{'fraction_non_alphanumeric': 0.03009259259259259, 'fraction_numerical': 0.016534391534391533, 'mean_word_length': 5.505376344086022, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Unanswered Questions in High-Risk Women Undergoing Risk-Reducing Salpingo-oophorectomy.

For more than 15 years, risk-reducing salpingo-oophorectomy has been the cornerstone of management for patients with BRCA1 or BRCA2 mutations to decrease the risk of ovarian and fallopian tube carcinoma. Moreover, risk-reducing salpingo-oophorectomy has been shown to decrease overall mortality in BRCA1 or BRCA2 mutation carriers.1 The standard-of-care practice for risk-reducing salpingo-oophorectomy incorporates strict and thorough pathologic review of the fallopian tubes and ovaries by sectioning and extensively examining the fimbriated end. Consequently, this practice has led to the discovery of microscopic lesions such as occult tubal and ovarian carcinomas and serous tubal intraepithelial carcinoma. Despite the clear benefit of risk-reducing salpingo-oophorectomy for patients with the BRCA mutation, the occasional discovery of occult carcinoma results in clinical uncertainty. Given the lack of evidence, we are unsure how to counsel these patients regarding additional surgery, requirement of chemotherapy, or risk of recurrence. In this month’s issue of Obstetrics & Gynecology, Piedimonte et al2 (see page 498) address the valuable questions regarding the risk of occult tubal carcinoma and outcomes for high-risk patients undergoing risk-reducing salpingo-oophorectomy. Their systematic review of 27 studies found that the pooled prevalence of occult tubal carcinoma at the time of surgery was 1.19% in high-risk patients. This is low compared with two previous prospective studies, including GOG-0199, in which the prevalence of occult carcinoma was 2.6%, and, more specifically, 4.6% in BRCA1 mutation carriers, 3.5% in BRCA2mutation carriers, and 0.5% for non-carriers.3 Another study, by Finch et al,4 demonstrates similar prevalence among BRCA1 mutation carriers undergoing prophylactic oophorectomy of 4.2%. This highlights the importance of mutation status in providing precision for clinical outcomes. The current review incorporates studies that include all high-risk women, such as BRCA1 mutation carriers, BRCA2 mutation carriers, and women at risk based on family history. Generalizing neglects the advancements we have made in precision medicine, which allow us to associate mutation, not just family history, with specific risks and resultant recommendations. For instance, our current National Comprehensive Cancer Network guidelines have different recommendations based on specific mutations, including BRCA1, BRCA2, BRIP1, RAD51C, and RAD51D. Thus, we strongly advocate that patients should undergo genetic testing to determine their ovarian cancer risk and to drive subsequent decision-making around risk-reducing salpingo-oophorectomy and prevention options. An intriguing result from this systematic review was the high rate of cancer recurrence of 18.7% after occult carcinoma in high-risk women. Some of these instances occurred in women who had advanced-stage See related article on page 498.