Leiomyoma or sarcoma? MRI performance in the differential diagnosis of sonographically suspicious uterine masses.

PURPOSE: To assess the diagnostic performance of MRI in distinguishing between leiomyomas and malignant/potentially malignant mesenchymal neoplasms in patients with rapidly enlarging/sonographically suspicious uterine masses. METHODS: IRB-approved retrospective study including 88 patients (51 ± 11 years) who underwent MRI for rapidly enlarging/sonographically suspicious uterine mass at our Institution between January 2016 and December 2021, followed by surgery or >12 months follow-up. Qualitative image analysis was independently performed by 2 radiologists and included lesion's margins (sharp/irregular), architecture (homogeneous/inhomogeneous), presence of endometrial infiltration (yes/no), necrotic areas (yes/no), hemorrhagic areas (yes/no), predominant signal intensity on T1-WI, T2-WI, CE T1-WI, DWI, and ADC map. The same radiologists performed quantitative image analysis in consensus, which included lesion's maximum diameter, lesion/myometrium signal intensity ratio on T2-WI and CE T1-weighted images, lesion/endometrium signal intensity ratio on DWI and ADC map and necrosis percentage. Lesions were classified as benign or malignant. Imaging findings were compared with pathology and/or follow-up. RESULTS: After surgery (52/88 patients) or follow-up (36/88 patients, 33 ± 20 months), 83/88 (94.3%) lesions were classified as benign and 5/88 (5.7%) as malignant/potentially malignant. Presence of necrotic areas, high necrosis percentage, hyperintensity on DWI and high lesion/endometrium DWI signal intensity ratio were significantly associated with malignant/potentially malignant lesions (p = 0.027, 0.002, 0.008 and 0.015, respectively). The two readers identified malignant/potentially malignant lesions with 95.5% accuracy, 80.0% sensitivity, 96.4% specificity, 57.1 % PPV, 93.3% NPV. CONCLUSION: MRI has high accuracy in identifying malignant/potentially malignant myometrial masses. In everyday practice, however, MRI positive predictive value is relatively low given the low pre-test malignancy probability.

Childbirth Care among SARS-CoV-2 Positive Women in Italy.

The new coronavirus emergency spread to Italy when little was known about the infection's impact on mothers and newborns. This study aims to describe the extent to which clinical practice has protected childbirth physiology and preserved the mother-child bond during the first wave of the pandemic in Italy. A national population-based prospective cohort study was performed enrolling women with confirmed SARS-CoV-2 infection admitted for childbirth to any Italian hospital from 25 February to 31 July 2020. All cases were prospectively notified, and information on peripartum care (mother-newborn separation, skin-to-skin contact, breastfeeding, and rooming-in) and maternal and perinatal outcomes were collected in a structured form and entered in a web-based secure system. The paper describes a cohort of 525 SARS-CoV-2 positive women who gave birth. At hospital admission, 44.8% of the cohort was asymptomatic. At delivery, 51.9% of the mothers had a birth support person in the delivery room; the average caesarean section rate of 33.7% remained stable compared to the national figure. On average, 39.0% of mothers were separated from their newborns at birth, 26.6% practised skin-to-skin, 72.1% roomed in with their babies, and 79.6% of the infants received their mother's milk. The infants separated and not separated from their SARS-CoV-2 positive mothers both had good outcomes. At the beginning of the pandemic, childbirth raised awareness and concern due to limited available evidence and led to "better safe than sorry" care choices. An improvement of the peripartum care indicators was observed over time.

Non-human papilloma virus associated adenocarcinomas of the cervix uteri. Cytologic features and diagnostic agreement using whole slide digital cytology imaging.

BACKGROUND: Non-Human Papilloma Virus associated adenocarcinomas (NHPVAs) are uncommon tumors of the cervix uteri which often show a deceptive morphology. Therefore, their diagnostic assessment may be challenging. Slide digital cytology imaging may be an useful tool to improve cytological diagnostic accuracy. However, this novel technology has not been applied to NHPVAs associated cytologies yet. METHODS: The study included 31 whole slide digital cytology cases from 10 women with a proven histological diagnosis of NHPVA. As a control group, three further digital slides, from two women with a histological diagnosis of squamous intraepithelial lesion (SIL), were included. The digitally scanned cytological slides were revised to assess the concordance rate among three observers and to find out the most relevant NHPVA cytological criteria. RESULTS: Overall diagnostic agreement between observers was 67.60% (K = 0.50; P < 0.0001). At the consensus diagnosis 34 cases were re-classified as at least suspicious for glandular lesion (n = 24), SIL (n = 2) and negative (n = 8). The most relevant cytologic features for atypical glandular cells or adenocarcinoma at consensus were evident nucleoli, nuclear overlapping and atypical enlarged nuclei. CONCLUSIONS: The diagnosis of NHPVA in digital cytology is feasible using criteria which are also used in conventional microscopy. Our study shows a moderate agreement for the cytological diagnosis of NHPVAs using whole slide digital cytology approach. These results are discussed taking into account the most relevant differential diagnostic issues.

Laparoscopic Radiofrequency Thermal Ablation for Uterine Adenomyosis.

BACKGROUND AND OBJECTIVES: Symptomatic uterine adenomyosis, unresponsive to medical therapy, is a challenging condition for patients who desire to preserve their uterus. This study was an evaluation of the feasibility and efficacy of laparoscopic radiofrequency thermal ablation of symptomatic nodular uterine adenomyosis. METHODS: Fifteen women with symptomatic nodular adenomyosis, who had no plans for pregnancy but declined hysterectomy, underwent radiofrequency thermal ablation. Ultrasonography was performed at baseline and at postoperative follow-ups at 3, 6, 9, and 12 months. The impact of uterine adenomyosis-related symptoms was assessed according to the visual analog scale. RESULTS: The median number of nodular lesions treated per patient was 1 (range, 1-2). The median baseline volume of the adenomyosis area was 60 cm(3) (range, 18-128). The median reduction in volume was 32, 49.4, 59.6, and 65.4% at 3, 6, 9, and 12 months, respectively. A significant progressive improvement in the symptoms score was observed at the 4 follow-ups. CONCLUSION: In this study, laparoscopic radiofrequency thermal ablation reduced uterine adenomyosis-related symptoms and volume, with significant relief of symptoms.

Distribution of endometriotic lesions in endometriosis stage IV supports the menstrual reflux theory and requires specific preoperative assessment and therapy.

A detailed picture of the prevalence and distribution of abdomino-pelvic endometriosis in more that 1,500 cases of endometriosis stage IV is presented. A great prevalence of endometriotic localizations in the posterior pelvic compartment compared to the other quadrants with more frequently observed lesions on the left part of the pelvis supports the menstrual reflux theory. The extent of anatomical sites suggests the opportunity to plan a proper preoperative instrumental study for patients with clinical suspect of severe endometriosis possibly to set a multidisciplinary clinical or surgical management.

Laparoscopic ileocecal resection for bowel endometriosis.

BACKGROUND: Ileocecal endometriosis is a very rare entity, and its diagnosis is usually made during surgery for other endometriosis sites or, rarely, because of direct complications of ileal involvement. This study was designed to analyze perioperative and long-term outcomes after bowel resection for ileocecal endometriosis. METHODS: All patients who underwent surgery for ileocecal endometriosis between October 2004 and January 2008 were prospectively collected and analyzed. RESULTS: Thirty-one women (median age, 34 (range, 25-40) years) were identified. Ileocecal endometriosis was diagnosed during surgery in all patients, and it was associated with colorectal endometriosis in 29 patients (94%). All patients underwent laparoscopic ileocecal resection with no laparotomic conversion. Rectosigmoid or rectal resections was associated in 28 patients (90%) and nodulectomy for sigmoid endometriosis in 1 patient. Median duration of surgery was 301 (range, 90-480) min. Other associated surgical procedures included total hysterectomy (n = 3, 14%), ureterolysis (n = 7, 23%), excision of vesical (n = 4, 13%), vaginal (n = 8, 26%), and parametrial (n = 3, 14%) nodules. There was no mortality. Four patients (13%) required blood transfusions and one a reoperation for bleeding. In a patient who performed ureterolysis, a ureteral fistula occurred. The median hospital stay was 7 (range, 5-18) days. Long-term (>12 months) follow-up data were available for 18 patients. After a median follow-up of 27 months, in 12 of 18 patients (67%) defecation after surgery was normal. Only one patient developed recurrence, which is under medical treatment. CONCLUSIONS: Laparoscopic ileocecal resection is safe and feasible and should be considered as part of surgery for endometriosis with radical intent.

Endometriosis in the north Italian province of South Tyrol.

Here, we report regarding the health status and medical support for patients suffering from endometrioisis in South Tyrol, which is a politically autonomous province in the north of Italy containing three different ethnic groups. The health service is administered largely by the autonomous regional government. Because of the establishment of a centre for reproductive medicine and the introduction of laparoscopy as a prime surgery method, the gynaecological department of the hospital in Bruneck developed into a reference centre for diagnosis and surgical treatment for endometriosis. The planned future social, health care and insurance developments on local and national level regarding this illness will be discussed.

Successful laparoscopic management of spontaneous hemoperitoneum at 15 weeks of pregnancy: case report and review of literature.

We present a case report of laparoscopic management of a spontaneous hemoperitoneum in the second trimester of pregnancy. The patient was a 40-year-old woman at 15 weeks of gestation. At laparoscopic surgery, the hemoperitoneum was evacuated, and the right-sided uterine vessels were closed with diathermocoagulation. Every pregnant woman with severe abdominal pain, vomiting, and imminent hypovolemic shock should be carefully evaluated. After ruling out the most prevalent causes of hemoperitoneum, idiopathic spontaneous hemoperitoneum should be considered. Rapid diagnosis and aggressive fluid replacement together with prompt surgical intervention may be the only chance for a favorable outcome for both mother and child in the presence of such a rare complication. Moreover, in early stages of pregnancy, the laparoscopic approach should be considered but only in the hands of experienced laparoscopic surgeons.

Patient with pelvic pains: retroperitoneal fibrosis or pelvic endometriosis? A case report and review of literature.

OBJECTIVE: To describe how a hydronephrosis can lead to a difficult differential diagnosis between endometriosis and retroperitoneal fibrosis. DESIGN: Case report. SETTING: Department of Obstetrics and Gynecology, Sacro Cuore Don Calabria General Hospital, Negrar, Verona, Italy. PATIENT(S): The history of a 34-year-old woman revealed the appearance of hydroureteronephrosis on the right side at the 35th week of pregnancy. She had an magnetic resonance imaging scan and was diagnosed with a spread retroperitoneal fibrosis. After 2 months, the patient reported the occurrence of pelvic pain, dyspareunia and dysmenorrhea. She was treated with corticosteroids and tamoxifen with no results. INTERVENTION(S): Laparoscopic surgery. A complete retroperitoneal extirpation was done of an endometriotic nodule of the right broad ligament, near the right ureter (without stenosis). MAIN OUTCOME MEASURE(S): Reduction of pelvic pain. RESULT(S): She noticed an important decrease of pain. CONCLUSION(S): The cause of hydronephrosis could be a physiologic hydroureteronephrosis, which is the most common cause of dilatation of the urinary tract in pregnancy. The pain symptoms of the patients seemed to be linked to endometriosis and not to retroperitoneal fibrosis. Magnetic resonance imaging sometimes does not enable a correct diagnosis between these two pathologies. Fertile women with suspected fibrosis should undergo a diagnostic laparoscopy by an expert surgeon in retroperitoneal surgery.