A 59-year-old woman was referred to Nicole Gaulin, MD, a gynecologic oncologist at Roswell Park Comprehensive Cancer Center, after learning she had a BRCA2 mutation linked with both breast cancer in a cousin and colon cancer in her father.
During a routine screening for high-risk patients, the woman opted for a risk-reducing salpingo-oophorectomy to remove her ovaries, during which it was found that she had a serous tubal intraepithelial lesion, a precancerous condition that could have developed into ovarian cancer if left untreated.
“This is a somewhat unique case as it allowed us to detect a future ovarian cancer before it became invasive,” Dr. Gaulin says. “The ability to detect and remove pre-cancer prior to becoming invasive disease can save our patients from having to undergo this difficult treatment regimen and improve survival.”
Hello, my name is Doctor Nicole Gollin, and I'm a gynecologic oncologist at Roswell Park Comprehensive Cancer Center. This is a case discussion of a patient I took care of. She was a 59-year-old referred to me for consideration of risk reducing surgery secondary to a new diagnosis of a BRCA2 mutation. This was identified on genetic testing based on family history, which was remarkable for breast cancer in her cousin and colon cancer in her father. Her cousin underwent genetic testing, remarkable for the BRCA2 mutation. Given this family history, the patient also underwent genetic testing, which demonstrated the same mutation. She was feeling well at the time of our first visit with no symptoms or complaints. We performed a pelvic ultrasound and a baseline CA 125 to evaluate for any abnormalities. It is important to note that there is no good screening test for ovarian cancer. The positive and negative predictive value for ultrasound and CA-125 are quite limited and can often lead to further unnecessary intervention and testing. That said, there are no other options for monitoring these patients who are at high risk for the development of ovarian cancer. After discussion, the patient opted to undergo risk reducing bilateral salpingo-oophorectomy. The surgery was quite uncomplicated with no visible metastatic disease throughout the abdomen and pelvis. The final pathology report demonstrated focal epithelial atypia of the bilateral fallopian tubes with CFIM protocol utilized. Based on P53 and KI67 testing, along with morphologic evaluation, the diagnosis of serous tubal intraepithelial lesion, or still, was rendered. It has been shown that the fallopian tube, particularly the fibriated end of the fallopian tube, is a common location for the development of ovarian cancer. It is believed that pre-cancerous lesions develop in this region of the fallopian tube over the course of years, and ultimately turn into invasive carcinoma. The theory is that the fibriated end of the fallopian tube is exposed to inflammation during. Ovulation. Rupture of the dominant follicle during ovulation can also expose the ovarian stroma to the abnormal fimbria epithelium. This sequence of precancerous lesions begins with a P53 signature. These areas demonstrate abnormal P53 staining in at least 12 consecutive normal appearing tubal epithelial cells. This progresses through still into a stick or serous tubal intraepithelial carcinoma. A stick lesion is characterized by enlarged nuclei, increased atypia, loss of polarity, abnormal P53 expression, and increased proliferation. Stick lesions are present in approximately 2 to 10% of patients with BRCA mutations. Still is managed conservatively with observation alone, as there is currently no evidence to support additional surgical staging, adjuvant therapy, or intensified surveillance. A still is considered a lesion of uncertain malignant potential. Patients are counseled about the risk of the development of primary peritoneal cancer and advised to monitor for the development of symptoms with routine gynecologic follow-up. Manage of stick lesions is a little more nuanced, and surgical staging may be considered in select cases. This is a somewhat unique case, as it allowed us to detect a future ovarian cancer prior to when it would become invasive. Most often, we diagnose ovarian cancer at advanced stage, typically stage 3C or stage 4. Treatment regimens are difficult, including a combination of surgery and chemotherapy. The ability to detect and Remove pre-cancer prior to becoming invasive disease can save our patients from having to undergo this difficult treatment regimen and improve survival. In order to reduce the risk of the development of ovarian cancer, it is imperative to have accurate family history and perform germline genetic testing based on the presence of risk factors. Approximately 15 to 20% of ovarian cancers are driven by genetic mutations. So this allows for a lot of room to reduce the risk for these patients. If you don't perform genetic testing in your office, our clinical genomics department is able to perform an extensive personal and family history with appropriate genetic testing and subsequent referral for risk reducing strategies. In addition to genetic testing, consideration for opportunistic salpingectomy is appropriate for patients who desire permanent contraception. An article was published in JAMA in early February 2026 synthesizing the existing data surrounding this practice. Incidence of tubal ovarian cancer can be reduced up to 80% with opportunistic self-inectomy compared to no self-inectomy, and importantly, ovarian cancer mortality could be reduced by up to 15%. This paper also discussed the risk of premature ovarian failure with opportunistic salpingectomy by looking at AMH levels, menopausal symptom questionnaires, and prescriptions for medication hormone therapy. There is no data to suggest that opportunistic salinectomy adversely affects short-term ovarian. Reserve. There is also no increased risk for postoperative complications when this is performed during gynecologic and non-gynecologic surgeries, including cholecystectomy, hernia repair, bariatric surgery, colon resection, and planned uncomplicated appendectomy. Additional operative time was around 10 minutes and was performed by general surgeons with the assistance from gynecologists. In summary, P53 signatures, still, and stick represent important early alterations in the fallopian tube epithelium within the spectrum of ovarian cancer carcinogenesis. While these lesions lack the features of invasive carcinoma, the recognition of these precursors underscores the central role of the fallopian tube in the development of ovarian. cancer and highlights the importance of careful pathologic evaluation, standardized diagnostic criteria, and continued research to clarify its clinical significance. As our understanding of these precursor lesions evolve, they serve as a reminder that early epithelial changes may hold key insights into the development of ovarian cancer. Opportunities to disrupt this pathway and prevent progression include opportunistic salpingectomy and risk reducing BSO for patients with identified genetic mutations. Ongoing investigation will be critical to defining the natural history, reproducibility, and clinical relevance of these lesions. If you have any questions about this patient or any patients that you may have in your office who require genetic testing or additional surveillance or intervention, please don't hesitate to give us a call.
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