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Bogani G, Scambia G, Fagotti A, Fanfani F, Ciavattini A, Sopracordevole F, Malzoni M, Casarin J, Ghezzi F, Vizza E, Cosentino F, Berretta R, Cuccu I, Ferrari FA, Chiappa V, Vizzielli G, Raspagliesi F. Sentinel node mapping, sentinel node mapping plus back-up lymphadenectomy, and lymphadenectomy in Early-sTage cERvical caNcer scheduled for fertilItY-sparing approach: The ETERNITY project. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108467. [PMID: 38901291 DOI: 10.1016/j.ejso.2024.108467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 05/20/2024] [Accepted: 06/04/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE To investigate the safety of sentinel node mapping for patients with early-stage cervical cancer undergoing cervical conization plus nodal evaluation. METHODS The ETERNITY project is a retrospective, multi-institutional study collecting data of patients with early-stage cervical cancer undergoing fertility-sparing treatment. Here, we compared outcomes related to three methods of nodal assessment: sentinel node mapping (SNM), SNM plus backup lymphadenectomy (SNM + LND); pelvic lymphadenectomy (LND). RESULTS Charts of 123 patients (with stage IA1-IB1 cervical cancer) were evaluated. Median patients' age was 34 (range, 22-44) years. SNM, SNM + LND, and LND were performed in 32 (26 %), 31 (25.2 %), and 60 (48.8 %) patients, respectively. Overall, eight (6.5 %) patients were diagnosed with positive nodes. Two (3.3 %), three (9.7 %), and three (9.4 %) patients were detected in patients who had LND, SNM + LND, and SNM respectively. Considering the 63 patients undergoing SNM (31 SNM + LND and 32 SNM alone), macrometastases, micrometastases, and isolated tumor cells were detected in four (3.2 %), three (2.4 %), and one (0.8 %) patients, respectively. All patients with positive nodes discontinued the fertility sparing treatment. Other two patients (one (1.7 %) in the LND group and one (3.1 %) in the SNM group) required hysterectomy even after negative nodal evaluation. After a median follow-up of 53.6 (range, 1.3, 158.0) months, nine (7.3 %) and two (1.6 %) patients developed cervical and pelvic nodes recurrences, respectively. Disease-free (p = 0.332, log-rank test) and overall survival (p = 0.769, log-rank test) were similar among groups. CONCLUSIONS In this retrospective experience, SNM upholds long-term oncologic effectiveness of LND, reducing morbidity.
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Affiliation(s)
- Giorgio Bogani
- Gynecologic Oncologic Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milano, Italy.
| | - Giovanni Scambia
- Gynecologic Oncology Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Institute of Obstetrics and Gynecology, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Anna Fagotti
- Gynecologic Oncology Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Institute of Obstetrics and Gynecology, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Francesco Fanfani
- Gynecologic Oncology Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Institute of Obstetrics and Gynecology, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy
| | - Francesco Sopracordevole
- Gynecologic Oncology Unit, Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy
| | - Mario Malzoni
- Endoscopica Malzoni, Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Ospedale di Circolo Fondazione Macchi, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Ospedale di Circolo Fondazione Macchi, Varese, Italy
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCSS-Regina Elena National, Cancer Institute, Rome, Italy
| | - Francesco Cosentino
- Department of Medicine and Health Science, "V.Tiberio" Università Degli Studi Del Molise, Campobasso, Italy
| | - Roberto Berretta
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Ilaria Cuccu
- Gynecologic Oncologic Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milano, Italy; Department of Gynecological, Obstetrical and Urological Sciences, 'Sapienza' University of Rome, Rome, Italy
| | - Filippo Alberto Ferrari
- Gynecologic Oncologic Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milano, Italy; Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - Valentina Chiappa
- Gynecologic Oncologic Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milano, Italy
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, "S. Maria Della Misericordia" University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Francesco Raspagliesi
- Gynecologic Oncologic Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milano, Italy
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Bogani G, Scambia G, Raspagliesi F, Corso G. Human papillomavirus vaccination coverage in Italy. Eur J Cancer Prev 2024:00008469-990000000-00155. [PMID: 38870022 DOI: 10.1097/cej.0000000000000896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Affiliation(s)
- Giorgio Bogani
- Department of Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan
| | - Giovanni Scambia
- Department of Woman's and Child Health and Public Health Sciences, Gynecologic Oncology Unit
- Gynecologic Oncology Unit, Department of Woman, Child and Public Health, Fondazione Policlinico Universitario Agostino, Gemelli IRCCS, Rome
| | | | - Giovanni Corso
- Department of Oncology and Hemato-Oncology, University of Milano, Milan, Italy
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Gazzetta S, Valent F, Sala A, Driul L, Brunelli L. Sexually transmitted infections and the HPV-related burden: evolution of Italian epidemiology and policy. Front Public Health 2024; 12:1336250. [PMID: 38560434 PMCID: PMC10978588 DOI: 10.3389/fpubh.2024.1336250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
Sexually transmitted infections (STIs) are a major public health problem worldwide, with a high prevalence between the ages of 15 and 25 in most Western countries. High notification rates of chlamydia, gonorrhea, and syphilis are reported in the WHO European Region, with differences between countries. In Italy, the total number of STIs alerts increased by 18% from 2020 to 2021. HPV is the most common sexually transmitted infection; globally one in seven women is infected by this virus, and certain sexual behaviors are important risk factors for HPV-related cancers, particularly cervical cancer (CC), anogenital cancers and cancers of the head and neck. The burden of CC is relevant worldwide, in particular in Europe CC is the third leading cause of cancer-related deaths in women aged 15-44. This HPV-related tumor is preventable through a combined strategy of vaccination and screening for precursor lesions. In Italy, the coverage of organized screening varies from region to region and the average HPV vaccination rate is still far from the expected optimal threshold of 95% at the age of 12. To address the challenges of health promotion and HPV prevention, priority actions are needed such as: promoting education and information at every level, from schools to healthcare professionals. In Italy, education of adolescents on sexual and reproductive health, still remains critical, regionally inhomogeneous and much lower than in other European countries. Equitable measures need to be taken, and schools are an important place for health promotion activities.
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Affiliation(s)
| | - Francesca Valent
- Institute of Hygiene and Clinical Epidemiology, Friuli Centrale University Healthcare Trust, Udine, Italy
| | - Alessia Sala
- Departement of Medicine, University of Udine, Udine, Italy
| | - Lorenza Driul
- Departement of Medicine, University of Udine, Udine, Italy
- Department of Obstetrics and Gynaecology, ASUFC, Ospedale Santa Maria Della Misericordia, Udine, Italy
| | - Laura Brunelli
- Departement of Medicine, University of Udine, Udine, Italy
- Accreditation, Quality and Clinical Risk Unit, Friuli Centrale University Healthcare Trust, Udine, Italy
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Dellino M, Pinto G, D’Amato A, Barbara F, Di Gennaro F, Saracino A, Laganà AS, Vimercati A, Malvasi A, Malvasi VM, Cicinelli E, Vitagliano A, Cascardi E, Pinto V. Analogies between HPV Behavior in Oral and Vaginal Cavity: Narrative Review on the Current Evidence in the Literature. J Clin Med 2024; 13:1429. [PMID: 38592283 PMCID: PMC10932293 DOI: 10.3390/jcm13051429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
Human genital papilloma virus infection is the most prevalent sexually transmitted infection in the world. It is estimated that more than 75% of sexually active women contract this infection in their lifetime. In 80% of young women, there is the clearance of the virus within 18-24 months. In developed countries, oral squamous cell carcinoma (OSCC) is now the most frequent human papilloma virus (HPV)-related cancer, having surpassed cervical cancer, and it is predicted that by 2030 most squamous cell carcinomas will be the HPV-related rather than non-HPV-related form. However, there are currently no screening programs for oral cavity infection. While the natural history of HPV infection in the cervix is well known, in the oropharynx, it is not entirely clear. Furthermore, the prevalence of HPV in the oropharynx is unknown. Published studies have found wide-ranging prevalence estimates of 2.6% to 50%. There are also conflicting results regarding the percentage of women presenting the same type of HPV at two mucosal sites, ranging from 0 to 60%. Additionally, the question arises as to whether oral infection can develop from genital HPV infection, through oral and genital contact or by self-inoculation, or whether it should be considered an independent event. However, there is still no consensus on these topics, nor on the relationship between genital and oral HPV infections. Therefore, this literature review aims to evaluate whether there is evidence of a connection between oral and cervical HPV, while also endorsing the usefulness of the screening of oral infection in patients with high-risk cervical HPV as a means of facilitating the diagnosis and early management of HPV-related oral lesions. Finally, this review emphasizes the recommendation for the use of the HPV vaccines in primary prevention in the male and female population as the most effective means of successfully counteracting the increasing incidence of OSCC to date.
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Affiliation(s)
- Miriam Dellino
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy; (M.D.); (A.V.); (A.M.); (E.C.); (A.V.); (V.P.)
| | - Grazia Pinto
- Dentistry Unit, Department of Interdisciplinary Medicine, University of Bari Medical School, 70124 Bari, Italy;
| | - Antonio D’Amato
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy; (M.D.); (A.V.); (A.M.); (E.C.); (A.V.); (V.P.)
| | - Francesco Barbara
- Unit of Otolaryngology, Department of Ophtalmology and Otolaryngology, University of Bari, 70124 Bari, Italy;
| | - Francesco Di Gennaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University Hospital Polyclinic, University of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy; (F.D.G.); (A.S.)
| | - Annalisa Saracino
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University Hospital Polyclinic, University of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy; (F.D.G.); (A.S.)
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
| | - Antonella Vimercati
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy; (M.D.); (A.V.); (A.M.); (E.C.); (A.V.); (V.P.)
| | - Antonio Malvasi
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy; (M.D.); (A.V.); (A.M.); (E.C.); (A.V.); (V.P.)
| | | | - Ettore Cicinelli
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy; (M.D.); (A.V.); (A.M.); (E.C.); (A.V.); (V.P.)
| | - Amerigo Vitagliano
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy; (M.D.); (A.V.); (A.M.); (E.C.); (A.V.); (V.P.)
| | - Eliano Cascardi
- Pathology Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari, Piazza Giulio Cesare 11, 70121 Bari, Italy;
| | - Vincenzo Pinto
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy; (M.D.); (A.V.); (A.M.); (E.C.); (A.V.); (V.P.)
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D'Oria O, Bogani G, Cuccu I, D'Auge TG, Di Donato V, Caserta D, Giannini A. Pharmacotherapy for the treatment of recurrent cervical cancer: an update of the literature. Expert Opin Pharmacother 2024; 25:55-65. [PMID: 38159033 DOI: 10.1080/14656566.2023.2298329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Cervical cancer is the fourth most common cause of cancer-related death worldwide. High-risk locally advanced or recurrent/metastatic cervical cancers have a poor prognosis with routine treatments. The objective of this study is to analyze the data available in the literature on therapies and molecules currently in use to improve the prognosis of recurrent cervical cancer. AREAS COVERED An extensive literature search was conducted by authors to identify relevant trials on various databases. Articles in English published until September 2023 that investigate different pharmacotherapy strategies for the treatment of recurrent cervical cancer, were included. Results of various pharmacological regimens including different combinations of chemotherapy, immune checkpoint inhibitors, DNA damage repair inhibitors and antibody-drug conjugates were analyzed. EXPERT OPINION In recent years, there have been significant improvements in the outcomes of recurrent/metastatic cervical cancer. However, these improvements do not address the unmet need in terms of oncological outcomes. The introduction of immunotherapy and targeted therapies showed advantages in cervical cancer patients. New therapies and combination strategies must be implemented. Centralization of care and enrollment in clinical trials are of paramount importance. Primary and secondary prevention remains the fundamental goal to reduce the burden of cervical cancer.
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Affiliation(s)
- Ottavia D'Oria
- Department of Medical and Surgical Sciences and Translational Medicine, Course in "Translational Medicine and Oncology", Sapienza University, Rome, Italy
- Obstetrics and Gynecological Unit, Department of Woman's and Child's Health, San Camillo-Forlanini Hospital, Rome, Italy
| | - Giorgio Bogani
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Ilaria Cuccu
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Tullio Golia D'Auge
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Violante Di Donato
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Donatella Caserta
- Gynecology Division, Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital Sapienza University of Rome, Rome, Italy
| | - Andrea Giannini
- Department of Medical and Surgical Sciences and Translational Medicine, Course in "Translational Medicine and Oncology", Sapienza University, Rome, Italy
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
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Giannella L, Ciavattini A. Editorial. J OBSTET GYNAECOL 2023; 43:2277039. [PMID: 37909308 DOI: 10.1080/01443615.2023.2277039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Affiliation(s)
- Luca Giannella
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy
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Giannella L, Delli Carpini G, Di Giuseppe J, Bogani G, Sopracordevole F, Clemente N, Giorda G, De Vincenzo RP, Evangelista MT, Gardella B, Dominoni M, Monti E, Alessi C, Alessandrini L, Pagan A, Caretto M, Ghelardi A, Amadori A, Origoni M, Barbero M, Raspagliesi F, Simoncini T, Vercellini P, Scambia G, Ciavattini A. In Situ/Microinvasive Adenocarcinoma of the Uterine Cervix and HPV-Type Impact: Pathologic Features, Treatment Options, and Follow-Up Outcomes-Cervical Adenocarcinoma Study Group (CAS-Group). Cancers (Basel) 2023; 15:cancers15112876. [PMID: 37296839 DOI: 10.3390/cancers15112876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/09/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
It is unknown whether human papillomavirus (HPV) status impacts the prognosis of early stage cervical glandular lesions. This study assessed the recurrence and survival rates of in situ/microinvasive adenocarcinomas (AC) according to HPV status during a 5-year follow-up. The data were retrospectively analyzed in women with available HPV testing before treatment. One hundred and forty-eight consecutive women were analyzed. The number of HPV-negative cases was 24 (16.2%). The survival rate was 100% in all participants. The recurrence rate was 7.4% (11 cases, including four invasive lesions (2.7%)). Cox proportional hazards regression showed no difference in recurrence rate between HPV-positive and HPV-negative cases (p = 0.148). HPV genotyping, available for 76 women and including 9/11 recurrences, showed a higher relapse rate for HPV-18 than HPV-45 and HPV-16 (28.5%, 16.6%, and 9.52%, p = 0.046). In addition, 60% and 75% of in situ and invasive recurrences, respectively, were HPV-18 related. The present study showed that most ACs were positive for high-risk HPV, and the recurrence rate was unaffected by HPV status. More extensive studies could help evaluate whether HPV genotyping may be considered for recurrence risk stratification in HPV-positive cases.
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Affiliation(s)
- Luca Giannella
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Giovanni Delli Carpini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Jacopo Di Giuseppe
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Giorgio Bogani
- Gynecological Oncology Unit, Fondazione IRCCS-Istituto Nazionale Tumori, 20133 Milan, Italy
| | - Francesco Sopracordevole
- Gynecologic Oncology Unit, IRCCS-Centro di Riferimento Oncologico di Aviano, 33081 Aviano, Italy
| | - Nicolò Clemente
- Gynecologic Oncology Unit, IRCCS-Centro di Riferimento Oncologico di Aviano, 33081 Aviano, Italy
| | - Giorgio Giorda
- Gynecologic Oncology Unit, IRCCS-Centro di Riferimento Oncologico di Aviano, 33081 Aviano, Italy
| | - Rosa Pasqualina De Vincenzo
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Scienze della Vita e Sanita Pubblica, Università Cattolica Del Sacro Cuore, 00168 Rome, Italy
| | - Maria Teresa Evangelista
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Barbara Gardella
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, 27100 Pavia, Italy
| | - Mattia Dominoni
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, 27100 Pavia, Italy
| | - Ermelinda Monti
- Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Chiara Alessi
- UOC Ostetricia Ginecologia, Dipartimento per la Salute della Donna e del Bambino, Azienda Ospedaliera-Università di Padova, 35128 Padova, Italy
| | - Lara Alessandrini
- Pathological Anatomy Unit, Department of Medicine DIMED, University of Padova, 35128 Padova, Italy
| | | | - Marta Caretto
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Alessandro Ghelardi
- Azienda Usl Toscana Nord-Ovest, UOC Ostetricia e Ginecologia, Ospedale Apuane, 54100 Massa, Italy
| | | | - Massimo Origoni
- Department of Gynecology & Obstetrics, Vita Salute San Raffaele University School of Medicine, 20132 Milan, Italy
| | - Maggiorino Barbero
- Department of Obstetrics and Gynecology, Asti Community Hospital, 14100 Asti, Italy
| | - Francesco Raspagliesi
- Gynecological Oncology Unit, Fondazione IRCCS-Istituto Nazionale Tumori, 20133 Milan, Italy
| | - Tommaso Simoncini
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Scienze della Vita e Sanita Pubblica, Università Cattolica Del Sacro Cuore, 00168 Rome, Italy
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
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