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Case report

  1. Top of page
  2. Case report
  3. Discussion
  4. References

A 54 year old woman attended the genetics service for consideration of screening for ovarian cancer. She was found to be a BRCA2 mutation carrier. Her mother and grandmother had died of breast cancer at an early age, and the woman herself had undergone a right mastectomy in 1994 for breast cancer. Following this, she suffered two pulmonary emboli and was commenced on lifetime warfarin therapy.

Her lifetime risk of ovarian cancer was calculated as being 10–20%. The options of screening with annual ultrasound scans and serum CA125 estimation or prophylactic salpingo-oophorectomy were discussed. She previously had a hysterectomy for postpartum complications and a left salpingo-oophorectomy for benign indications. She elected to undergo prophylactic removal of her remaining ovary and tube and was offered laparoscopic salpingo-oophorectomy.

Warfarin was stopped pre-operatively and the laparoscopy was undertaken with unfractionated heparin cover. The procedure was uncomplicated. The ovary and tube appeared grossly normal but subsequent histologic analysis of the specimen revealed a moderately differentiated papillary serous adenocarcinoma of the fallopian tube arising at the fimbrial end (1.5 × 0.6 × 0.4 cm) The ovary was not affected. Peri-operative serum CA125, taken immediately post-operatively was 28 u/L. She was treated with six cycles of carboplatin and paclitaxel.

Discussion

  1. Top of page
  2. Case report
  3. Discussion
  4. References

Primary fallopian tube cancer is rare, accounting for 0.1–0.5% of gynaecologic malignancies. There is mounting evidence1–3 that women with BRCA1 and BRCA2 gene mutations have a lifetime risk of ovarian cancer of 20–40% and 10–20%, respectively4. The risk of primary fallopian tube cancer in these women is unknown, as variables such as genetic penetrance of the mutations have yet to be clarified. There are, however, five case reports in the literature describing fallopian tube cancer in this group of women2,3,5,6.

Women whose family history suggests a familial predisposition to ovarian or breast cancer should be offered genetic counselling and screening if appropriate7. Screening is justified as both ultrasound and CA125 are efficient in the detection of asymptomatic ovarian cancer8. The Cancer Genetics Studies Consortium suggested that screening should be offered to BRCA1 carriers but that prophylactic oophorectomy was still of uncertain benefit, even in such high risk cases7, there being a minimal increase in life expectancy9. The woman, however, opted for surgery, since she felt that her high lifetime risk of ovarian cancer justified the risk.

There was no suspicion of malignancy pre-operatively, and so the tumour was not formally staged. Paley et al.1 described the clinical course of two women with fallopian tube carcinoma incidentally diagnosed at the time of prophylactic oophorectomy performed because of their BRCA1 carrier status. Paley et al.1 argued that these findings justify hysterectomy and formal staging as surgical prophylaxis. There is, however, little evidence to support this recommendation. Although the risk of primary fallopian tube tumour in this context remains undefined, it is unlikely to be large enough to justify a formal staging laparotomy in women undergoing prophylactic laparoscopic salpingo-oophorectomy. The risks of such extensive surgery are likely to outweigh any potential benefit. Surgeons undertaking prophylactic salpingo-oophorectomy must ensure that the whole length of the fallopian tube is excised. Pre-operative serum CA125 estimation may assist in deciding the extent of surgery, as a significantly elevated CA125 in the absence of clinical disease may justify a formal staging procedure.

References

  1. Top of page
  2. Case report
  3. Discussion
  4. References
  • 1
    Paley PJ, Swisher EM, Garcia RL, et al. Occult cancer of the fallopian tube in BRCA-1 germline mutation carriers at prophylactic oopherectomy: a case for recommending hysterectomy at surgical prophylaxis. Gynecol Oncol 2001;80: 176180.
  • 2
    Rose PG, Shrigley R, Wiesner GL. Germline BRCA2 mutation in a patient with fallopian tube carcinoma: a case report. Gynecol Oncol 2000;77(2):319320(May).
  • 3
    Zweemer RP, Van Diest PJ, Verheijen RH, et al. Molecular evidence linking primary cancer of the fallopian tube to BRCA 1 germ line mutations. Gynecol Oncol 2000;76(1):4550(January).
  • 4
    Lu KH, Garber JE, Cramer DW, et al. Occult ovarian tumours in women with BRCA1 or BRCA2 mutations undergoing prophylactic oopherectomy. J Clin Oncol 2000;18(14):27282732.
  • 5
    Hartley A, Rollason T, Spooner D. Clear cell carcinoma of the fimbria of the fallopian tube in a BRCA1 carrier prophylactic surgery. Clin Oncol (R Coll Radiol) 2000;12(1):5859.
  • 6
    Sobol H, Jacquemier J, Bonaiti C, et al. Fallopian tube cancer as a feature of BRCA 1 associated syndromes. Gynecol Oncol 2000;78: 263266.
  • 7
    Cancer Genetics Studies ConsortiumRecommendation for follow up care of individuals with an inherited predisposition to cancer. II: BRCA 1 and BRCA 2. JAMA 1997;277(12):9971003(March 26).
  • 8
    Jacobs I, Oram D. Screening for ovarian cancer. Biomed Pharmacother 1998;42: 589596.
  • 9
    Schraget al. Decision analysis—effects of prophylactic mastectomy and oopherectomy on live expectancy among women with BRCA 1 or BRCA 2 mutations. N Engl J Med 1997;336(20):14651471(May 15).