Dr Dasgupta was invited to deliver lecture on "Prophylactic Salpingectomy" at Yuva FOGSI East Zone Conference held at Puri, 2015

1. PROPHYLACTIC
SALPINGECTOMY
DR SUJOY DASGUPTA
MBBS (Gold Medalist, Hons)
MS (Obst & Gynae- Gold Medalist)
DNB (Obst & Gynae)
Fellow- Reproductive Endocrinology & Infertility, ACOG (USA)

3. OVARIAN
CANCER
Surgery
Chemo
therapy
Targeted
Therapy
Immuno
Therapy
Viral
Therapy
Gene
Therapy
•Docetaxel
•Trabectedin
•Liposomal
Doxorubicin
•Nanotherapy
•Oncolytic
Measles
•AdV-tk
•Veliparib
•Bevacizumab
•Therapeutic Vaccine-
FANG vaccine,
TroVax
•Adaptor T cell Transfer
• Monoclonal Ab- Demcizumab
•Antibody-Drug Conjugate-
Ipilimumab, urelumab

4. RESULTS

5. Cure?????
National Institute of Health, SEER Stat Fact Sheets: Ovary Cancer

6. Advanced Epithelial Ovarian Cancer- 75%

7. Prevention

8. Screening

9. Precancerous Stage
• Cervix
• Colon
• Breast

10. BSO Specimens in BRCA Mutations
• Colgan TJ, Murphy J, Cole DE, Narod S, Rosen B. Am J Surg
Pathol.2001;25:1283–9.
• Piek JM, van Diest PJ, Zweemer RP, et al. J Pathol. 2001;195:451–6.
TP53 Ki67
Serous Tubal Intraepithelial Carcinoma
(STIC)

11. In hereditary “ovarian” cancer the precursors are in the fallopian tube
(tubal intraepithelial carcinoma or TIC)

13. Further Studies in BSO Specimens
BRCA Mutation Status STIC in histopathology1-5
BRCA Carriers 60-100%
BRCA Non-Carriers 30-60%
1. Kamran MW, Vaughan D, et al. Eur J Obstet Gynecol Reprod Biol
2013;170:251–4.
2. Erickson BK, Conner MG, Landen CN Jr. Am J Obstet Gynecol
2013;209:409–14.
3. Kurman RJ, Shih I. Am J Surg Pathol 2010;34:433–43.
4. Crum CP. Mol Oncol 2009;3:165–70.
5. Kindelberger DW, Lee Y, et al. Am J Surg Pathol 2007;31:161–9.

16. Seih, Salvador, et al. Int J Epidemiology. 2013

17. Potential to develop
endometrioid/ clear cell
carcinomas
Retrograde
menstruation
(Inflammation,
Endometriosis)
Infection
Irritants
(Talc)
Fallopian tube as conduit
Ovarian Cancer- a Misnomer!!!

18. Potential to develop
endometrioid/ clear cell
carcinomas
Tubal ligation
(or salpingectomy)
blocks passage
Retrograde
menstruation
(Inflammation,
Endometriosis)
Infection
Irritants
(Talc)
Development of
high-grade serous
carcinomas
Salpingectomy
removes at-risk
tissue
Fallopian tube as conduit Fallopian tube as source
Ovarian Cancer- a Misnomer!!!

19. Potential to develop
endometrioid/ clear cell
carcinomas
Tubal ligation
(or salpingectomy)
blocks passage
Retrograde
menstruation
(Inflammation,
Endometriosis)
Infection
Irritants
(Talc)
Development of
high-grade serous
carcinomas
Salpingectomy
removes at-risk
tissue
Fallopian tube as conduit Fallopian tube as source
Ovarian Cancer- a Misnomer!!!
Prophylactic
Salpingectomy

20. Research vs Practice

21. SOGC, 2010

23. Change 1

24. Change 2

26. ACOG Recommendations (2015)
1. The surgeon and patient should discuss the potential
benefits of the removal of the fallopian tubes during a
hysterectomy in women at population risk of ovarian cancer
who are not having an oophorectomy.
2. When counselling women about laparoscopic sterilization
methods, clinicians can communicate that bilateral
salpingectomy can be considered a method that provides
effective contraception.
3. Prophylactic salpingectomy may offer clinicians the
opportunity to prevent ovarian cancer in their patients.
4. Randomized controlled trials are needed to support the
validity of this approach to reduce the incidence of ovarian
cancer.

27. Procedure
Route
• Decision for salpingectomy-
should not alter route for
hysterectomy (ACOG Committee
Opinion, Number 620, Jan 2015)
How much to remove
•Remove completely from
fimbrial end up to utero-tubal
junction
•Cauterize/ remove any fimbrial
attachment on the ovary
•Preserve blood supply to
ovary through hilum

28. Short Term Results
No differences in
• Length of hospital stay
• Surgical Complications
• Blood transfusion
• Re-admission to hospital

29. Operating Time
Minimal additional time*
*McAlpine JN, Hanley GE, Woo MM, et al. Am J
Obstet Gynecol 2014;210:471.e1–471.e11
Hysterectomy + 16 Min
Sterilization + 10 Min

30. Ovarian Function?

33. BRCA Mutation
1. Screening- Breast, Ovary
2. Life-style modification-
Pregnancy, Lactation, Tubal
Ligation
3. Chemoprevention- COC,
Tamoxifen
4. Prophylactic Surgery-
• Mastectomy
• Bilateral Salpingo-
Oohorectomy(BSO)

34. High Risk Women
• Recommend risk-reducing salpingo-
oophorectomy, ideally between 35 and 40 years,
and upon completion of child bearing, or
individualized based on early age of onset of
ovarian cancer in the family, after family is
completed

35. • Salpingectomy (BSOR)
in place of
Salpingo-oophorectomy
(BSO)???

36. • Bilateral salpingectomy with ovarian
retention (BSOR), may have a public health
benefit for women undergoing benign
gynecologic surgery, especially in those for
whom BSO is recommended but who are
reluctant to have their ovaries removed due
to hormonal implications.

37. • Salpingectomy alone is not the standard of
care and is discouraged outside a clinical trial.
The concern for risk-reducing salpingectomy
alone is that women are still at risk for
developing ovarian cancer.

38. Solution???
• Two step procedure
 Salpingectomy alone (BSOR)-
in early age
followed by
 Oophorectomy- after
menopause

39. We do not know
• Necessary cause of Ovarian
Cancer?
• Why ovarian mass dominates
over tubal mass?
• How tubal cancer cells seeds
into ovary/ peritoneum?

40. Future
• Still many missed
opportunities
• ?Other surgical procedures
• Long term effects
• Overall impact on survival
• Cost-effectiveness

41. Indian Scenario
• Restricted access to health
care system
• A substantial portion of
Indian women opt for tubal
ligation
• Total tubectomy is seldom
performed
• Hysterectomy with BSOR ?

42. Final thought
• Prophylactic salpingectomy should be routine
during hysterecomy for benign gynaecological
conditions
• Should be discussed as permanent contraceptive
measures for women seeking tubal ligation
• Absolutely safe
• Puts ray of hope in prevention of ovarian cancer
• Women positive for BRCA1 or BRCA2 who
have not completed child-bearing?

43. Ideal trial
RCT
(High-Risk Women)
BSOR
f/b delayed
oophorectomy
BSO
as single surgery
RCT
(High-Risk & Average-Risk
Women)
Hysterectomy
with BSOR
Hysterectomy
alone

44. Bertrand Russel
Thank You