Risk-reducing salpingo-oophorectomy for BRCA mutation carriers.

It has been twenty years since the region of the BRCA1mutationwas identified on chromosome 17q. There are now over 3000 risk reducing salpingo-oophorectomy (RRSO) cases reported and an estimated 150 cases describing unsuspected cancers of the ovaries and tubes or in situ lesions. Connor et al. in their current study add to the literature on RRSO outcomes [1]. They report on 345 cases of RRSO in BRCAmutation carriers from a single institution, finding a HGTIN/cancer rate of 5.4%, 9.2% in BRCA1 and 3.4% in BRCA2. Mean age of neoplasia was 54.4 years which was higher than those without neoplasia (47.8 years). The authors then present 29 cases collected from 3 institutions of HGTIN/cancer followed for a median of 5 years. 1/11 HGTIN recurred and 3/18 invasive cancers recurred (17%). What havewe learned about RRSO in these 2 decades since the identification of BRCA1 mutations? The rate of unsuspected neoplasia at RRSO of 5.4% in Connor's study, is consistent with other reports from Finch et al. of 4.4%, Manchanda et al. of 5.1%, Mingels et al. of 7.1% and Powell et al. of 7.9% [2–5]. Unsuspected lesions are more likely to be detected in BRCA1 mutation carriers as compared with BRCA2, when rigorous microsectioning protocols are used for processing ovaries and tubes and at increasing age at the time of RRSO (as shown so clearly in Connor's figure 2). Pooling 9 studies, and 2035RRSOdescribing STIC, there are 62 independent reports of STIC without concomitant invasion or ovarian involvement, an overall rate of 3.0% (Table 1a). Connor adds a third case to the reports of Manchanda and Powell of recurrence or peritoneal primary after a finding of STIC at RRSO, all three associated with BRCA1 [1,3,6]. RRSO and recurrences occurred respectively at age 44 and 6 years later, age 49 and 3.5 yrs later and at age 46 with recurrence 4 years later. Cytology was performed in 2 of the 3 and was negative. Are the 3 reports of peritoneal primary after STIC different from the baseline rate of 1–4% peritoneal primary after RRSO? This low incidence and the 100% overall survival in Connor and Powell's reports supports not adding adjuvant chemotherapy when STIC is discovered. Performing cytology at RRSO may be helpful as positive cytology may increase the index of suspicion for an occult lesion andwill upstage an early invasive cancer. Some have advocated for adjuvant chemotherapy if STIC is associatedwith positive cytology. Data is extremely limited (10 cases,) with about half receiving chemotherapy and half not. No recurrences have been reportedwhen positive cytology is associatedwith only STIC [7].