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Risk-reducing salpingectomy as a new and safe strategy to prevent ovarian cancer

      To the Editors:
      We read with great interest the recent review regarding the role of the fallopian tube in the origin of ovarian cancer,
      • Erickson B.K.
      • Conner M.G.
      • Landen Jr., C.N.
      The role of the fallopian tube in the origin of ovarian cancer.
      and we totally agree that risk-reducing salpingectomy (RRS) has the potential to reduce the risk of serous carcinoma. At the time of the review submission, however, paucity of information on ovarian function following salpingectomy existed in literature, and one important concern was that it might be adversely affected by the procedure.
      Considering our recent results, we are pleased to add an important piece in this issue because we have just concluded an analysis on 79 patients who underwent total laparoscopic hysterectomy at our department.
      • Morelli M.
      • Venturella R.
      • Mocciaro R.
      • et al.
      Prophylactic salpingectomy in premenopausal low-risk women for ovarian cancer: primum non nocere.
      In all these women, ovaries were preserved but RRS was added.
      Since 2010, indeed, we discuss the RRS risks and benefits with suitable patients (eg, women who accomplished their reproductive desire and undergoing any surgery for benign disease, such as hysterectomy, myomectomy, third or more cesarean section, ovarian cyst enucleation, or cholecystectomy).
      We believe that in the general population, RRS might reduce the risk of sporadic ovarian cancer, improving at the same time the quality of life and reducing the risk of premature death caused by cardiovascular disease, seen in women subjected to salpingo-oophorectomy before the onset of natural menopause.
      • Parker W.H.
      • Broder M.S.
      • Chang E.
      • et al.
      Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses' Health Study.
      Nevertheless, from the beginning of our initiative, we have been aware that to validate RRS with ovarian preservation as a safe strategy, it is mandatory to assess surgical or long-term hormonal complications associated with it. Research groups around the world have looked forward to this awareness.
      Our published data
      • Morelli M.
      • Venturella R.
      • Mocciaro R.
      • et al.
      Prophylactic salpingectomy in premenopausal low-risk women for ovarian cancer: primum non nocere.
      demonstrate that if RRS is performed with care in preserving blood vessels in the proximity of the ovarian hilum, no patient will have negative effects in terms of ovarian function, and no perioperative complication is attributable to the salpingectomy step. Despite the retrospective fashion of the data, according to our post hoc analysis, this equivalence study resulted to have a statistical power of 96.8%. This result allows us to comment on these data with a very good statistical reliability.
      Obviously future trials are necessary to determine the real impact of RRS on preventing high grade serous cancer, but we believe that a discussion with patients about tube removal at the time of hysterectomy or tubal ligation should be part of the informed consent process. Women are aware that salpingectomy will not prevent cancer certainly, but we can reassure patients that this intervention does not harm them.

      References

        • Erickson B.K.
        • Conner M.G.
        • Landen Jr., C.N.
        The role of the fallopian tube in the origin of ovarian cancer.
        Am J Obstet Gynecol. 2013 Apr 10; ([Epub ahead of print]. pii: S0002-9378(13)00382-7)
        • Morelli M.
        • Venturella R.
        • Mocciaro R.
        • et al.
        Prophylactic salpingectomy in premenopausal low-risk women for ovarian cancer: primum non nocere.
        Gynecol Oncol. 2013; 129: 448-451
        • Parker W.H.
        • Broder M.S.
        • Chang E.
        • et al.
        Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses' Health Study.
        Obstet Gynecol. 2009; 113: 1027-1037

      Linked Article

      • The role of the fallopian tube in the origin of ovarian cancer
        American Journal of Obstetrics & GynecologyVol. 209Issue 5
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          Advanced cases of epithelial ovarian, primary peritoneal, and primary tubal malignancies have a relatively poor prognosis and collectively remain the most deadly of all gynecologic malignancies. Although traditionally thought of as one disease process, ongoing research suggests that there is not 1 single site or cell type from which these cancers arise. A majority of the serous tumors appear to originate from dysplastic lesions in the distal fallopian tube. Therefore, what we have traditionally considered “ovarian” cancer may in fact be tubal in origin.
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      • Reply
        American Journal of Obstetrics & GynecologyVol. 209Issue 4
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          We appreciate the opportunity to review the manuscript of Morelli et al,1 which was recently e-published ahead of print in Gynecologic Oncology. Ensuring surgical feasibility and safety is important as we move forward to use strategies of risk reduction. In this single-institution retrospective study, 79 patients who had salpingectomy with their total laparoscopic hysterectomy (TLH) since 2010 were compared with 79 patients who underwent a simple TLH from 2008 to 2010. The authors importantly found no increase in complications with additional salpingectomy and also found that there was no significant change in ovarian reserve 3 months after surgery.
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