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Background: Risk-reducing bilateral salpingo-oophorectomy reduces mortality from high-grade serous carcinoma in patients with hereditary breast and ovarian cancer associated gene mutations. Ideal surgical management includes 5 steps outlined in 2005 by the Society of Gynecologic Oncology and the American College of Obstetricians and Gynecologists. In addition, it is recommended that pathologic examination include serial sectioning of specimens. In practice, risk-reducing salpingo-oophorectomy is performed by both gynecologic oncologists and general gynecologists. To ensure optimal detection of occult malignancy, standardized adherence to outlined guidelines is necessary., Objective: This study aimed to evaluate the adherence to optimal surgical and pathologic examination guidelines and to compare the rate of occult malignancy at the time of surgery between 2 provider types., Study Design: Institutional review board exemption was obtained. A retrospective review of patients undergoing risk-reducing bilateral salpingo-oophorectomy without hysterectomy from October 1, 2015, to December 31, 2020, at 3 sites within a healthcare system was conducted. The inclusion criteria included age ≥18 years and a documented indication for surgery being a mutation in BRCA1 or BRCA2 or a strong family history of breast and/or ovarian cancer. Compliance with 5 surgical steps and pathologic specimen preparation was based on medical record documentation. Multivariable logistic regression was used to determine differences in adherence between provider groups and surgical and pathologic examination guidelines. A P value of <.025 was considered statistically significant for the 2 primary outcomes after Bonferroni correction was applied to adjust for multiple comparisons., Results: A total of 185 patients were included. Among the 96 cases performed by gynecologic oncologists, 69 (72%) performed all 5 steps of surgery, 22 (23%) performed 4 steps, 5 (5%) performed 3 steps, and none performed 1 or 2 steps. Among the 89 cases performed by general gynecologists, 4 (5%) performed all 5 steps, 33 (37%) performed 4 steps, 38 (43%) performed 3 steps, 13 (15%) performed 2 steps, and 1 (1%) performed 1 step. Gynecologic oncologists were more likely to document adherence to all 5 recommended surgical steps in their surgical dictation (odds ratio, 54.3; 95% confidence interval, 18.1-162.7; P<.0001). Among the 96 cases documented by gynecologic oncologists, 41 (43%) had serial sectioning of all specimens performed, compared with 23 of 89 cases (26%) performed by general gynecologists. No difference in adherence to pathologic guidelines was identified between the 2 provider groups (P=.0489; note: P value of >.025). Overall, 5 patients (2.70%) had occult malignancy diagnosed at the time of risk-reducing surgery, with all surgeries performed by general gynecologists., Conclusion: Our results demonstrated greater compliance with surgical guidelines for risk-reducing bilateral salpingo-oophorectomy in gynecologic oncologists than in general gynecologists. No considerable difference was determined between the 2 provider types in adherence to pathologic guidelines. Our findings demonstrated a need for institution-wide protocol education and implementation of standardized nomenclature to ensure provider adherence to evidence-based guidelines., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Survival from ovarian cancer is strongly dependent on the stage at diagnosis. Therefore, when confronted with a woman with an isolated adnexal mass, clinicians worry about missing the opportunity to detect cancer at an early stage. High-grade serous ovarian cancers account for 80% of ovarian cancer deaths, largely because of their tendency to be diagnosed at a late stage. Among adnexal masses, large size and the presence of solid areas on ultrasound examination have been found to be associated with cancer, but it is unclear whether these characteristics identify early-stage cases., Objective: This study aimed to evaluate the ultrasound findings associated with clinically detected early-stage high-grade serous ovarian cancer., Study Design: This was a retrospective cohort study of women diagnosed with stage I or II high-grade serous ovarian or fallopian tube cancer measuring at least 1 cm at pathology from 2007 to 2017. Preoperative ultrasound examinations were independently reviewed by 3 radiologists. Adnexal masses were scored for size and volume; overall appearance; presence, thickness, and vascularity of septations; morphology and vascularity of other solid components; and degree of ascites. Characteristics were compared between masses of <5 cm and larger masses and between stage I and stage II cases. Interobserver variability was assessed., Results: Among 111 women identified, 4 had bilateral ovarian involvement, for a total of 115 adnexal masses characterized by ultrasound examination. The mean age at diagnosis was 61.8 years (range, 42-91 years). The median mass size was 9.6 cm (range, 2.2-23.6 cm) with 87% of cases having a mass size of ≥5 cm. A mixed cystic and solid appearance was most common (77.4%), but a completely solid appearance was more frequently seen for tumors of <5 cm compared with larger tumors (26.7% vs 13.0%). Solid components other than septations were seen in 97.4% of cases. The characteristics of stage I and II cases were similar other than ascites, which was more commonly seen in stage II cases (18.0% vs 3.1%, respectively). Interobserver concordance was high for size and volume measurements (correlation coefficients, 0.96-0.99), with moderate agreement observed across the other ultrasound characteristics (Fleiss kappa, 0.45-0.58)., Conclusion: In this community-based cohort, early-stage high-grade serous cancers rarely presented as masses of <5 cm or masses without solid components other than septations. Our findings provide additional support for the observation of small masses without solid areas on ultrasound examination., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Complete surgical resection affords the best prognosis at the time of interval debulking surgery. When complete surgical resection is unachievable, optimal residual disease is considered the next best alternative. Despite contradicting evidence on the survival benefit of interval debulking surgery if macroscopic residual disease remains, the current definition of "optimal" in patients undergoing interval debulking surgery is defined as largest diameter of disease measuring ≤1.0 cm, independent of the total volume of disease., Objective: To examine the relationship between volume and anatomic distribution of residual disease and oncologic outcomes among patients with advanced-stage epithelial ovarian/fallopian tube/primary peritoneal carcinoma undergoing neoadjuvant chemotherapy then interval debulking surgery. For patients who did not undergo a complete surgical resection, a surrogate for volume of residual disease was used to assess oncologic outcomes., Study Design: Patient demographics, operative characteristics, anatomic site of residual disease, and outcome data were collected from medical records of patients with International Federation of Gynecology and Obstetrics stage IIIC and IV epithelial ovarian cancer undergoing interval debulking surgery from January 2010 to July 2015. Among patients who did not undergo complete surgical resection but had ≤1 cm of residual disease, the number of anatomic sites (single location vs multiple locations) with residual disease was used as a surrogate for volume of residual disease. The effect of residual disease volume on progression-free survival and overall survival was evaluated., Results: Of 270 patients undergoing interval debulking surgery, 173 (64.1%) had complete surgical resection, 34 (12.6%) had ≤1 cm of residual disease in a single anatomic location, 47 (17.4%) had ≤1 cm of residual disease in multiple anatomic locations, and 16 (5.9%) were suboptimally debulked. Median progression-free survival for each group was 14, 12, 10, and 6 months, respectively (P<.001). Median overall survival for each group was: 58, 37, 26, and 33 months, respectively (P<.001)., Conclusion: Following interval debulking surgery, patients with complete surgical resection have the best prognosis, followed by patients with ≤1 cm single-anatomic location disease. In contrast, despite being considered "optimally debulked," patients with ≤1 cm multiple-anatomic location disease have a survival similar to suboptimally debulked patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Primary cytoreduction followed by platinum-based chemotherapy is the primary treatment for advanced ovarian cancer. However, neoadjuvant chemotherapy followed by interval debulking is an alternative option, particularly in those who may be poor surgical candidates., Objective: The objective of this study was to determine factors associated with short-term, significant perioperative morbidity and mortality for women undergoing surgery for ovarian cancer and to create a nomogram to predict the risk of adverse perioperative outcomes., Study Design: We used the National Surgical Quality Improvement Program database to identify women with ovarian, fallopian tube, or primary peritoneal cancer who underwent surgery from 2011 to 2015. Demographic factors, clinical characteristics, comorbidity, functional status, and the extent of surgery were used to predict the risk of severe perioperative complications or death using multivariable models. Multiple imputation methods were employed for missing data. A nomogram was developed based on the final model. The discrimination ability of the model was assessed with a calibration plot and discrimination concordance index., Results: We identified a total of 7029 patients. Overall, 5.8% of patients experienced a Clavien-Dindo IV complication, 9.8% of patients were readmitted, 3.0% of patients required a reoperation, and 0.9% of patients died within 30 days. Among the baseline variables assessed, increasing age, emergent surgery, ascites, bleeding disorder, low albumin, higher American Society of Anesthesiology classification score, and a higher extended procedure score were associated with serious perioperative morbidity or mortality. Of these factors, performance of ≥3 cytoreductive procedures (adjusted odds ratio 4.53, 95% confidence interval 3.01-6.82), American Society of Anesthesiology classification score ≥ class 4 (adjusted odds ratio 2.89, 95% confidence interval 1.17-7.14), bleeding disorder (adjusted odds ratio 2.73, 95% confidence interval 1.82-4.10), and age ≥80 years (adjusted odds ratio 2.46, 95% confidence interval 1.66-3.63) were most strongly associated with risk of an event. The final nomogram included the above variables and had an internal discrimination concordance index of 0.71, with accurate predictions in an internal validation set, indicating a 71% correct identification of patients across all possible pairs., Conclusion: Women undergoing surgery for ovarian cancer are at significant risk for the occurrence of adverse perioperative outcomes. Using readily identifiable characteristics, this nomogram can predict adverse outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to compare clinical characteristics and survival between patients with stage I epithelial ovarian cancer and fallopian tube cancer., Study Design: We identified women with stage I epithelial ovarian cancer and fallopian tube cancer who underwent treatment from 2000-2010. Correlation between categoric variables was assessed with χ2 test. The Kaplan-Meier survival analysis was used to generate overall survival data. Factors predictive of outcome were compared with the use of the log-rank test and Cox proportional hazards model., Results: The study group consisted of 385 women with epithelial ovarian cancer and 43 women with fallopian tube cancer. Patients with fallopian tube cancer had a higher rate of stage IA disease (65% vs 48%; P=.02) and grade 3 tumors (60.4% vs 30.9%; P<.001). Patients with fallopian tube cancer had a significantly higher rate of breast cancer (25.6% vs 5.7%; P<.001) and BRCA 1 mutations (45.8% vs 9.1%; P<.001). There was no difference in the rates of platinum-based and paclitaxel chemotherapy between the groups. Women with fallopian tube cancer were more likely to have received ≥6 cycles of chemotherapy (58.1% vs 44.1%; P=.02). The 5-year disease-free survival rates were 100% in women with fallopian tube cancer and 93% in patients with epithelial ovarian cancer (P=.04). The 5-year overall survival rates were 100% and 95% for fallopian tube cancer and epithelial ovarian cancer, respectively (P=.7)., Conclusion: We found a higher rate of stage IA, grade 3, and serous carcinoma in fallopian tube cancer. Women with fallopian tube cancer had a higher rate of breast cancer. There was no difference in overall survival between the groups., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: The fallopian tube has been implicated as the primary origin of pelvic serous cancers. We proposed to determine the survival outcomes of serous tubal, ovarian, peritoneal, and uterine cancer patients., Study Design: Data were obtained from the National Cancer Institute between 2004 and 2009. Kaplan-Meier and Cox proportional hazards models were used for analysis., Results: Of 12,336 high-grade serous cancer patients, 563 were tubal (TC), 8560 ovarian (OC), 1037 primary peritoneal (PPC), and 2176 uterine cancer (USC). The median ages of these patients were 63 vs 62 vs 67 vs 68 years, respectively. The majority were white (89% vs 88% vs 91% vs 74%). The overall 5 year, disease-specific survival was 37%. The survivals of those with TC, OC, PPC, and USC were 50%, 37%, 26%, and 40% (P < .01). There was no detailed staging on PPC cancers. Adjusted for stage, the survival of those with stage I, II, III, and IV TC were 73%, 62%, 44%, and 22% (P < .01), OC were 83%, 64%, 34%, and 15% (P < .01), and USC were 88%, 72%, 55%, and 17% (P < .01). On multivariate analysis, younger age, white race, earlier stage, and tubal origin were independent predictors for improved survival., Conclusion: In advanced-staged serous cancer patients, tubal cancer patients have better survivals compared with ovarian, peritoneal, and uterine cancer., (Copyright © 2015. Published by Elsevier Inc.)

Advanced cases of epithelial ovarian, primary peritoneal, and primary tubal malignancies have a relatively poor prognosis and collectively remain the most deadly of all gynecologic malignancies. Although traditionally thought of as one disease process, ongoing research suggests that there is not 1 single site or cell type from which these cancers arise. A majority of the serous tumors appear to originate from dysplastic lesions in the distal fallopian tube. Therefore, what we have traditionally considered "ovarian" cancer may in fact be tubal in origin. In this article, we will review epithelial ovarian cancer classification and genetics, theories regarding cells of origin with a focus on tubal intraepithelial carcinoma, and implications for prevention and screening., (Copyright © 2013 Mosby, Inc. All rights reserved.)

We present a patient with ovarian atypical proliferative serous tumor and low-grade serous carcinoma, related to KRAS mutation. Bilateral fallopian tubes had papillary tubal hyperplasia, providing additional evidence that it is the putative precursor of low-grade serous tumors. Mutation analysis of papillary tubal hyperplasia has not been done in previous literature., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Extranodal marginal zone B-cell lymphomas are uncommon. Most occur in the gastrointestinal tract. Marginal zone B-cell lymphomas of the female genital tract are rare, and few cases exist of marginal zone B-cell lymphomas of the uterus, cervix, and fallopian tubes. We report the first marginal zone B-cell lymphoma of the ovary, fallopian tube, and appendix arising in endometriosis., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: To evaluate the role of laparoscopy for staging of early ovarian cancers., Study Design: Case series conducted at the University Hospital with 36 patients who had presumed early-stage adnexal cancers. Laparoscopic staging/restaging was performed., Results: Cases included 20 invasive epithelial tumors, 11 borderline tumors, and 5 nonepithelial tumors. Mean number of peritoneal biopsies, paraaortic nodes, and pelvic nodes were 6, 12.23, and 14.84, respectively. Eighty-three percent of the patients had laparoscopic omentectomy. On final pathology, 7 patients were upstaged. Postoperative complications included 1 small bowel obstruction, 2 pelvic lymphoceles, and 1 lymphocele cyst. Mean duration of follow-up is 55.9 months. Three patients had recurrences. All patients are alive without evidence of the disease., Conclusion: This represents 1 of the largest series and longest follow-ups of laparoscopic staging for early-stage adnexal tumors. Laparoscopic staging of these cancers appears to be feasible and comprehensive without compromising survival when performed by gynecologic oncologists experienced with advanced laparoscopy.

Objective: The purpose of this study was to determine the feasibility of laparoscopically staging patients with incompletely staged cancers of the uterus, ovary, fallopian tube, and primary peritoneum, and to evaluate related effects., Study Design: Patients without evidence of metastatic disease had laparoscopic bilateral para-aortic and pelvic lymph node dissection. Other procedures were individualized based on extent of the primary surgery; laparotomy was undertaken for identified resectable disease., Results: Ninety-five eligible patients were entered on 2 Gynecologic Oncology Group (GOG) protocols. Eleven were excluded. Fifty-eight patients (69%) underwent complete endoscopic staging with photographic documentation. Nine others (10%) were incompletely staged. Seventeen patients (20%) had laparotomy. In patients undergoing laparoscopy, 6% had bowel complications; 11% were found to have more advanced disease. Hospital stay was significantly shorter with laparoscopy alone (3 vs 6 days, P = .04)., Conclusion: Interval laparoscopic staging of gynecologic malignancies can be successfully undertaken in selected patients, but laparotomy for adhesions or metastatic disease and risk of visceral injury may be anticipated.

Objective: To compare the safety and efficacy of laparoscopic staging of ovarian or fallopian tube cancers to staging via laparotomy for epithelial ovarian carcinoma., Study Design: We performed a case-control study of all patients with apparent stage I adnexal cancers who had laparoscopic staging from October 2000 to March 2003. The control group consisted of all patients with apparent stage I epithelial ovarian carcinoma who had staging via laparotomy during the same time period., Results: Staging was laparoscopic in 20 patients and via laparotomy in 30. There were no differences in mean age and body mass index. There were also no differences in omental specimen size and number of lymph nodes removed. Estimated blood loss and hospital stay were lower for laparoscopy, but operating time was longer. There were no conversions to laparotomy or complications in the laparoscopic group, compared with 3 minor complications in the laparotomy group., Conclusion: In this preliminary analysis, it appears that patients with apparent stage I ovarian or fallopian tube cancer can safely and adequately undergo laparoscopic surgical staging.

Objective: To clarify the pathogenesis of endometriosis on the basis of analysis of primary lesion sites, age at onset, rate of progression, and response to drug treatment., Study Design: The clinical records of 690 women with laparoscopically confirmed endometriosis were retrospectively analyzed based on the revised American Fertility Society point system., Results: The primary site of endometriosis was the uterosacral ligament and pelvic peritoneum/pouch of Douglas in 73% of patients with stage I disease, whereas only 16% had ovarian lesions. However, disease progression was associated with an increasing frequency of ovarian lesions. In terms of the revised American Fertility Society score, endometriosis progressed at a mean rate of 0.3 point per month. Thus the earliest onset of endometriosis was estimated at 3 to 4 years after menarche. Drug therapy improved the revised American Fertility Society score by about 50%. Patients with a low response to an initial cycle of therapy generally showed further improvement after an additional treatment cycle., Conclusions: Because endometriosis may occur as early as 3 to 4 years after menarche and gradually progresses, drug therapy, including long-term treatment, should be carried out in women with definitive evidence of endometriosis who must maintain their reproductive potential.

We report a tubal hydatidiform mole, most likely resulting from dispermic fertilization. Early hatching of the embryo, because of a defective zona pellucida, may have favored tubal implantation.

Endosalpingosis, a condition characterized by ectopic oviduct epithelium, is diagnosed histologically by the appearance of benign ciliated and nonciliated columnar cells in an abnormal location. Endosalpingosis is typically without symptoms. Our unusual case report shows symptomatic endosalpingosis first seen with chronic pelvic pain. Various aspects of this disease will also be discussed.

These case presentations are submitted to focus attention on positive (Class V) cervicovaginal cytologic results compatible with adenocarcinoma in the face of benign endocervical and endometrial tissue and in the absence of clinically detectable adnexal disease. Two patients were found to have primary ovarian malignancy, and one patient had adenocarcinoma of the distal end of the right Fallopian tube. Provided that there is confidence in the cytologic diagnosis and that primary disease has been ruled out elsewhere, the clinician is encouraged to utilize additional diagnostic methods, such as laparoscopic visualization of the pelvis and peritoneal fluid studies, in an attempt to facilitate early diagnosis of nonpalpable adnexal disease.

The apparently smallest primary adenocarcinoma (2.3 mm in diameter) of the fallopian tube ever described was diagnosed by repeated blind sectioning of the surgical specimen after the preoperative finding of an abnormal cervical Papanicolaou smear and the subsequent finding of abnormal cells in fluid obtained by laparoscopic peritoneal lavage, although a survey of the patient for a primary cancer was negative.

A clinicopathologic study of 15 cases of primary adenocarcinoma of the uterine tube occurring over a 12-year period is presented. The mean age of the patients was 54.8 years. Predominant symptoms were abnormal bleeding, abnormal vaginal discharge, and pelvic pain. Abnormal vaginal cytology was noted in two instances (13%). A pelvis mass was detected in two thirds of patients. The neoplasm was bilateral in three instances (20%). Lymph nodes were involved in eight cases (53%), and metastatic spread to the para-aortic nodes was present in five (33%). The most common primary treatment was total abdominal hysterectomy and bilateral salpingo-oophorectomy. Various combinations of adjuvant radiation therapy and chemotherapy were also employed. Six patients (40%) are alive without evidence of recurrent cancer. It is concluded that lymphatic spread, especially to the para-aortic nodes, is a major pattern of disseminaton for adenocarcinoma of the uterine tube. The presence of tumor in capillary-like spaces bears a strong relationship to lymph node metastases, and the para-aortic nodes are a frequent site of involvement even when the disease is apparently limited to the tube.

From 1964 through 1983, 47 patients with a mean age of 63 years underwent primary treatment of fallopian tube carcinoma. Vaginal bleeding, abdominopelvic pain or pressure, and a palpable pelvic mass (or masses) were frequent retrospective clinical associations. Survival analysis demonstrated a rapid initial rate of patient attrition with stabilization after 3 years, resulting in an overall 5-year survival rate of 41%. While independent of age, histologic grade, or original tumor size, patient longevity was significantly decreased (p less than 0.01) by the presence of disease beyond the pelvis, neoplastic cells in the peritoneal washings, and size of residual disease. Therapy consisted of primary surgical resection, usually followed by adjunctive radiotherapy or chemotherapy. Initial sites of relapse were predominantly (88%) within the intraperitoneal cavity. The study supports definitive surgical staging and tumor reduction, as well as more selective adjuvant therapy based on surgical stage and residual tumor size and location.