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CASE HISTORY

Case History

image A 39-year-old female attended the gynaecology clinic following referral from the clinical genetics team. She had been diagnosed with a right sided breast cancer 12 months previously. This had been treated with neoadjuvant chemotherapy, followed by a right mastectomy with axillary clearance and radiotherapy. Histology showed a grade 3 invasive ductal carcinoma, T2N1, oestrogen receptor Allred score 8, HER2 receptor negative. Following surgery she was started on GnRH analogue and exemestane. Adjuvant bisphosphonate therapy was also commenced.

Subsequent genetic testing, for personal reasons, found that she had a breast cancer (BRCA2) mutation. She was referred to the gynaecology service for discussion with regards to prophylactic bilateral salpingo-oophorectomy, whilst simultaneously being referred for prophylactic left mastectomy.

She had no other past medical or surgical history. She had two children, the first born via caesarean and the second by forceps delivery. Her smear history was up to date and had been normal. Her grandmother had endometrial cancer at an unknown age.

The patient was seen in the gynaecology clinic to discuss risk-reducing surgery. Given the family history of endometrial cancer, the patient also wished to consider hysterectomy, in addition to bilateral salpingo-oophorectomy. The lack of evidence to support hysterectomy in this situation was discussed, as the family history was non-significant, however the patient was listed for a laparoscopic hysterectomy and bilateral salpingo-oophorectomy.

The procedure was completed with no complications and a 1 day stay in hospital. Histological examination of the specimen revealed no abnormality.

What is the benefit of salpingo-oophorectomy with regards to breast cancer prognosis and ovarian cancer prophylaxis?

What are the long-term health outcomes following risk reducing salpingo-oophorectomy?

If there was a wish to preserve ovaries, how would ovarian cancer risk change over time?

If this patient opted for risk reducing salpingo-oophorectomy without hysterectomy, would screening for endometrial changes be offered with endocrine therapy?

If there was a wish to preserve fertility, what factors should be considered when counselling the patient?

What is the risk of offspring inheriting BRCA2 mutation and how should the patient be counselled?

What is the benefit of salpingo-oophorectomy with regards to breast cancer prognosis and ovarian cancer prophylaxis?

Over recent years there has been data emerging to confirm that ovarian suppression, in addition to hormonal therapy, improves disease-free survival in patients at high risk of recurrence; this is now embedded in national guidance.1 Ovarian suppression can be achieved through GnRH-agonist treatment or ovarian ablation with radiotherapy or oophorectomy. Most trials have used ovarian suppression with GnRH-agonists rather than oophorectomy; there are no trials comparing the efficacy of these methods.

The decision for oophorectomy for this patient was influenced by the risk of ovarian cancer with a BRCA mutation. Risk reducing bilateral salpingo-oophorectomy (RRBSO) has been shown to reduce ovarian cancer risk by 80–96%.2 When performed laparoscopically complication rates have been quoted at 3.9%.2 With the risk of ovarian cancer ...

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