Role of prophylactic oophorectomy at the time of hysterectomy in ovarian cancer prevention in Thailand

AIM: To determine the impact of prophylactic oophorectomy on ovarian cancer prevention in Thai women by estimating the magnitude of reduction in ovarian cancer incidence in Thailand if the procedure was routinely offered. METHODS: A database of 752 women with epithelial ovarian cancer treated at Chiang Mai University Hospital between January 1990 and December 2001 was reviewed in an attempt to identify those who had hysterectomy performed for indications other than ovarian and corpus cancer with conservation of one or both ovaries prior to diagnosis of ovarian cancer. Pertinent clinical and pathologic data of the women in this subset were further reviewed in detail. RESULTS: Of 752 ovarian cancer patients, 13 (1.73%) had hysterectomy performed prior to the diagnosis of ovarian cancer with only one woman (0.13%) having had a hysterectomy at the age of 45 or above. The mean interval between the hysterectomy and the diagnosis of ovarian cancer was 9.9 years (range 2-25 years). Considering the rate of prior hysterectomy at age 45 or beyond of 0.13% and the annual national ovarian cancer incidence of 1252 cases, an estimated one to two cases of ovarian cancer could be prevented annually if prophylactic bilateral oophorectomy at the time of hysterectomy in a woman age 45 or beyond were routinely offered in Thailand. CONCLUSION: Prophylactic oophorectomy at the time of hysterectomy in general Thai population as a preventive measure for subsequent ovarian cancer should not be recommended without complete knowledge of patients' socioeconomic background and propensity to comply with hormone replacement therapy regimens.     

Attitudes of Italian gynaecologists towards prophylactic oophorectomy at hysterectomy for non-malignant conditions

OBJECTIVE: To compare the attitudes of Italian oncologic gynaecologists towards prophylactic oophorectomy at hysterectomy for a non-neoplastic reason. STUDY DESIGN: A four-item two-part questionnaire was submitted to 170 gynaecologists attending a national conference on gynaecologic oncology. RESULTS: About 92% of gynaecologists reported they would perform prophylactic oophorectomy in women over 50 years, but only 14% said they would in patients aged 45-50; a family history of cancer emerged as a major decision-making criterion for performing oophorectomy in the younger set of patients. CONCLUSION: Our brief survey confirms the wide variability in attitudes among gynaecologists towards performing prophylactic oophorectomy at hysterectomy for a non-neoplastic pathology in women aged 40-50.     

An exploratory qualitative study of women's perceptions of risk management options for familial ovarian cancer: implications for informed decision making

OBJECTIVE: Women who are at increased risk of familial ovarian cancer face complex decisions about strategies for managing their risk due to a lack of evidence regarding the benefits of ovarian cancer screening (OCS) and prophylactic surgery. At present, there is a limited understanding of women's attitudes towards these options. METHOD: In-depth interviews were conducted to explore perceptions of ovarian cancer screening and prophylactic oophorectomy (PO) in 10 women who were newly identified as being at increased risk of familial ovarian cancer. RESULTS: The study findings highlight the gaps in women's knowledge about risk management options. Although most women derived considerable reassurance from ovarian screening, many were not aware of the limitations of the screening process or the likelihood of receiving false positive results. Areas in which women's knowledge about prophylactic oophorectomy could be improved include the practicalities of surgery, the risks and benefits of HRT given postsurgically, the limitations of surgery in removing risk, and the absence of concrete information on which to base surgical decisions. In particular, women who were not previously aware of their increased risk may need additional psychological support and preparation. CONCLUSIONS: The present study raises serious questions about the extent to which women are making informed decisions about familial ovarian cancer risk management strategies. Suggestions are made for improving the information and support provided to women and for large-scale prospective research.     

Surgical risk reduction: prophylactic salpingo-oophorectomy and prophylactic mastectomy

Investigators have used retrospective and prospective study designs to provide much needed data on the extent of risk reduction after prophylactic oophorectomy and mastectomy in women at increased risk for breast and ovarian cancer. In this publication we identify those women who may wish to consider prophylactic surgery, review data demonstrating the efficacy of prophylactic surgery, and discuss potential surgical complications. We also present data about the frequency of use and psychosocial impact of prophylactic surgery in this typically young group of women. Finally, we provide general treatment guidelines for the practicing clinician.     

Role of hysterectomy and lymphadenectomy in the management of early-stage borderline ovarian tumors

Objective

To examine survival of women with stage T1 borderline ovarian tumors (BOTs) stratified by hysterectomy and lymphadenectomy status at surgery.

Cancer risk in young women at risk of hereditary nonpolyposis colorectal cancer: implications for gynecologic surveillance

OBJECTIVES: The lifetime risk of endometrial and ovarian cancers in hereditary nonpolyposis colorectal cancer (HNPCC) is up to 60 and 12%, respectively, in addition to the high risk of colorectal cancer. International guidelines recommend surveillance of those at risk with colonoscopy every 1--2 years from age 20--25 years and annual gynecologic surveillance from 25--35 years for women. We reviewed our own experience to see whether these recommendations were appropriate. METHODS: Pedigrees of 120 HNPCC families registered with the Familial Bowel Cancer Service at The Royal Melbourne Hospital were reviewed. Ninety families met our criteria for HNPCC and were included in the study. Pedigrees were analyzed to identify early-age onset colorectal and gynecologic cancers and to calculate cumulative incidence of both cancer types for at-risk women (HNPCC-affected and first-degree female relatives of affected family members) for comparison with the general population. RESULTS: Colorectal cancer occurred in 434 individuals, endometrial cancer in 43, and ovarian cancer in 24. Gynecologic and colorectal cancers were diagnosed at similar ages (mean 49.3 versus 51.8 years; P = 0.25), with 5 (7.1%) gynecologic cancers diagnosed by 35 years. Cumulative incidences of gynecologic and colorectal cancers to ages 25, 30, 35, and 40 years were substantially higher among at-risk women than in the general population. CONCLUSIONS: Consideration should be given to offering gynecologic cancer surveillance from the age of 25 years, as for colorectal cancer. However, this approach should be individualized as it has yet to be demonstrated that surveillance reduces the mortality of gynecologic cancer in HNPCC.     

Decision making about prophylactic oophorectomy among at-risk women: psychological influences and implications

OBJECTIVE: Women with a family history of ovarian cancer are confronted with difficult decisions regarding the management of their risk status. Currently, the main preventive option available is prophylactic oophorectomy. The objective of the present paper is to review research and theory on psychological factors that influence decision making about preventive surgery and discuss the implications for patient management. METHODS: Guided by a cognitive-social framework, the literature on decision making about preventive surgery is reviewed and integrated. RESULTS: The available studies show that women are more likely to opt for surgery if they feel more vulnerable to cancer, believe that surgery will prevent cancer, and are worried about developing cancer. Further, the response to ovarian risk is influenced by the individual's characteristic psychological style: monitors (who typically scan for and amplify threatening cues) tend to feel more vulnerable to cancer and more distressed about their cancer risk than blunters (who typically distract from threatening cues) do. CONCLUSION: On the basis of prior research, monitors may be more likely to choose surgical intervention to reduce their distress, without fully anticipating the psychological and medical consequences of that decision. In order to facilitate informed decision making, counseling protocols should be designed to enable the patient to understand and take account of the psychological consequences of the available medical options. Future studies are needed to systematically extend and explore the proposed theory-based relationships.     

Acceptability of prophylactic salpingectomy with delayed oophorectomy as risk-reducing surgery among BRCA mutation carriers

Objective

Given the emerging evidence for the fimbria as the site of origin for many serous carcinomas in BRCA mutation carriers, consideration is being given in studying prophylactic salpingectomy with delayed oophorectomy (PSDO) as a risk-reducing surgery. We aimed to determine the interest in a study of PSDO among these women.

Methods

We evaluated the results of an online survey conducted by Facing Our Risk of Cancer Empowered (FORCE), a patient advocacy group, from October 2010 to August 2012. Premenopausal BRCA mutation carriers with no history of ovarian cancer or prior bilateral salpingo-oophorectomy (BSO) were included.

Results

Of the 204 women meeting inclusion criteria, median age was 35 years, 92.5% were white, 25.7% were Jewish, and 16.7% had a history of breast cancer. Overall, 34.3% reported interest in a study of salpingectomy, 35.3% were unsure, and 30.4% were not interested in the study. Women noted the possibility of lowering ovarian cancer risk without menopause as a compelling reason to participate (83.8%). Reasons for not participating in a salpingectomy study included surgical complications (46.6%), potential ovarian damage (42.2%), planning BSO soon (32.4%), and surgical costs (32.8%). Acceptable study risks included the need for two surgeries (77.2%), possibility of not lowering ovarian cancer risk (68%), and disruption of ovarian blood supply (66.5%).

Conclusions

One-third of BRCA mutation carriers indicated definite interest in a PSDO study. Potential study risks were acceptable to most women. These findings suggest that patient accrual for a clinical trial of prophylactic salpingectomy with delayed oophorectomy is possible.     

子宫腺肌症患者子宫次全切除术后的危险性探讨

目的 :探讨子宫腺肌症患者子宫次全切除术后的危险性 ,为临床子宫腺肌症患者手术方式的选择提供指导。方法 :对子宫腺肌症患者行子宫次全切除术标本的子宫体下切缘进行常规病理组织学检查。结果 :子宫体下切缘子宫内膜异位病灶 (切缘阳性 )的发生率为 12 %。切缘阳性子宫腺肌症患者的子宫肌层最大厚度、临床症状以及是否合并子宫内膜异位症与切缘阴性的子宫腺肌症患者差异无显著性 (P >0 .0 5)。但切缘阳性子宫腺肌症患者的宫体纵形长度明显小于切缘阴性者 (P <0 .0 5)。结论 :子宫腺肌症患者的病程较长 ,病变弥漫、痛经明显且时间较长、合并子宫内膜异位症可能是子宫体下切缘阳性的高危因素 ,手术时切口过高是子宫体下切缘阳性的直接因素。子宫腺肌症患者如年龄较大同时存在高危因素 ,则应行全子宫切除术 ,如行子宫次全切除术 ,切口位置应尽量低 ,而且应对子宫体下切缘行病理组织学检查     

Synchronous occult cancers of the endometrium and fallopian tube in an MSH2 mutation carrier at time of prophylactic surgery

BackgroundWomen with Lynch syndrome have a 40 to 60% lifetime risk of endometrial cancer and a 10 to 12% lifetime risk of ovarian cancer and may consider prophylactic gynecological surgery as an option for risk reduction.CaseWe report a case of synchronous primary cancers of the endometrium and fallopian tube diagnosed at time of prophylactic surgery in an MSH2 mutation carrier.ConclusionRisk-reducing gynecological surgery in Lynch syndrome must include complete removal of the fallopian tubes in addition to the ovaries and endometrium, followed by careful pathological review. Prospective studies are needed to clarify the incidence of occult primary carcinoma of the fallopian tube among female MMR mutation carriers undergoing prophylactic surgery.     

Efficacy of screening women at high risk of hereditary ovarian cancer: results of an 11-year cohort study

Abstract.   Gaarenstroom KN, van der Hiel B, Tollenaar RAEM, Vink GR, Jansen FW, van Asperen CJ, Kenter GG. Efficacy of screening women at high risk of hereditary ovarian cancer: results of an 11-year cohort study. Int J Gynecol Cancer 2006; 16(Suppl. 1): 54–59.
The outcome of screening and prophylactic surgery in 269 women at high risk of hereditary ovarian cancer is reported. Screening was performed using transvaginal ultrasound and serum CA125 testing. Mean follow-up was 26 months (583 person-years). A total of 113 (42%) of 269 women had a pathogenic BRCA1 or BRCA2 mutation, and 127 (47%) of 269 women underwent salpingo-oophorectomy. No occult cancers were found. In eight women having both elevated CA125 levels and abnormal ultrasound findings, a malignancy was found. Four of these cancers (one borderline, one stage Ia, one stage IIIb, and one stage IIIc ovarian or peritoneal cancer) were detected at the first screening visit. One stage IIIb and one stage IIIc cancer were detected at the second screening visit after 12 months, and two interval stage IIIc and IV cancers were detected 8 and 10 months after the first screening visit. No peritoneal carcinoma was found among those 114 women who underwent bilateral salpingo-oophorectomy with normal or benign pathology results, after a mean follow-up of 16 months (152 person-years). We conclude that the efficacy of screening women at high risk of ovarian cancer seems poor because the majority of cancers were detected at an advanced stage.     

Occult endometrial cancer and decision making for prophylactic hysterectomy in hereditary nonpolyposis colorectal cancer patients

BACKGROUND AND OBJECTIVE: Hereditary nonpolyposis colorectal cancer (HNPCC) is the most frequent form of hereditary colorectal cancer. In addition to the high lifetime risk for colorectal cancer in mutation carriers, there is also a remarkably increased risk for endometrial cancer (EC). METHODS: In this retrospective study, clinical and molecular approach to the individual decision making as to whether or not to perform a prophylactic hysterectomy in a subset of HNPCC patients is discussed. 147 female patients meeting at least one criterion of the Bethesda guidelines were included in this analysis between 1995 and 2003. After clinical and genetic counseling, patients gave informed written consent and microsatellite analysis, immunohistochemistry and sequencing of the mismatch repair genes MLH1, MSH2 and MSH6 was performed. RESULTS: 11 of the analyzed patients had a personal history of EC and had undergone previous hysterectomy at ages 26 to 62 years. Prophylactic hysterectomy with oophorectomy was considered in postmenopausal women meeting the Amsterdam criteria and/or carrying a disease causing mismatch repair gene mutation who were operated on because of diagnosed colorectal cancer in our center for hereditary cancer. This procedure was performed in 4 patients. None of them had shown any symptoms of a gynecologic malignancy. Preoperative gynecological examination showed no evidence for EC or ovarian cancer in these patients. Postoperative histological examination showed EC stage T1b N0 M0 in 2 patients. CONCLUSIONS: Since the efficiency of gynecological surveillance is uncertain, prophylactic hysterectomy could be an option for a subset of HNPCC patients and mutation carriers.     

Screening for familial ovarian cancer—management and outcome of women with moderate to high risk of developing ovarian cancer

Abstract.   Rieck GC, Lim K, Rogers MT, France E, Gray JR, Amso N, Evans AS, Howells RH, & Fiander AN. Screening for familial ovarian cancer—management and outcome of women with moderate to high risk of developing ovarian cancer. Int J Gynecol Cancer 2006; 16(Suppl. 1): 86–91.
Five percent to ten percent of ovarian cancers are hereditary. Individual genetic risk of developing ovarian malignancy is discussed in women. Currently, prophylactic surgery is advised to women with a moderate to high risk of developing ovarian cancer. Workload and outcome of the multidisciplinary familial ovarian screening clinic in South Wales were assessed. This was an observational study of 145 women registered with the Familial Ovarian Screening Clinic between January 1998 and December 2003. The data were retrieved from the medical notes. Yearly follow-ups were investigated with a transvaginal scan and CA125 level. Post-surgery women were followed up with yearly CA125 estimations: 46.9% fell into moderate-risk and 50.3% into high-risk category. The median age was 42 (SD 10.4), 71.7% were pre menopausal, and 10.3% had a personal history of breast cancer and 1.4% colon cancer. Whereas 36.5% opted for surgery, the remaining women (but two) opted for annual follow-up. Histology of the women who had surgery showed three cases of malignancies (fallopian tube carcinoma, atypical ovarian epithelial cells, and metastatic breast cancer). Seven women developed breast cancer during the observation period. The follow-up period is too short to come to a final conclusion as to the benefits of yearly screening in this group of women. In our series, a significant number of patients developed malignancies, despite prophylactic surgery.     

Current status of prophylactic surgery for hereditary breast and gynecologic cancers

Given the limitations regarding the impact of screening and the uncertainties concerning chemoprevention for women with significant genetic susceptibilities to breast, endometrial and ovarian cancers, recent research and publications on prophylactic surgery for cancer prevention and improved long-term survival for women at hereditary risk have increasing importance.     

Long-term impact and risk factors for hysterectomy after hysteroscopic surgery for menorrhagia

The objective of this study was to assess the long-term impact of management and establish the incidence of hysterectomy, and to identify factors predictive of failure of the procedure among women who had undergone hysteroscopic endometrial resection with or without myomectomy for menorrhagia. Clinical history and data on additional treatment and follow-up status were obtained by medical record review and postal questionnaire for 279 women who had undergone hysteroscopic surgery. Follow-up data were available for 259 (93%) cases, and the mean follow-up was 6.0 years. Subsequent hysterectomy was the primary endpoint, and its incidence was calculated by survival analysis. Univariant analysis and Cox regression model were used to identify predictors of failure. Myomas, polyps, adenomyosis, or endometrial hyperplasia were found in 40.9% of hysteroscopic procedures. Perioperative complications occurred in 5.7% and late complications in 7.7%. During the follow-up period, 97 (37.5%) of 259 women underwent at least one gynecological procedure. The incidence of hysterectomy was 23.6% (95% confidence interval: 18.8–29.1%). Positive predictive factors for hysterectomy were long uterine cavity (≥9 cm) and tubal ligation. Most (82.8%) of the 198 women who did not undergo hysterectomy had postoperative oligo- or amenorrhea. Hormone replacement therapy was common (67%) among postmenopausal women after endometrial resection. Hysteroscopic resection of the endometrium and concomitant hysteroscopic resection of fibroids for the treatment of menorrhagia is a suitable alternative to hysterectomy and offers lasting results. A large uterine cavity indicating possible uterine pathology and tubal ligation associated with hematometra increase the risk of hysterectomy.     

Epidural analgesia is associated with an increased incidence of postoperative complications in patients requiring an abdominal hysterectomy for early stage endometrial cancer

Objective

Analgesia and early quality of recovery may be improved by epidural analgesia. We aimed to assess the effect of receiving epidural analgesia on surgical adverse events and quality of life after laparotomy for endometrial cancer.

Methods

Patients were enrolled in an international, multicentre, prospective randomised trial of outcomes for laparoscopic versus open surgical treatment for the management of apparent stage I endometrial cancer (LACE trial).The current analysis focussed on patients who received an open abdominal hysterectomy via vertical midline incision only (n = 257), examining outcomes in patients who did (n = 108) and did not (n = 149) receive epidural analgesia.

Results

Baseline characteristics were comparable between patients with or without epidural analgesia. More patients without epidural (34%) ceased opioid analgesia 3–5 days after surgery compared to patients who had an epidural (7%; p < 0.01). Postoperative complications (any grade) occurred in 86% of patients with and in 66% of patients without an epidural (p < 0.01) but there was no difference in serious adverse events (p = 0.19). Epidural analgesia was associated with increased length of stay (up to 48 days compared to up to 34 days in the non-epidural group). There was no difference in postoperative quality of life up to six months after surgery.

Conclusions

Epidural analgesia was associated with an increase in any, but not serious, postoperative complications and length of stay after abdominal hysterectomy. Randomised controlled trials are needed to examine the effect of epidural analgesia on surgical adverse events, especially as the present data do not support a quality of life benefit with epidural analgesia.     

调强放射治疗在宫颈癌术后治疗中的临床研究

目的 探讨调强放射治疗（IMRT）用于宫颈癌术后提高靶区受照射剂量,减少并发症的价值。方法 对2002年6月至2006年6月山东省肿瘤医院20例宫颈癌术后患者放疗前均给予2-3个周期化疗,并行全程IMRT,每日1次,每次1.8-2.2Gy,每周5次,给予处方剂量50-60Gy,中位剂量54.5Gy;同时拟设计该20例患者的普通2野放疗计划,拟给予相同的处方剂量,比较危险器官（OAR）受照射剂量;选取同期23例接受普通放疗的完整病例,比较调强放疗和普通放疗急、慢性毒副反应及近期存活率。结果 20例患者均完成全程IMRT,放射治疗计划靶区（planning target volume,PTV）内的平均剂量为56.2Gy,90%的等剂量曲线（中位剂量54.5Gy）可以覆盖99%以上的肉眼靶区（gross target volume,GTV）体积。IMRT与拟行普通2野放疗计划比较,小肠、直肠、膀胱的受照射剂量均明显减小,P均〈0.01;IMRT与普通放疗比较,急慢性毒副反应明显降低,但1、2、3年存活率比较差异无显著性意义,P〉0.05。结论 IMRT技术使宫颈癌术后患者的靶区获得理想的剂量分布,邻近危险器官得到很好的保护,毒副反应可以耐受,但未能提高患者近期存活率。