Opportunistic salpingectomy: Remove the tubes and save the ovaries.

“All truths are easy to understand once they are discovered; the point is to discover them.”

The title seems counterintuitive as how can ovarian cancer be saved by removing the tubes and not ovaries themselves. This may be explained by the recent evidence of work done in BRCA carriers. There has been a new understanding on the role of fallopian tube in cancer of the ovaries. Ovarian carcinoma is the fifth cause of cancer deaths among women and the leading cause of death from gynecological malignancy. In spite of improvement in diagnosis and treatment, 5-year survival has not changed much in the last 20 years. Recent evidence suggests that 75%–80% of ovarian cancers are type II including high-grade serous, undifferentiated, and here, primary tissue of origin is the fallopian tube.[1] The risk-reducing bilateral salpingo-oophorectomy (BSO) recommended in high-risk BRCA carriers may not be appropriate in the low-risk general population due to health risks associated with removal of ovaries. Here emerged the concept of opportunistic salpingectomy (OS), i.e., performing bilateral salpingectomy, either at the time of hysterectomy with ovarian retention or in place of tubal ligation for permanent contraception. This preventive potential of OS was first of all recommended by the Society of Gynecologic Oncology Society of Canada in 2011[2] and later by the US Society for Gynecology Oncology[3] and recently by the American College of Obstetricians and Gynecologists (ACOG) in 2015.[4] However, in high-risk women, oophorectomy definitely offers protection. Bilateral salpingectomy reduces the risk of ovarian cancer by 40%.

However, many experts criticize the rush to offer salpingectomy on a wider scale because of nonavailability of the absolute numbers as yet there is no level I evidence.[5] An answer to the expected risk reduction in ovarian cancer by OS would require a case-control study involving 500 women in each group and that might take 20 years.[6]

OS with ovarian retention may be better than elective BSO in a young premenopausal woman at low risk of ovarian cancer as that is associated with an increased risk of cardiovascular disease, bone, and other health problems. ACOG advises conservation of ovaries in women not at increased risk of hysterectomy. In case of alternative to tubal ligation, OS also eliminates the risk of subsequent hydrosalpinx and ectopic pregnancy, but then, it blocks the option of reversal of tubal ligation in case needed.

In conclusion, OS is a potential ovarian cancer risk reduction strategy in low-risk population but not supported by evidence. A prospective cohort study will be promising although time required is a long one to know the benefit. In the meantime, it would be practical to continue opportunistic bilateral salpingectomy prospectively and see the results.