输卵管感染与癌变及预防性输卵管切除术的价值

临床病理资料提示,输卵管感染可能与输卵管癌、卵巢癌的发生有一定关系,但目前尚无定论。近年来“卵巢癌的输卵管起源学说”使人们日益关注输卵管预防性切除术的价值。目前研究显示,预防性附件切除能有效降低遗传性卵巢癌,尤其是BRCA1/2基因突变携带者的卵巢癌的发病风险,能否降低散发性卵巢癌的发生需进一步探讨。单纯预防性输卵管切除能否降低遗传性及散发性卵巢癌以及其他盆腹腔浆液性腺癌的发病风险也需进一步研究。临床应用预防性附件或输卵管切除时,应慎重评估患者综合情况,权衡手术获益和风险,为患者争取最大手术获益。     

遗传性妇科肿瘤致病基因携带者的降风险手术

<正>妇科肿瘤中，遗传性因素导致的卵巢癌可高达20%。对于高致病性基因携带者，如BRCA1及BRCA2突变的女性，预防性切除输卵管卵巢可有效地降低卵巢癌的风险，从而改善预后，降低死亡率。本文就遗传性妇科肿瘤致病基因携带者降风险手术的治疗和进展，特别是对于遗传性卵巢癌综合征患者降低风险的双侧输卵管-卵巢切除术(risk-reducing salpingo-oophorectomy, RRSO)进行总结和回顾。主要从适宜手术人群和干预时机、     

卵巢癌的输卵管起源学说对妇科手术决策的影响

近年来有观点认为卵巢浆液性癌和腹膜浆液性癌可能起源于输卵管。因此,手术方式上的一些简单改变,如对于有基因风险人群行预防性双侧输卵管切除术取代双侧输卵管卵巢切除术,在降低卵巢癌和腹膜癌的发生风险的同时尚可避免卵巢切除术后的一些相关并发症。     

有卵巢癌遗传倾向妇女处理选择的系统回顾

通过对有关卵巢癌遗传倾向妇女处理选择的文献复习,特别是卵巢癌的发病率、患者的预期寿命、预防性卵巢切除的益处、手术的并发症、预防性卵巢切除术后的抉择,以便为有卵巢癌遗传倾向的妇女选择适当的处理方案。BRCA1和2基因突变与卵巢癌发病有前。带有BRCA突变基因的人群成为卵巢癌的遗传倾向人群,BR CA1基因突变的携带者估计卵巢癌的发病率为16%～54%,而BR CA2突变的携带者危险性较低,约10%～25%。研究分4组(2组回顾性,2组前瞻性)检验预防性卵巢切除术能否降低卵巢发生的危险。在4组中,卵巢预防性切除都可降低卵巢癌发生的危险,但…     

机会性输卵管切除研究进展

全子宫切除术是妇科良性疾病常见的手术方式,行全子宫手术时联合行输卵管切除可作为卵巢癌的一级预防。对于机会性输卵管切除可否降低卵巢癌的发病风险,手术的安全性,以及对卵巢功能的影响,仍存许多争议。本文结合这些争议,探讨全子宫切除术时联合输卵管切除的可行性。     

因良性病变行子宫切除时保留卵巢

因子宫良性病变行子宫切除时常预防性切除卵巢，其目的主要是为降低卵巢癌的发病风险。在美国，切除子宫同时行双侧附件切除的比例由1965年的25％增至1999年的55％。1999年美国妇产科学会发布的临床治疗指南中建议：预防性卵巢切除术不仅要考虑患者的年龄．还要权衡发生卵巢癌的风险以及丧失卵巢功能的利弊。     

子宫切除术中行预防性双侧输卵管切除对卵巢功能的影响

子宫切除术是妇科最常见的手术,以往良性的子宫病变行子宫切除术时并不常规切除双侧输卵管,近年研究提出卵巢浆液性癌可能起源于输卵管的学说,为子宫切除术中行预防性输卵管切除术提供了理论支持,得到了许多临床医生的认可。目前对于子宫切除术中行预防性双侧输卵管切除是否会进一步加重患者围绝经期症状及对卵巢的基础内分泌功能产生影响,目前仍存在争议。本文就子宫切除术中行预防性双侧输卵管切除的风险与意义综述如下。     

因良性病变行子宫切除时保留卵巢

因子宫良性病变行子宫切除时常预防性切除卵巢,其目的主要是为降低卵巢癌的发病风险.在美国,切除子宫同时行双侧附件切除的比例由1965年的25%增至1999年的55%.1999年美国妇产科学会发布的临床治疗指南中建议:预防性卵巢切除术不仅要考虑患者的年龄,还要权衡发生卵巢癌的风险以及丧失卵巢功能的利弊.     

有卵巢癌遗传倾向妇女处理选择的系统回顾[英]／Rosen B…／／Gynecol Oncol

通过对有关卵巢癌遗传倾向妇女处理选择的文献复习，特别是卵巢癌的发病率、患者的预期寿命、预防性卵巢切除的益处、手术的并发症、预防性卵巢切除术后的抉择，以便为有卵巢癌遗传倾向的妇女选择适当的处理方案。     

预防性输卵管切除的应用价值与潜在风险

卵巢浆液性癌发病率呈逐年上升趋势,被视为发展最为迅猛的恶性肿瘤,临床发现时多为晚期。近年研究发现,输卵管伞端可能是女性盆腔浆液性癌前病变或癌的来源,输卵管腹膜接合部位(the fallopian tube-peritoneal junction,TPJ)可能与卵巢表面肿瘤有关。因子宫良性病变需切除子宫的绝经前女性,同时接受预防性双侧输卵管切除可能降低其患盆腔浆液性癌和卵巢表面肿瘤的风险。另外,有研究在输卵管组织发现间充质干细胞,其可作为多能干细胞新来源,并在修复生殖系统损伤中存在优势。综述盆腔肿瘤输卵管起源学说,预防性输卵管切除对盆腔良恶性病变的预防作用、术中及术后并发症,预防性输卵管切除在其他领域的应用价值,切除输卵管对卵巢功能的影响,探讨预防性输卵管切除的安全性及可行性。     

Surgical Implications of the Potential New Tubal Pathway for Ovarian Carcinogenesis

Since 2001, many studies by different investigators have demonstrated that the fallopian tube might be at the origin of most high-grade ovarian and peritoneal serous carcinomas. Simple changes in surgical practice (ie, prophylactic bilateral salpingectomy instead of salpingo-oophorectomy) could have significant implications for death from ovarian cancer and, on the other hand, for the morbidity caused by ovariectomy (surgical menopause). In this review, we describe the new tubal carcinogenic sequence, the advantages and disadvantages of exclusive use of salpingectomy in the general population, and in cases of hereditary predisposition to ovarian cancer such as for carriers of BRCA mutation.     

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.     

Revisiting the pathogenesis of ovarian cancer: the central role of the fallopian tube

Background

Among all gynecological malignancies, ovarian cancer is associated with the highest rate of mortality. Recent findings now propose a pivotal role for the fallopian tube during ovarian cancer pathogenesis.

New insights

Until recently, ovarian cancer was thought to derive from the ovarian surface epithelium. Nevertheless, attempts to define a precursor lesion from this tissue failed. Instead, prophylactic surgery performed on BRCA mutation carriers and subsequent histological analyses revealed a characteristic pre-neoplastic alteration at the fimbriated end of the fallopian tubes, the so-called serous tubal intraepithelial carcinoma (STIC). By morphology and molecular genetics, STIC was found to resemble serous ovarian cancer. As STIC can also be detected in >60 % of BRCA-unrelated serous ovarian carcinomas, it is now considered to be the precursor of the most common ovarian cancer subtype.

Consequences

Based on this hypothesis, a salpingectomy, i.e., the removal of the post-reproductive fallopian tubes may remove the actual site of tumorigenesis and thereby prevent spreading over the ovarian surface and throughout the peritoneum. Consequently, prophylactic salpingectomy might protect against serous ovarian cancer. Moreover, the procedure interrupts the connection between the uterine cavity and the lesser pelvis. Hence, it prevents the ascension of exfoliated endometrial cells which will likely reduce the incidence of endometrioid and clear cell ovarian cancers. Increasing evidence suggests that serous ovarian cancer originates from the fimbriated distal end of the fallopian tube, whereas the ovary gets only involved at a later stage.

Conclusion

Given the lack of suitable screening or early detection strategies for ovarian cancer, post-reproductive salpingectomy deserves serious consideration as a prophylactic intervention that will likely confer significant protection against an often deadly disease.     

Cancer Risk-Reducing Opportunities in Gynecologic Surgery

This review article discusses cancer risk-reducing opportunities in gynecologic surgery. We cover strategies to reduce ovarian and uterine cancer risk by presenting general practice guidelines and expanding on the literature behind clinical decision points. We address populations of women at increased hereditary risk and those at population risk. We specifically discuss risk-reducing salpingo-oophorectomy, prophylactic salpingectomy with delayed oophorectomy, concomitant hysterectomy, opportunistic salpingectomy, bilateral tubal ligation, and hysterectomy. For clinical scenarios in which data are limited or conflicting, we detail the studies on which clinicians' decisions hinge to allow the reader to weigh the available evidence.     

Physician Opinions Regarding Elective Bilateral Salpingectomy With Hysterectomy and for Sterilization

Study ObjectiveTo gather opinions about the benefits and concerns of performing bilateral salpingectomy without oophorectomy during hysterectomy for benign indications and as a sterilization procedure.DesignSurvey study (Canadian Task Force classification III).SettingPracticing physicians in US institutions that have obstetrics and gynecology residency programs listed on the FREIDA website were surveyed electronically.InterventionA validated, standardized questionnaire designed to gather opinions about bilateral salpingectomy performed during hysterectomy or for sterilization was administered via SurveyMonkey to practitioners of obstetrics and gynecology.Measurements and Main ResultsResults were compiled and presented as percentages of total responders. A total of 234 surveys were returned. Fifty-four percent of physicians perform bilateral salpingectomy during hysterectomy, most commonly to reduce the risks of cancer (75%) and repeat operation (49.1%). Of the 45.5% of physicians who do not perform bilateral salpingectomy during hysterectomy, most (69.4%) believe there is no benefit. Fifty-eight percent of practitioners believe that bilateral salpingectomy is the most effective method of sterilization after age 35 years but choose this method only in patients in whom one sterilization procedure has failed or because of tubal disease. Only 7.2% of surgeons prefer it as an interval sterilization procedure.ConclusionMost practitioners believe that bilateral salpingectomy is beneficial. Most also believe that bilateral salpingectomy is the most effective sterilization procedure; however, only 7.2% use this method as an interval procedure. More data are needed to evaluate the prophylactic effect of bilateral salpingectomy against postoperative sequelae.     

Outcome of surveillance and prophylactic salpingo-oophorectomy in asymptomatic women at high risk for ovarian cancer

OBJECTIVE: Women at high risk of ovarian cancer are currently offered two options: either surveillance or prophylactic bilateral salpingo-oophorectomy. The efficacy and outcome of surveillance remain unclear. METHODS: We performed a retrospective study. Between 1994 and 2000, we screened 383 high-risk women, of which 152 were BRCA1/2 mutation carriers. Surveillance consisted of annual gynecological examination, transvaginal ultrasound, and serum CA125 measurement. Exploratory or prophylactic surgery was performed in selected cases. RESULTS: There were no screen-detected primary ovarian cancers. Abnormal results at surveillance were observed in 74 (19.3%) of women; in 47 (63.5%), the abnormalities disappeared spontaneously. Exploratory surgery was performed in 20 (27.0%) women in whom one malignancy was found (metastatic breast cancer in the ovary). A rising CA125 value prompted further (non-surgical) evaluation in three women with a history of breast cancer: recurrent breast cancer was diagnosed in two women; in the third, a chondrosarcoma was found. 133 women opted for prophylactic bilateral salpingo-oophorectomy, whereby two unexpected malignancies were found (fallopian tube cancer and metastatic breast cancer). One interval primary ovarian cancer occurred, presenting as papillary serous carcinoma of the peritoneum 14 months after prophylactic bilateral salpingo-oophorectomy. Complications of prophylactic surgery were encountered in 15 (11.5%) women. CONCLUSIONS: Ovarian cancer surveillance has limited sensitivity, and a high number of false positive findings. This can lead to unnecessary surgical interventions, possibly resulting in surgery-related complications. It is important to inform high-risk women of these limitations. For now, prophylactic bilateral salpingo-oophorectomy remains the optimal risk-reducing strategy for women at high risk.     

BRCA基因突变女性携带者生育力保存研究进展

长期以来,乳腺癌易感基因1（BRCA1）和BRCA2突变被认为是乳腺癌及卵巢癌的独立危险因素。针对肿瘤的任何治疗方式（如双侧输卵管切除术等）都不可避免地对患者生育力带来破坏或丢失。随着女性生育年龄的普遍推迟和癌症发病年龄的年轻化,生育力保护已成为肿瘤治疗决策时经常需要面临的问题。同时,一些研究表明BRCA基因突变也可导致卵巢功能障碍,尤其是卵巢储备能力的下降。就BRCA1/2基因突变携带者可能面临的生育力问题及目前已有的保存生育力技术进行综述为临床提供参考。     

Ovarian pregnancy resulting from cornual fistulae in a woman who had undergone bilateral salpingectomy

OBJECTIVE: To report a case of ovarian pregnancy following in vitro fertilization-embryo transfer (IVF-ET) treatment for which the cornual fistulae was the most probable explanation of the cause. DESIGN: Case report. SETTING: University department and assisted reproduction unit. PATIENT(S): A 29-year-old woman with primary infertility. INTERVENTION(S): Hydrosalpinx of the bilateral fallopian tubes has been noted in patients who have decreased pregnancy rates in the IVF-ET treatment cycles. Salpingectomy before IVF cycles has been suggested to increase the pregnancy rate. We report a patient who presented with bilateral hydrosalpinx for whom bilateral salpingectomy was performed before IVF treatment. MAIN OUTCOME MEASURE(S): Clinical pregnancy. RESULT(S): The treatment cycle resulted in a primary ovarian pregnancy and required laparoscopic operation. A cornual fistulae was found that have might led to ectopic implantation of the embryos. CONCLUSION(S): Ovarian pregnancy may be an unexpected complication of those receiving bilateral salpingectomy before IVF treatment. The presence of cornual fistulae after salpingectomy was probably the cause of the ectopic pregnancy.