This question arose as an unexpected nexus of a discussion that centered on two important clinical observations. First, bilateral tubal ligation has been suggested to be associated with a reduction in the risk of both sporadic5
ovarian cancer, particularly among BRCA1
mutation carriers. However, this risk reduction has not been consistently observed. Although Narod and colleagues showed that bilateral tubal ligation was associated with a 61% reduction in ovarian cancer risk among BRCA1
this observation was not replicated in a larger study.8
There has been considerable speculation regarding the physiologic basis for this association, including putative compromise of ovarian blood supply and mechanical interruption of the transport of environmental carcinogens from the lower female reproductive tract to the ovaries. The former is not anatomically compelling, since the ovarian blood supply is typically not altered by tubal ligation.9-11
The second – most notably in the form of the “talc hypothesis” of ovarian carcinogenesis – remains controversial despite being observed in multiple studies.12, 13
Regardless of the mechanism, the association between interruption of the fallopian tubes and ovarian cancer risk reduction is potentially substantial. However, tubal ligation is seldom raised as a treatment option among young mutation carriers.
Second, the increasingly wide-spread application of RRSO as a management strategy in high-risk women, coupled with more careful histopathologic scrutiny of the fallopian tubes obtained at the time of surgery,14
has shown that a significant proportion of the clinically-occult malignancies detected in these pathology specimens originated in the fallopian tube rather than the ovary.15
We now know that the fallopian tube is a target for BRCA1/2
an insight that has resulted in the routine incorporation of bilateral salpingectomy into the surgical management of women with BRCA1/2
Furthermore, these findings have led several groups of investigators to more carefully evaluate the role of the fallopian tube in ovarian carcinogenesis.23-28
A potential paradigm-altering hypothesis has emerged from their work, i.e.
, that a significant proportion of what has historically been classified as ovarian cancer is actually cancer of fallopian tube origin.15, 29
Thus the term “pelvic serous carcinoma” (PSC) may be a more precise over-arching concept which subsumes the site-specific entities of ovarian, fallopian tube, and primary peritoneal malignancies. This new terminology acknowledges the difficulty related to determining the precise site of initial malignant transformation among these morphologically and clinically similar neoplasms. The full spectrum of proliferative and neoplastic lesions seen in most other epithelial malignancies in adults (but conspicuously absent in the ovaries themselves) has now been observed in the fallopian tube mucosa of BRCA1/2
mutation carriers. This then raises the question of whether there might be significant risk-reduction associated with a strategy of bilateral salpingectomy, followed later by definitive risk-reducing bilateral oophorectomy, in pre-menopausal women who have completed their planned family but who are not yet ready to undergo bilateral oophorectomy.