Fertility-Sparing Treatment for Early-Stage Cervical Cancer ≥ 2 cm: A Problem with a Thousand Nuances-A Systematic Review of Oncological Outcomes.

BACKGROUND: Fertility-sparing treatments (FSTs) have played a crucial role in the management of early-stage cervical cancer (ECC). The guidelines have recognized various approaches, depending on the tumor stage and other risk factors such as histotype and lymphovascular positivity. Much more debate has centered around the boundary within which these treatments should be considered. Indeed, these are methods to be reserved for ECC, but tumor size may represent the most significant limitation. In particular, there is no consensus on the strategy to be adopted in the case of ECC ≥ 2 cm. Therefore, this systematic review was to collect the literature evidence regarding the management of these patients. METHODS: Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the Pubmed and Scopus databases was conducted in April 2022, from the date of the first publication. We made no limitation on the country. We included all studies containing data on disease-free survival, overall survival, recurrence rate (RR), or complete response rate (CRR) to chemotherapy. RESULTS: Twenty-six studies fulfilled the inclusion criteria, and 691 patients were analyzed regarding FST. Surgery-based FST showed an RR of between 0 and 42.9%, which drops to 12.9% after excluding the vaginal or minimally invasive approaches. Furthermore, papers regarding FST based on the neoadjuvant chemotherapy (NACT) approach showed a CRR of between 21.4 and 84.5%, and an RR of between 0 and 22.2% CONCLUSION: This paper focused on the significant heterogeneity present in the clinical management of FST of ECC ≥ 2 cm. Nevertheless, from an oncological point of view, approaches limited to the minimally invasive or vaginal techniques showed the highest RR. Vice versa, the lack of standardization of NACT schemes and the wealth of confounders to be attributed to the histological features of the tumor make it difficult, if not impossible, to set a standard of treatment.

Is Uterine Myomectomy a Real Contraindication to Vaginal Delivery? Results from a Prospective Study.

OBJECTIVES: The main goal of our research was to explore correlations between a history of uterine myomectomy and maternal-fetal outcomes, throughout a comparison between vaginal deliveries in patients with or without a history of uterine myoma excision. MATERIALS AND METHODS: A prospective study was carried out at two tertiary care hospitals between January 2019 and January 2020. Women were assigned into two groups according to the history of laparoscopic or laparotomic myomectomy (Group 1) or without myomectomy (Group 2). RESULTS: 80 women successfully delivered after myomectomy. Pregnancies with previous laparoscopic or laparotomic myomectomy were associated with a minor rate of spontaneous labor onset (RR 1.17; 95% CI 1.04 - 1.31) and with an increased rate of emergency cesarean section (RR 1.22; 95% CI 1.09 - 1.36). Moreover, myomectomy group had a significant number of indications to emergency cesarean section correlated to suspected uterine rupture (RR 1.19; 95% CI 1.02-1.39). There were no uterine ruptures or neonatal deaths recorded. First stage of labor was longer in the myomectomy group (316 vs 204 mins, p = 0.01). No differences in the rates of the prolonged first and second stage of labor, postpartum hemorrhage and vaginal laceration, and no neonatal adverse outcomes were found between groups. CONCLUSIONS: Pregnancies after myomectomy might be associated with an elevated rate of emergency cesarean section only due to a higher percentage of suspected uterine rupture, without a real hazard of adverse obstetric or neonatal outcomes.

Hysteroscopic and ultrasonographic evaluation of ulipristal acetate treatment for symptomatic myomas in premenopausal women: a prospective study.

OBJECTIVE: This study aimed to analyze the effects of a six-month therapy with ulipristal acetate (UPA) on myoma size and endometrial thickness in premenopausal women. MATERIAL AND METHODS: Seventy-four women undergoing conservative therapy with UPA were enrolled for this study. All women underwent transvaginal ultrasound evaluation to assess the endometrial thickness, and the number and size of myomas at the beginning and after six months. Hysteroscopy and biopsy were performed after six months, if necessary. RESULTS: After six months of treatment, sonographic examination showed a statistically significant (p < .05) reduction of the size of the largest myoma (56.3 ± 5.1 vs. 31.7 ± 10.1 mm) and a statistically significant (p < .05) increase in endometrial thickness (5.9 ± 2.1 vs. 9.7 ± 3.4 mm). Twenty-two patients with endometrial thickness >10 mm or nonhomogeneous pattern and ten patients with metrorrhagia underwent hysteroscopy: the most frequent finding was the combination of endometrial hypotrophy, floating surface, and chicken-wire vascular pattern aspect (14 cases, 43.7%). Histologic findings showed no case of complex hyperplasia. CONCLUSION: UPA is a safe, effective and assured method to decrease symptoms, reduce the need for surgery in premenopausal women suitable for the treatment.

TNF-α effect on human delivery onset by CB1/TRPV1 crosstalk: new insights into endocannabinoid molecular signaling in preterm vs. term labor. Analysis of the EC/EV pathway and predictive biomarkers for early diagnosis of preterm delivery.

BACKGROUND: Endocannabinoids/endovanilloid (EC/EV) system and inflammation are recognized as key regulators of cell-signaling pathways in female reproduction. The knowledge of predictive biomarkers involved in preterm birth (PTB) represents an important goal to make an early diagnosis. The aim of the study was to investigate the role of EC/EV system and inflammation in human delivery, in placental samples from spontaneous deliveries. METHODS: We examined the expression of genes encoding for the components of EC/EV system (CB1, CB2, TRPV1, MAGL, FAAH, DAGL, NAPE-PLD) and for inflammatory cytokines (IL-6, TNF-α) with qRT-PCR techniques, in human placental samples from preterm delivery (at 30 and at 34 weeks) compared to term delivery (40 weeks, control group). RESULTS: We found a marked increase of CB1, anandamide, and inflammatory cytokines, mainly TNF-α, together with TRPV1 down-regulation in term delivery group, compared to preterm groups (P<0.05). CONCLUSIONS: Our findings highlighted the emergent pivotal role of the EC/EV system and inflammation in spontaneous term delivery and provided the framework for future studies that investigate the CB1/TRPV1 crosstalk in preterm birth. Particularly, we found a link between the stimulation of CB1 receptors and the antagonism of TRPV1 channels, that could be used in PTB prevention, through selected molecules.

[Diagnostic accuracy of endocervicoscopy as preoperative tool to improve the excisional treatment of cervical preneoplastic lesions].

BACKGROUND: The aim of this study was to evaluate the diagnostic accuracy of endocervicoscopy as a preoperative examination to improve the outcome of the excisional treatment (LEEP) of high-grade cervical preneoplastic lesions. METHODS: Patients with histologic diagnosis of CIN II-CIN III undergoing LEEP divided in two groups: in group A (85 women) a preoperative endocervicoscopy was performed, in group B (85 women) no additional examination was performed before LEEP. The size of the surgical specimen (H, D, W) and the margins of the lesion were evaluated. RESULTS: Seventy-four women in group A and 80 in group B completed the follow-up. group A showed significant correlation between colposcopic examination and endocervicoscopic examination (P=0.001, k=0.30) and between endocervicoscopic and definitive histological examination (P<0.05, k=0.16). The depth of the operative sample was significantly lower (P<0.0001) in group A (0.91±0.4) than in group B (1.58±0.2), group A showed fewer patients B with positive endocervical margins than group B (3 vs. 17, P<002). Colposcopic, cytological and virological follow-up did not show significant differences between the two groups. CONCLUSIONS: Endocervicoscopy as preoperative tool for excisional treatment of cervical lesions showed high diagnostic effectiveness and allows to perform a conservative surgery.

Conservative Resectoscopic Surgery, Successful Delivery, and 60 Months of Follow-Up in a Patient with Endometrial Stromal Tumor with Sex-Cord-Like Differentiation.

Uterine tumors with sex-cord-like differentiation are extremely rare types of uterine stromal neoplasm. These tumors were classified into two groups with considerable practical relevance because clinical behaviour of uterine tumor resembling ovarian sex cord tumor (UTROSCT) differs widely from its closely related endometrial stromal tumors with sex-cord-like elements (ESTSCLE). Treatment and prognosis of these tumors are unresolved issues because of the exiguous number of reported cases. We describe a rare case of endometrial stromal tumor with sex-cord-like differentiation successfully treated by resectoscopic surgery and conservation of the uterus, in an infertile patient affected by metrorrhagia. This procedure resulted in a pregnancy immediately after treatment and in a successful delivery. During 60 months of follow-up no evidence of recurrence was observed.

Stress urinary incontinence: usefulness of perineal ultrasound.

PURPOSE: Perineal ultrasound provides the most sensitive assessment of the degree of urethral mobility by measuring the pubo-urethral distance and angle. To evaluate whether these indices may be determinants of success in prosthetic surgery for stress urinary incontinence, we conducted a retrospective study of patients treated with tension-free vaginal tape-obturator (TVT-O) surgery and assessed, by measuring the pubo-urethral distance and angle after TVT-O, whether there was any quantitative difference between the mean values measured in the group of cured patients and uncured patients. MATERIALS AND METHODS: We selected 51 patients who underwent TVT-O and evaluated the failure rate by means of urogynaecological assessment. We also measured, using perineal ultrasound, the mean values of the pubo-urethral distance and angle between the two groups of patients. RESULTS: We recorded a difference in the average pubo-urethral distance of 3 mm ± 1.2 at rest and 2.7 mm ± 1.2 under stress and a difference in the average pubo-urethral angle of 13° ± 6.3° at rest and 8° ± 6.3° under stress between the two groups. CONCLUSIONS: We obtained higher mean values of pubo-urethral distance and angle in uncured patients compared to those found in the group of cured patients.