers patients a viable option if childbearing is desired.
The bottom line
More data are needed to determine if sporadic ovarian cancer also originates in the distal Fallopian tube. The ovarian cancer risk reduction efficacy data for BS will take time to produce but look promising. I support BS at the time of BTL as an ovarian cancer risk reduction measure because of the low morbidity of the procedure and the potential significant benefit. Bilateral salpingectomy does not increase the overall time of the surgical procedure or decrease its safety and, with appropriate education, could be implemented into routine practice. Approximately 600,000 BTLs are performed in the United States annually.9
Performing BS rather than BTL for women desiring permanent sterilization can theoretically decrease the incidence of ovarian cancer by more than 50% in this large population of women with little to no increased surgical risk.
References
1. Quirk JT, Natarajan N, Mettlin CJ. Age-specific ovarian cancer incidence rate patterns in the United States. Gynecol Oncol. 2005;99:248–250.
2. Lancaster JM, Powell CB, Kauff ND, et al. Society of Gynecologic Oncologists Education Committee statement on risk assessment for inherited gynecologic cancer predispositions. Gynecol Oncol. 2007;107:159–162.
3. Finch A, Beiner M, Lubinski J, et al. Salpingo-oophorectomy and the risk of ovarian, fallopian tube, and peritoneal cancers in women with a BRCA1 or BRCA2 Mutation. JAMA. 2006;296:185–192.
4. Rebbeck TR, Kauff ND, Domchek SM. Meta-analysis of risk reduction estimates associated with risk-reducing salpingo-oophorectomy in BRCA1 or BRCA2 mutation carriers. J Natl Cancer Inst. 2009;101:80–87.
5. Chene G, Rahimi K, Mes-Masson AM, Provencher D. Surgical implications of the potential new tubal pathway for ovarian carcinogenesis. J Minim Invasive Gynecol. 2013;20:153–159.
6. Yates MS, Meyer LA, Deavers MT, et al. Microscopic and early-stage ovarian cancers in BRCA1/2 mutation carriers: building a model for early BRCA-associated tumorigenesis. Cancer Prev Res (Phila). 2011;4:463–470.
7. McAlpine JN, Hanley GE, Woo MM, et al. Opportunistic salpingectomy: uptake, risks, and complications of a regional initiative for ovarian cancer prevention. Am J Obstet Gynecol. 2014;210:471 e1- e11.
8. Hsieh GL, Antony K, Masand R, Anderson M. A prospective feasibility study of postpartum distal salpingectomy. Obstet Gynecol. 2014;123 Suppl 1:92S.
9. Westhoff C, Davis A. Tubal sterilization: focus on the U.S. experience. Fertil Steril. 2000;73:913–922.
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