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Prophylactic Surgery: Oophorectomy or Adnexectomy?

Institut Gustave Roussy Villejuif, France

To the Editor:In a recent article, Eisen et al¹ presented a comprehensive updated review, together with management recommendations, for prophylactic surgery in women from breast/ovarian cancer families. Although we agree with most of the proposed attitudes, we would like to emphasize the need for reflection regarding the extent of the surgical procedure of oophorectomy. Indeed, several reports have recently described the occurrence of fallopian tube carcinomas among BRCA1/BRCA2 mutation carriers.^2-5 One of them clearly demonstrated a molecular link between the two tumors studied and BRCA1 germline mutations.⁴ In our series, among 44 BRCA1 and 17 BRCA2 families identified to date, in which 23 and four ovarian carcinomas, respectively, have been diagnosed in carriers of deleterious mutations, one fallopian tube carcinoma occurred in a 33-year-old woman carrying a germline BRCA1 mutation (3660del16). Fallopian tubes, like the ovaries and peritoneum, are derived from the coelomic epithelium. Although the residual risk of primary peritoneal carcinoma in prophylactically oophorectomized patients has been studied extensively,⁶ little is known regarding the risk of fallopian tube cancer in the same context. Interestingly, a recent case report described a fallopian tube carcinoma discovered fortuitously during the pathologic examination of adnexa that had been removed prophylactically in a BRCA1 carrier.⁷ Since laparoscopic adnexectomy has been demonstrated to be as safe and as simple as oophorectomy using the same technique,^8,9 we currently recommend the prophylactic removal of both ovaries and fallopian tubes, together with systematic peritoneal biopsies, in women with a hereditary risk of ovarian cancer.

REFERENCES

1. Eisen A, Rebbeck TR, Wood WC, et al: Prophylactic surgery in women with a hereditary predisposition to breast and ovarian cancer. J Clin Oncol 18: 1980-1995, 2000[Abstract/Free Full Text]

2. Shubert EL, Lee MK, Mefford HC, et al: BRCA2 in American families with four or more cases of breast or ovarian cancer: Recurrent and novel mutations, variable expression, penetrance, and the possibility of families whose cancer is not attributable to BRCA1 or BRCA2. Am J Hum Genet 60: 1031-1040, 1997[Medline]

3. Rose PG, Shrigley R, Wiesner GL: Germline BRCA2 mutation in a patient with fallopian tube carcinoma: A case report. Gynecol Oncol 77: 319-320, 2000[Medline]

4. Zweener RP, van Diest PJ, Verheijen RHM, et al: Molecular evidence linking primary cancer of the fallopian tube to BRCA1 germline mutations. Gynecol Oncol 76: 45-50, 2000[Medline]

5. Tong D, Stimpfl M, Reinthaller A, et al: BRCA1 gene mutations in sporadic ovarian carcinomas: Detection by PCR and reverse allele-specific oligonucleotide hybridization. Clin Chem 45: 976-981, 1999[Abstract/Free Full Text]

6. Struewing JP, Watson P, Easton DF, et al: Prophylactic oophorectomy in inherited breast/ovarian cancer families. J Natl Cancer Inst Monogr 17: 33-35, 1995

7. Hartley A, Rollason T, Spooner D: Clear cell carcinoma of the fimbria of the fallopian tube in a BRCA1 carrier undergoing prophylactic surgery. Clin Oncol 12: 58-59, 2000

8. Eltabbakh GH, Piver MS, Hempling RE, et al: Laparoscopic management of women with a family history of ovarian cancer. J Surg Oncol 72: 9-13, 1999[Medline]

9. Morice P, Pautier P, Mercier S, et al: Laparoscopic prophylactic oophorectomy in women with inherited risk of ovarian cancer. Eur J Gynaecol Oncol 20: 202-204, 1999[Medline]

Response

McMasterUniversity, Hamilton, Ontario, Canada; University of Pennsylvania Health System Philadelphia, PA; Emory University, Atlanta, GA

In Reply:Drs Delaloge, Morice, Chompret, and Lhommé suggest that BRCA1 and BRCA2 mutation carriers should have their fallopian tubes removed at the time of prophylactic oophorectomy in order to prevent the development of fallopian tube carcinoma. For technical reasons, the fallopian tubes are routinely removed at the time of oophorectomy at our institutions. Although we agree that case reports have suggested an association between germline BRCA1 and BRCA2 mutations and fallopian tube carcinoma,^1-5 this has not been confirmed in large series.^6,7

REFERENCES

1. Schubert EL, Lee MK, Mefford HC, et al: BRCA2 in American families with four or more cases of breast or ovarian cancer: Recurrent and novel mutations, variable expression, penetrance, and the possibility of families whose cancer is not attributable to BRCA1 or BRCA2 [see comments]. Am J Hum Genet 60: 1031-1040, 1997

2. Rose PG, Shrigley R, Wiesner GL: Germline BRCA2 mutation in a patient with fallopian tube carcinoma: A case report. Gynecol Oncol 77: 319-320, 2000

3. Zweemer RP, van Diest PJ, Verheijen RH, et al: Molecular evidence linking primary cancer of the fallopian tube to BRCA1 germline mutations. Gynecol Oncol 76: 45-50, 2000

4. Tong D, Stimpfl M, Reinthaller A, et al: BRCA1 gene mutations in sporadic ovarian carcinomas: Detection by PCR and reverse allele-specific oligonucleotide hybridization. Clin Chem 45: 976-981, 1999

5. Hartley A, Rollason T, Spooner D: Clear cell carcinoma of the fimbria of the fallopian tube in a BRCA1 carrier undergoing prophylactic surgery. Clin Oncol (R Coll Radiol) 12: 58-59, 2000[Medline]

6. Ford D, Easton DF, Bishop DT, et al: Risks of cancer in BRCA1-mutation carriers: Breast Cancer Linkage Consortium. Lancet 343: 692-695, 1994[Medline]

7. The Breast Cancer Linkage Consortium: Cancer risks in BRCA2 mutation carriers. J Nat Cancer Inst 91: 1310-1316, 1999[Abstract/Free Full Text]

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