Risk Reducing Salpingooophorectomy

[levels x3]

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**topic change**

Given a patient with a known BRCA mutation, I submit these specimens entirely, a la Christopher Crum, fanning out the fimbria, etc.

But what if you don't know the BRCA status? Case I received today is a hysterectomy/BSO from a 38 year-old woman who was diagnosed with unilateral breast cancer at age 33. BRCA testing was never done. How would you gross the BSO? Routinely or like a BRCA RRSO?

If I ask my partners they would all tell me do do it routinely (representative sections, 2 blocks tops). But then again, I'm out in the community in an older group. I had to teach them how to gross a BRCA positive RRSO when I arrived.

**please resume job market threads...sorry for the interruption**

 

[2121115]

**topic change**

Given a patient with a known BRCA mutation, I submit these specimens entirely, a la Christopher Crum, fanning out the fimbria, etc.

But what if you don't know the BRCA status? Case I received today is a hysterectomy/BSO from a 38 year-old woman who was diagnosed with unilateral breast cancer at age 33. BRCA testing was never done. How would you gross the BSO? Routinely or like a BRCA RRSO?

If I ask my partners they would all tell me do do it routinely (representative sections, 2 blocks tops). But then again, I'm out in the community in an older group. I had to teach them how to gross a BRCA positive RRSO when I arrived.

**please resume job market threads...sorry for the interruption**

At my institution, if there is a suspicion then we stamp the requistion as "treat as if BRCA carrier" when the specimen arrives and it gets grossed like a BRCA. Now that the gynecologists know we sometimes do this they often request it up front if they are worried about the patient.

 

[icpshootyz]

I agree with the above. If there is any suspicion you are better off treating it like a BRCA patient upfront, rather than finding out later and having to go back. It's easy enough.

 

[lipomas]

If it's a prophylactic resection, treat it like it's a mutation case. Presumably they either did BRCA testing somewhere else or they are treating them as high-risk. They don't always do hysterectomies in those cases though, so it might have been a TAH for other reasons and they just did a BSO because she elected to reduce her future risk. I doubt anyone is going to kill you if you submit the whole protocol though on these cases. Every group has a scrooge who objects to extra sections and may call you out on it, but you can usually demonstrate the importance of doing it.

 

[levels x3]

I agree with all of the above comments. That was my original plan (and what I've already done). I asked the question primarily for validation. I work in a group of 5 where I am minimum 20 years younger than my partners. Often, what seems like a no brainer to me, seems completely insane to them they've been out of training for so long. I know they are looking to me to bring them up to date for that very reason, but sometimes it's a tough sell being so much the "junior" staff member.

 

[lipomas]

Yeah I agree with those comments. Most of my group is much older than me. And while most are pretty up on current practice and literature, sometimes I leave them a little confused with some of my new fangled ideas. Don't shirk from speaking up though - just because they are older and more experienced doesn't mean they can't still learn (just like you can learn from their experience).

 

[Ruination]

As others have mentioned, we treat them like RRSO's at my institution as well. All in.

 

[green mantis]

Is there a specific way to submit these, aside from just putting the whole darn thing in? What exactly are we looking for?

I'm sure I've seen a couple of these as a SP fellow last year, but it probably doesn't always get written on the requisition form. (It's not the 1st time important information has been left off.) I've just put in the routine 1 section of FT & 1 of ovary (sometimes in the same cassette).


----- Antony

 

[yaah]

There have been some articles on it.

http://www.ncbi.nlm.nih.gov/pubmed/...med_ResultsPanel.Pubmed_RVDocSum&ordinalpos=6

Not sure if that one has the specific protocol recommended in it.

 

[Ruination]

Is there a specific way to submit these, aside from just putting the whole darn thing in? What exactly are we looking for?

I'm sure I've seen a couple of these as a SP fellow last year, but it probably doesn't always get written on the requisition form. (It's not the 1st time important information has been left off.) I've just put in the routine 1 section of FT & 1 of ovary (sometimes in the same cassette).


----- Antony

We amputate the fimbria and then cut longitudinally into 2-3 thin slices. We then cross section the remaining tube at 2-3 mm intervals. The ovary is serially sectioned perpendicular to the long axis at 2-3 mm intervals. We submit ours entirely-- I can get most of them into 7-8 cassettes per side. You are trying to identify an occult carcinoma (more likely to be in the fimbriated end, however, I've seen at at least one case where carcinoma was arising in the isthmus).

 

[Sean2tall]

There is a gross picture of the fallopian tube procedure on the cover of July 2009 Archives.

 

[levels x3]

What Ruination described is essentially how I submit them as well and that's usually what it takes me, 6-8 cassettes per side. This is the method described by Crum and others in their January 2008 article in the International Journal of Gyn Pathology, "Serous Carcinogenesis of the Fallopian Tube: A Descriptive Classification". The gross protocol may have come from somewhere else and was adapted, but that's what I was taught to do. Histologically you're looking for intraepithelial or otherwise occult carcinoma. Once, in residency, I thought something looked funny, so I ordered p53 and Ki-67 on a few blocks. The interpretation of that was such a pain that I haven't done it since. You can drive yourself crazy looking for borderline lesions that may or may not have any significance. Now if it doesn't really smack me in the face as being abnormal I move on.

I'm glad to know that my method seems to be in line with other places. Thanks for the feedback.

p.s. Ruination IPA is amazing.

 

[BierstiefelAndy]

Histologically you're looking for intraepithelial or otherwise occult carcinoma. Once, in residency, I thought something looked funny, so I ordered p53 and Ki-67 on a few blocks. The interpretation of that was such a pain that I haven't done it since. You can drive yourself crazy looking for borderline lesions that may or may not have any significance. Now if it doesn't really smack me in the face as being abnormal I move on.

Practically, this is in essence the thought process. The diagnosis of an intraepithelial carcinoma is based on morphology in the far majority of cases.
Immunohistochemistry for p53 can confuse matters because tubal lesions that are immunopositive for p53 are not necessarily in situ carcinomas. Those p53+ lesions that do not morphologically satisfy the criteria for intraepithelial carcinomas are mostly "p53 signatures" or "tubal intraepithelial lesions in transition" (TILT) and these usually display insufficient Ki-67 proliferation indices anyway; these lesions are more academic diagnoses and are typically omitted from reports to prevent confusion. God forbid a clinician overinterpret these and do something drastic like treat the patient with carboplatin/taxol chemotherapy. Usually the intraepithelial carcinomas that are morphologically recognizable are pretty obvious and the p53/Ki-67 immunostains are merely confirmatory. So just because some tubal lesion "looks funny" but does not meet the criteria for an intraepithelial carcinoma, one may only create more confusion by doing the p53/Ki-67 immunostains to begin with. This is a clear instance of how immunostains can make your life more difficult and how a certain diagnosis is best made based on morphologic interpretation of H&E stains.

The exact protocol used by an increasing number of groups for extensively examining the fallopian tube is described by Medeiros et al in 2006. Chris Crum is the senior author on the study.

 

[BierstiefelAndy]

You are trying to identify an occult carcinoma (more likely to be in the fimbriated end, however, I've seen at at least one case where carcinoma was arising in the isthmus).

Although most serous tubal intraepithelial carcinomas arise in the fimbria, occasionally some arise more proximally in the fallopian tube. One could use this to argue that it is safer to just entirely submit the fallopian tube instead of just entirely submitting the distal end. Nonetheless, many of these in situ carcinomas are quite microscopic and will only be detected in deeper levels for instance. Does that mean blocks of fallopian tube sections should be leveled through the block to catch the event? Who knows but this is analogous to the whole sectioning issue of breast sentinel lymph nodes to catch micromets and the prognostic significance...

 

[pathstudent]

Has anyone studies whether or not identifying these lesions matter? The thing is out of her body.

Practically, this is in essence the thought process. The diagnosis of an intraepithelial carcinoma is based on morphology in the far majority of cases.
Immunohistochemistry for p53 can confuse matters because tubal lesions that are immunopositive for p53 are not necessarily in situ carcinomas. Those p53+ lesions that do not morphologically satisfy the criteria for intraepithelial carcinomas are mostly "p53 signatures" or "tubal intraepithelial lesions in transition" (TILT) and these usually display insufficient Ki-67 proliferation indices anyway; these lesions are more academic diagnoses and are typically omitted from reports to prevent confusion. God forbid a clinician overinterpret these and do something drastic like treat the patient with carboplatin/taxol chemotherapy. Usually the intraepithelial carcinomas that are morphologically recognizable are pretty obvious and the p53/Ki-67 immunostains are merely confirmatory. So just because some tubal lesion "looks funny" but does not meet the criteria for an intraepithelial carcinoma, one may only create more confusion by doing the p53/Ki-67 immunostains to begin with. This is a clear instance of how immunostains can make your life more difficult and how a certain diagnosis is best made based on morphologic interpretation of H&E stains.

The exact protocol used by an increasing number of groups for extensively examining the fallopian tube is described by Medeiros et al in 2006. Chris Crum is the senior author on the study.

 

[BierstiefelAndy]

Has anyone studies whether or not identifying these lesions matter? The thing is out of her body.

Depends on context.

1) Most high grade serous carcinomas are stage III or higher at presentation...whether there is a tubal lesion or not is a lesser important point here.

2) The important question pertains to what should be done and what is the prognosis in the risk reducing BSO cohort where an incidental non-invasive intraepithelial carcinoma is found in the tube. The limited data out there seems to suggest that these patients do well with or without post-op chemotherapy but it is very difficult to truly ascertain the significance of these lesions without prospective, longitudinal data. Those studies, I assure you, are under way. It will be interesting if the hypothesis based on the limited data will hold up.

 

[pathstudent]

I would assume that they are most likely irrelevant. If they are being done for prophylactic reasons it is hard to believe that it was just timed such that you caught it before it is clinically and radiologically detectable and has already metastasized.

Do brca patients have a higher incidence of primary perioneal Serous carcinoma. They must.

Depends on context.

1) Most high grade serous carcinomas are stage III or higher at presentation...whether there is a tubal lesion or not is a lesser important point here.

2) The important question pertains to what should be done and what is the prognosis in the risk reducing BSO cohort where an incidental non-invasive intraepithelial carcinoma is found in the tube. The limited data out there seems to suggest that these patients do well with or without post-op chemotherapy but it is very difficult to truly ascertain the significance of these lesions without prospective, longitudinal data. Those studies, I assure you, are under way. It will be interesting if the hypothesis based on the limited data will hold up.