Quality of life in patients affected by endometrial cancer: comparison among laparotomy, laparoscopy and vaginal approach.

The aim of this study is to verify if the surgical approach (laparoscopy/laparotomy/vaginal) in stage-I endometrial cancer treatment, may have effects on intra- and post-operative outcomes and on the patient's quality of life. The study group consisted of patients with histological diagnosis of type-I endometrial adenocarcinoma, stage-I. They were divided into three groups according to surgical approach chosen (laparotomic/laparoscopic/vaginal). Every patient answered a telephone health survey (SF-36) at 30 and 180 days post-surgery. Surgical-operating times, hospitalization length and short/long-term complications after surgery were also compared. The SF-36 survey revealed a better performance status in patients who underwent laparoscopy as compared to those who received laparotomy or vaginal surgery. We found significantly better results considering General Health, Physical Functioning, Role-Physical and Bodily Pain in the laparoscopy group after 30 and 180 days. Patients who underwent laparoscopy had significantly shorter hospitalization and less post-operative complications even if laparoscopy required significantly longer surgical-operating times compared to vaginal surgery. Our data confirm the superiority of the laparoscopic approach respect to the laparotomic and vaginal ones both in term of hospitalization length and post-operative complications.

Assessment of tumor size as a useful marker for the surgical staging of endometrial cancer.

Accumulating evidence suggests that the estimation of tumor size may improve endometrial cancer treatment. We conducted an observational study aimed at elucidating the association between tumor size and other universally accepted prognostic factors in order to identify suitable preoperative parameters which can guide surgery in a subgroup of early corpus endometrial cancer. We found that when tumor size increased, both stage and grading were significantly increased. Tumor size was correlated with CA 125 serum values, node metastasis and peritoneal cytology status. Patients who have grade 1 or 2 endometrioid corpus cancer, myometrial invasion < 50% and ≤ 3 cm largest tumor diameter can only be treated with hysterectomy. The tumor largest diameter should be evaluated as a preoperative parameter that indicates patients who do not require lymphadenectomy.

Impact of Highly Active Antiretroviral Therapy on the Natural History of Cervical Precancerous Lesions: A 17-Year Institutional Longitudinal Cohort Study.

We performed an observational cohort study in order to assess the correlation between precancerous cervical lesions (cervical intraepithelial neoplasia [CIN]) and immunological state in human immunodeficiency virus (HIV)-positive women treated by highly active antiretroviral therapy (HAART). We analyzed 194 HIV-infected women referred to the Parma-Universitary Hospital for early detection of human papilloma virus-induced CINs. We analyzed cytology, colposcopy, and CIN degree according to HAART: group A untreated and group B treated. We compared the CD4+ count and viral load at the time of CIN onset and the time interval between diagnosis of HIV and the onset of CIN. Group A and group B showed homogeneous results for general features, CD4+ count, viral load, and Papanicolaou test features. Differences were not found in terms of histology and CD4+ value, viral load count, pharmacological treatment, years since the diagnosis of HIV, age, smoking, sexual promiscuity, previous intravenous narcotics abuse, prostitution, sexually transmitted diseases, ethnicity, and age at diagnosis. Histology and the clinical stage of HIV showed significant concordances between the high degree of cervical dysplasia and advanced stage of HIV disease.

Can the impact of pelvic inflammatory disease on fertility be prevented? Epidemiology, clinical features and surgical treatment: evolution over 8 years.

OBJECTIVE: To assess the epidemiological features and the trend of care of patients diagnosed with pelvic inflammatory disease (PID) and to assess most predictive parameters of severe disease, for which surgical management is warranted, in particular when surgery is certain to cause permanent infertility. STUDY DESIGN: The study population was divided into 3 groups: medical therapy only, conservative surgery, and destructive surgery (surgical procedures that impaired fertility). Data from the 3 groups were compared with respect to general and medical history data, clinical signs on admission, laboratory tests, and ultrasound findings. The p value was considered significant when < 0.05. RESULTS: The non-Italian women in the study appeared to be more at risk of developing PID and were overrepresented in the surgically treated groups. C-reactive protein (CRP) and D-dimer values most likely correlated with disease severity. Ultrasound evidence of ovaritis generally led to medical therapy. Conversely, when sonography revealed pyosalpinx or tuboovarian abscesses, surgery was performed. CONCLUSION: Clinical presentation is fundamental in diagnostic counseling but should be supplemented with further laboratory tests to detect inflammation and sonograms. The latter, along with CRP and D-dimer assays, may represent useful parameters to consider when planning patient management because they appear indicative of the need for surgical treatment.

Dedifferentiated endometrial cancer: an atypical case diagnosed from cerebellar and adrenal metastasis: case presentation and review of literature.

Dedifferentiated endometrial cancer (DEC) is microscopically characterized by the presence of high-grade areas emerging from low-grade tumour. DEC is an aggressive tumour even when the dedifferentiated component represents only 20% of the entire neoplasm. A proper histological diagnosis is essential to define the most appropriate therapeutic approach for these tumors, since they are characterized by a particularly aggressive trend and by an extremely poor prognosis. We report a single case of DEC associated with dedifferentiated and adrenal metastasis, for which the patient underwent both abdominal-pelvic and cerebellar surgery. Dedifferentiated carcinoma of the endometrium is a poorly recognized neoplasm since they have not been clearly defined the histological features discriminating this neoplasm from high-grade endometrioid adenocarcinoma. Revising existing literature we found 79 described cases of central nervous system secondary involvement and 13 cases where the onset of the disease was characterized by neurological signs and symptoms. We could only find two reported cases of adrenal metastases originating from endometrial neoplasia but in no case of dedifferentiated endometrial carcinoma previously described has been reported the concomitant adrenal-cerebellar involvement.

A prospective, case-control study on the lipid profile and the cardiovascular risk of menopausal women on oestrogen plus progestogen therapy in a northern Italy province.

PURPOSE: To evaluate the effects of oestrogen plus progestogen therapy (EPT) on the lipid metabolism of menopausal patients. METHODS: We conducted a prospective study on 223 patients with clinical and blood chemistry diagnosis of menopause, who were eligible for hormone therapy and a follow-up period lasting at least 5 years. We selected a control group. Patients attended annual or 6-monthly visits for the duration of the 5-year follow-up period. For each patient, total-cholesterol, HDL-cholesterol, LDL-cholesterol and triglyceride values were considered at the first visit and after 5 years. We compared these values of the above parameters in relation to time and EPT and the repercussions that the presence/absence of replacement therapy had in terms of lipid profile alteration between the groups studied. RESULTS: Of the 223 patients eligible for enrolment, 178 made up the study group (EPT Group) and 45 made up the control cohort (N-EPT-Group). At the first visit, median value was (EPT-Group vs. N-EPT-Group): cholesterol was 240 versus 226 mg/dL, LDL-cholesterol 169 versus 174 mg/dL, HDL-cholesterol 60 mg/dL in both groups, triglyceride 125 versus 92 mg/dL (p:n.s). Five years later, median value was (EPT-Group versus N-EPT-Group): cholesterol 225 versus 236 mg/dL (p < 0.001), LDL-cholesterol 125 versus 184 mg/dL (p < 0.001), HDL-cholesterol 64 versus 68 mg/dL (p:n.s.), triglyceride 72 versus 94 mg/dL (p:n.s.). No adverse effects of EPT were observed. CONCLUSIONS: Thorough risk/benefit assessment, associated with initially low doses and without rigid cutoffs, particularly when started early, EPT can be made a valid means of cardiovascular prevention, specifically because it positively alters the lipid profile of menopausal women.

Total laparoscopic hysterectomy: our experience from 2008 to 2012.

OBJECTIVES: Nowadays total laparoscopic hysterectomy (TLH) is a surgical procedure increasingly adopted for the treatment of benign and malign uterine disease. The aim of our study is to revise our recent experience of TLH. METHODS: This is a retrospective observational study conduced on 101 patients between 2008 and 2012. The surgical procedure has been performed by the same surgeon and with the same surgical technique. Patients with benign disease and I-II stage endometrial cancer (FIGO 2009) were considered eligible for the study. Data collected were concering weight, height, BMI, age; kind of disease; type of surgery performed and possible variants; surgery duration; intra-operative and post-operative complications. RESULTS: In 80 patients TLH was performed for benign disease, in 42 cases uterine fiboids; salpingo-oophorectomy has been performed in 37 patients; the mean surgical time was 81 minutes for benign disease and 112 minutes for malign disease. In 1 case conversion to laparotomy was required; in 5 patients we recorded post-surgical fever; in 1 patients we recorded deiscence of vaginal vault. None of the considered factors (age, BMI, kind of surgery) was significantly associated with increased frequency of intra- and post-operative complications. CONCLUSIONS: Our clinical experience on TLH is increasing as years pass by, and our results are in line with those reported by other Centers. On the basis of our experience, in agreement with recently published data, we believe that vaginal vault closure should be performed through vaginal access.

Calcium supplementation and prevention of preeclampsia: a meta-analysis.

BACKGROUND: Since the early 1980s, epidemiological evidence has suggested a connection between low calcium intake and preeclampsia The purpose of this meta-analysis is to summarize current evidence regarding calcium supplementation during pregnancy in predicting preeclampsia and associated maternal-fetal complications. METHODS: Literature revision of all RCT (random allocation of calcium versus placebo) available in MEDLINE/PUBMED up to 2/29/2012 regarding calcium supplementation during pregnancy for preventing preeclampsia. We used the Mantel-Haenszel's Method for four subgroup of patients: Adequate calcium intake; Low calcium intake; Low risk of preeclampsia; High risk of preeclampsia. We considered p < 0.05 as significant. RESULTS: There is no consensus in Literature about: (1) the efficacy of calcium supplementation in the prevention of preeclampsia, (2) other/adverse/long-term effects of calcium supplementation in pregnancy. CONCLUSIONS: Preeclampsia is likely to be a multifactorial disease. However, inadequate calcium intake represents a factor associated with an increased incidence of hypertensive disease. The results of our meta-analysis demonstrate that the additional intake of calcium during pregnancy is an effective measure to reduce the incidence of preeclampsia, especially in populations at high risk of preeclampsia due to ethnicity, gender, age, high BMI and in those with low baseline calcium intake.

Maternal hydration therapy improves the quantity of amniotic fluid and the pregnancy outcome in third-trimester isolated oligohydramnios: a controlled randomized institutional trial.

OBJECTIVES: Amniotic fluid is important for the maintenance of fetal well-being; therefore, an amniotic fluid deficiency, ie, oligohydramnios, can have multiple impacts on the prognosis of the pregnancy. In some cases, there are no evident fetal or maternal causes, and the condition is called isolated oligohydramnios. The aim of our study was to validate maternal intravenous and oral hydration therapy as a means for improvement of isolated oligohydramnios in the third trimester of pregnancy. METHODS: We conducted a prospective randomized controlled study on pregnancies complicated by idiopathic oligohydramnios (group A, 66 women) with a control group of women with normal pregnancies without oligohydramnios (group B, 71 women). Oligohydramnios was diagnosed using the amniotic fluid index (AFI; <5 cm). Sonographic examinations were performed with a convex 3.5-MHz probe. Group A underwent 6 days of intravenous infusion of 1500 mL of an isotonic solution per day. An AFI measurement, a nonstress test, and a fetal biophysical profile were performed at 0 and 7 days. Group A was randomized into subgroups A1 and A2. Subgroup A1 was prescribed home oral hydration therapy of 1500 mL/d and subgroup A2 2500 mL/d. We considered the AFI to compare the effectiveness of the therapy. RESULTS: General features did not reveal any significant differences between the two groups. In group A, the mean AFI ± SD at recruitment was 39.68 ± 11.11 mm; in group B, it was 126.92 ± 10.59 mm (P < .001). In group A, the mean AFI at 7 days was 77.70 ± 15.03 mm; in group B, it was unchanged. In subgroup A1, the mean AFI at birth was 86.21 ± 16.89 mm; in subgroup A2, it was 112.45 ± 14.92 mm (P < .001). CONCLUSIONS: Our data show that in pregnancies complicated by isolated oligohydramnios, hydration therapy significantly improves the quantity of amniotic fluid.

Extragenital Müllerian adenosarcoma with pouch of Douglas location.

BACKGROUND: Of all female genital tract tumors, 1-3% are stromal malignancies. In 8-10% of cases, these are represented by Müllerian adenosarcoma an extremely rare tumor characterized by a stromal component of usually low-grade malignancy and by a benign glandular epithelial component. Variant that arises in the pouch of Douglas is scarcely mentioned in the medical literature. CASE PRESENTATION: A 49-year-old para-0 woman, was seen at our OB/GYN-UNIT because she complained vaguely of pelvic pain. She had a mass of undefined nature in the pouch of Douglas. A simple excision of the mass showed low-grade Müllerian adenosarcoma with areas of stromal overgrowth. One and a half year after surgery, at another hospital, a mass was detected in the patient's posterior vaginal fornix and removed surgically. Six months later she came back to our observation with vaginal bleeding and mass in the vaginal fornix. We performed radical surgery. The pathological examination showed recurrent adenosarcoma. Surgical treatment was supplemented by radiation therapy. CONCLUSIONS: The case of Müllerian adenosarcoma reported here is the third known so far in the literature that was located in the pouch of Douglas. To date, only two other such cases have been reported, including one resulting from neoplastic degeneration of an endometriotic cyst.

CA 125 serum values in surgically treated endometriosis patients and its relationships with anatomic sites of endometriosis and pregnancy rate.

Endometriosis is a benign gynecologic disease defined as the presence of functional endometrial glands and stroma outside the uterine cavity, causing dysmenorrhea, dyspareunia, menstrual irregularities, and infertility. Serum CA-125 measurement is now a consolidated method for diagnosing this condition, and its interpretation has posed a number of problems, particularly regarding utility in diagnosing minimal-mild endometriosis, whereas its value as a diagnostic aid in moderate-severe stages is well recognized. In our cohort, serum CA-125 values were significantly elevated in patients with ovarian and mixed endometriosis lesions (median levels 48 U/mL), compared with those who had exclusively extraovarian foci (median levels 27 U/mL), and so the correlation between this marker and the surgical and pathologic finding of ovarian and deep endometriosis was found to be statistically significant; however, the location did not affect the fertility rate.

Randomised prospective study of abdominal wall closure in patients with gynaecological cancer.

BACKGROUND: Median laparotomy is the most common approach to the abdominopelvic cavity in patients with gynaecological tumours. AIMS: The primary endpoint of the study was to evaluate the onset of incisional hernia. The secondary endpoint was to evaluate the onset of infection, wound dehiscence, wound infection, and scar pain during the post-operative period. METHODS: A total of 191 patients were eligible for the study. They were divided into three groups. Group A underwent en bloc closure of the peritoneum and fascia with Premilene suture, Group B en bloc closure of the peritoneum and fascia with Polydioxanone suture, and Group C separate closure of the peritoneum and fascia with single stitches of Ethibond suture. Statistical analysis was performed using the Statistical Software Package for Social Sciences 12.0. RESULTS: Group A and Group B comprised 63 patients, and Group C included 65 patients. The three groups proved homogeneous on statistical analysis (P > 0.05). The statistical analysis did not reveal significant differences between the different suture types and techniques with respect to the incidence of incisional hernia (P > 0.05). CONCLUSION: In our study, the incidence of incisional hernia was 8%. Randomised patients were homogeneous for sample size and risk factors. No significant differences were found between suture types or techniques. Currently, there is no suture material or technique that can be considered superior to others. When possible, we believe that the best way to prevent incisional hernia is to preserve the integrity of the abdominal wall using minimally invasive techniques.

Caesarean delivery through deliberate posterior hysterotomy in irreducible uterine torsion: case report.

Gravid uterus rotation is a normal finding in the third trimester of pregnancy. However, a rotation greater than 45 degrees around the longitudinal axis of the uterus--uterine torsion--is a rare pathological condition in the obstetrical practice. We reporte the case of 180 degrees torsion of a myomatous uterus at preterm in which the foetus, in breech presentation, was delivered through a deliberate posterior hysterotomy. An emergency caesarean section was arranged after prolonged foetal bradycardia. Uterine torsion treatment depends on when the torsion occurs during the pregnancy. However, laparotomy is imperative in all cases. When derotation of the uterus is not possible, a transverse incision in the lower posterior uterine segment, if feasible, is a safe choice.

Cervical length as a predictor of preterm delivery: gestational age-related percentiles vs fixed cut-offs.

BACKGROUND: To determine whether preterm delivery is more effectively predicted by sonographic cervical length measurement using fixed cut-off or gestational age-specific percentiles. METHODS: One hundred and eight patients hospitalized for suspected preterm labor (PTL) were studied prospectively between the 20th and the 33rd week of gestation. RESULTS: Cervical length below 15 mm, 25 mm and the 2.5th centile showed substantially equivalent odds ratios for delivery within 7 days (7.5, 7.6, and 7.1, respectively), while for delivery before the 34th week the odds ratios varied between 3.6 with cervical length <2.5rh centile and 6.2 with cervical length <25 mm. Moreover, the negative predictive value for delivery within 7 days exceeded 90% when cervical length was above 25 mm, the 10th and the 2.5th percentile, and 85% when above 15 mm. CONCLUSION: The comparison of fixed and gestational age-specific cut-offs demonstrates a better reliability of fixed cut-offs (15 or 25 mm) in predicting preterm delivery, both before 34 weeks and within 7 days of the ultrasound examination.

Prelabour rupture of the membranes: recent evidence.

Premature rupture of the membranes (PROM) complicates 10% of all gestations and 2-4% of preterm pregnancy. Our success in preventing preterm PROM and preterm birth is hampered by our limited knowledge of its etiology. PROM remains the single most identifiable cause of preterm delivery and the major contributor to perinatal morbidity and mortality. Its clinical management continues to be controversial. The management dilemma associated with preterm PROM (PPROM) involves a balance between expectant management and intervention, taking into consideration the risks of infection with the increased duration of membrane rupture. Recent evidence on the use of antibiotics and amnioinfusion, together with advances in the prediction, diagnosis and estimation of risk based upon occupational factors and genetics have provided additional therapeutic tools in our approach to the problem of PPROM. While PPROM at very early gestation is a serious complication and a major management dilemma often associated with poor outcome, the prognosis is not without hope.

Amniotic fluid dynamics.

Amniotic fluid was once considered to be a stagnant pool, approximately circulating with a turnover time of one day. Adequate amniotic fluid volume is maintained by a balance of fetal fluid production (lung liquid and urine) and resorption (swallowing and intramembranous flow). Even though different hypotheses have been advanced on the mechanisms regulating this turnover, the inflow and outflow mechanism that keeps amniotic fluid volume within the normal range is not entirely clear. Regulatory mechanisms act at three levels: placental control of water and solute transfer; regulation of inflows and outflows from the fetus; and, maternal effect on fetal fluid balance. Amniotic fluid is 98-99% water. The chemical composition of its substances varies with gestational age. When fetal urine begins to enter the amniotic sac, amniotic osmolarity decreases slightly compared with fetal blood. After keratinization of the fetal skin, amniotic fluid osmolarity decreases further with advancing gestational age. The low amniotic fluid osmolarity, which is produced by the inflow of markedly hypotonic fetal urine, provides a large potential osmotic force for the outward flow of water across the intramembranous and transmembranous pathways. Within certain limits, amniotic fluid mirrors the metabolic status of the fetoplacental unit; for that reason, a study of its components and their respective variations in the different weeks of pregnancy provides useful indications, both for a correct assessment of fetal maturation and for an evaluation of kidney function parameters and placental insufficiency.

Effect of low-dose transdermal E2/NETA on the reduction of postmenopausal bone loss in women.

OBJECTIVE: To assess the efficacy of a continuous-combined transdermal patch (estradiol/ norethisterone acetate [E(2)/NETA] 25/125; Estragest TTS, Novartis, Basel, Switzerland) in the reduction of bone loss in postmenopausal women. DESIGN: In a 96-week, double-blind, randomized, multicenter, parallel study, 124 healthy women with an intact uterus more than 4 years after menopause received either transdermal continuous-combined E(2)/NETA (0.025/0.125 mg/day) or placebo patch for 24 treatment cycles; diet was normalized for calcium intake. Lumbar spine bone mineral density (BMD) ranged from 0.969 to 0.805 g/cm2 with a mean annual BMD decrement ranging from 3% to 8% within the last 24 months. BMD at lumbar spine L(2)-L(4) (postero-anterior) and femur were assessed by dual energy x-ray absorptiometry after 6, 12, and 24 cycles. Efficacy variables included measurement of biochemical markers of bone turnover (3, 6, 12, and 24 months). RESULTS: BMD at lumbar spine was significantly higher at all time points in the E(2)/NETA group than in the placebo group (P < 0.0001). Significant increases in BMD (P < 0.0008) from baseline were observed at all sites after 24 months in the E(2)/NETA group compared with placebo, which demonstrated a decrease from baseline. At endpoint, statistically significant decrements in the values of bone remodeling markers were observed (P < 0.05) with E(2)/NETA. CONCLUSIONS: E(2)/NETA 25/125 Estragest TTS was more effective than placebo in reducing the activation frequency of bone remodeling and in preventing bone loss at the spine and hip. Effects on the hip were similar to those observed for higher doses of estrogen.

Effect of soy-derived isoflavones on hot flushes, endometrial thickness, and the pulsatility index of the uterine and cerebral arteries.

OBJECTIVE: To determine the effect of soy-derived isoflavones on hot flushes, endometrial thickness, and the vascular reactivity of uterine and cerebral arteries. DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: Healthy volunteers in an academic research environment. PATIENT(S): Sixty-two postmenopausal women aged 45-60 years attending the Outpatient Menopause Clinic of our gynecological departments. INTERVENTION(S): The patients were administered 72 mg of soy-derived isoflavones or placebo under double-blind conditions. The daily number of hot flushes was recorded in a diary. Endometrial thickness was measured by means of transvaginal ultrasound; the uterine, internal carotid, and middle cerebral arteries were evaluated using Doppler ultrasound. MAIN OUTCOME MEASURE(S): The daily number of hot flushes, endometrial thickness, and arterial pulsatility index (PI). RESULT(S): Both treatments led to a 40% reduction in the number of hot flushes. Soy-derived isoflavones had no effect on endometrial thickness or the PI of the uterine and cerebral arteries. CONCLUSION(S): The daily administration of 72 mg of soy-derived isoflavones is no more effective than placebo in reducing hot flushes in postmenopausal women. It also has no effect on endometrial thickness or the PI of the uterine and cerebral arteries.