Uterine peristalsis in women affected by adenomyosis: A step towards functional assessment

OBJECTIVE

The non-pregnant uterus shows an intrinsic contractility pattern, actively involved in early reproductive processes. Uterine contractility is characterized by endometrial waves that originate from the junctional zone and varies throughout the menstrual cycle due to fluctuations in the concentrations of hormones. The aim of this study was to compare the uterine contractility patterns in the periovulatory phase in a group of patients with isolated adenomyosis and a group of healthy women using transvaginal ultrasound (TVUS).

METHODS

From March 2019 to March 2021, we enrolled consecutive nulliparous patients in the periovulatory phase of the menstrual cycle, divided in patients with isolated adenomyosis (group A, n = 18) and healthy patients in the control group (group B, n = 18). Patients who met the inclusion criteria underwent TVUS for the study of uterine contractility: the uterus was scanned on sagittal plane for 3 min and all the movies were recorded. Then, static images and video were evaluated offline and the uterine contractility patterns were defined.

RESULTS

The patients belonging to the study group had a higher incidence of painful symptoms (dysmenorrhea, 6.11 ± 2.81 vs 1.39 ± 2.17; chronic pelvic pain, 2.56 ± 3.01 vs 0.39 ± 1.04) and a larger uterine volume (137.48 ± 117.69 vs 74.50 ± 27.58 cm3; P = 0.04). Regarding the uterine contractility, a statistically significant difference was observed about the retrograde patterns (group A, 27.8% vs group B, 72.2%, P < 0.01) and opposing (group A, 38.9% vs, group B, 5.6%, P = 0.02).

CONCLUSION

The study confirms the presence of altered uterine peristalsis in the periovulatory phase in patients with adenomyosis. The abnormal uterine peristalsis could lead to both structural and functional changes, which are the basis of the clinical manifestations of adenomyosis and the perpetuation of the anatomical damage.

Conservative re-treatment of women with atypical endometrial hyperplasia and early endometrial carcinoma: We can hope, at least

BACKGROUND

In women with recurrent disease who were conservatively treated for atypical endometrial hyperplasia (AEH) and early endometrial carcinoma (EEC), the reasons why conservative treatment was chosen persist and outcomes of performing a conservative re-treatment are unclear, as pooled estimates on oncologic outcomes of such a re-treatment are lacking.

OBJECTIVES

To provide pooled estimates of oncologic outcomes of conservative re-treatment in women with recurrent AEH or EC.

SEARCH STRATEGY

A systematic review and meta-analysis was performed by searching six electronic databases from their inception to March 2022.

SELECTION CRITERIA

Studies that allowed extraction of data about oncologic outcomes of conservative re-treatment of women with recurrent AEH and EEC after a conservative treatment.

DATA COLLECTION AND ANALYSIS

Pooled prevalence of complete response (CR), poor response (PR), and recurrence after conservative re-treatment was calculated.

MAIN RESULTS

Fifteen studies (12 retrospective and 3 prospective) with 492 women (42.1% AEH and 57.9% EEC) were included in the systematic review, and 10 studies (8 retrospective and 2 prospective) were suitable for the meta-analysis. Pooled prevalence was 85.3% (95% confidence interval [CI] 77.0%-91.0%) for CR, 14.7% (95% CI 9.0%-23.0%) for PR, and 40.4% (95% CI 15.5%-71.4%) for recurrence.

CONCLUSIONS

Conservative re-treatment in AEH or EC recurrent women has a high CR rate and acceptable recurrence rate that might allow it to be considered a safe and viable option, at least as a first round of conservative treatment. Women with an unsatisfied desire for motherhood or with high surgical risk might avoid hysterectomy and attempt childbearing or spare high-risk surgery.

Diagnostic accuracy of MRI in the differential diagnosis between uterine leiomyomas and sarcomas: A systematic review and meta-analysis

BACKGROUND

Differential diagnosis between uterine leiomyomas and sarcomas is challenging. Magnetic resonance imaging (MRI) represents the second-line diagnostic method after ultrasound for the assessment of uterine masses.

OBJECTIVES

To assess the accuracy of MRI in the differential diagnosis between uterine leiomyomas and sarcomas.

SEARCH STRATEGY

A systematic review and meta-analysis was performed searching five electronic databases from their inception to June 2023.

SELECTION CRITERIA

All peer-reviewed observational or randomized clinical trials that reported an unbiased postoperative histologic diagnosis of uterine leiomyoma or uterine sarcoma, which also comprehended a preoperative MRI evaluation of the uterine mass.

DATA COLLECTION AND ANALYSIS

Sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and area under the curve on summary receiver operating characteristic of MRI in differentiating uterine leiomyomas and sarcomas were calculated as individual and pooled estimates, with 95% confidence intervals (CI).

RESULTS

Eight studies with 2495 women (2253 with uterine leiomyomas and 179 with uterine sarcomas), were included. MRI showed pooled sensitivity of 0.90 (95% CI 0.84-0.94), specificity of 0.96 (95% CI 0.96-0.97), positive likelihood ratio of 13.55 (95% CI 6.20-29.61), negative likelihood ratio of 0.08 (95% CI 0.02-0.32), diagnostic odds ratio of 175.13 (95% CI 46.53-659.09), and area under the curve of 0.9759.

CONCLUSIONS

MRI has a high diagnostic accuracy in the differential diagnosis between uterine leiomyomas and sarcomas.

Detection and Classification of Hysteroscopic Images Using Deep Learning

BACKGROUND

Although hysteroscopy with endometrial biopsy is the gold standard in the diagnosis of endometrial pathology, the gynecologist experience is crucial for a correct diagnosis. Deep learning (DL), as an artificial intelligence method, might help to overcome this limitation. Unfortunately, only preliminary findings are available, with the absence of studies evaluating the performance of DL models in identifying intrauterine lesions and the possible aid related to the inclusion of clinical factors in the model.

AIM

To develop a DL model as an automated tool for detecting and classifying endometrial pathologies from hysteroscopic images.

METHODS

A monocentric observational retrospective cohort study was performed by reviewing clinical records, electronic databases, and stored videos of hysteroscopies from consecutive patients with pathologically confirmed intrauterine lesions at our Center from January 2021 to May 2021. Retrieved hysteroscopic images were used to build a DL model for the classification and identification of intracavitary uterine lesions with or without the aid of clinical factors. Study outcomes were DL model diagnostic metrics in the classification and identification of intracavitary uterine lesions with and without the aid of clinical factors.

RESULTS

We reviewed 1500 images from 266 patients: 186 patients had benign focal lesions, 25 benign diffuse lesions, and 55 preneoplastic/neoplastic lesions. For both the classification and identification tasks, the best performance was achieved with the aid of clinical factors, with an overall precision of 80.11%, recall of 80.11%, specificity of 90.06%, F1 score of 80.11%, and accuracy of 86.74 for the classification task, and overall detection of 85.82%, precision of 93.12%, recall of 91.63%, and an F1 score of 92.37% for the identification task.

CONCLUSION

Our DL model achieved a low diagnostic performance in the detection and classification of intracavitary uterine lesions from hysteroscopic images. Although the best diagnostic performance was obtained with the aid of clinical data, such an improvement was slight.

Extrauterine adenomyoma: A case report and systematic review of the literature

OBJECTIVE

To describe a case of extrauterine adenomyoma (EA) and review all the cases of EA in the literature.

METHODS

Pubmed/MEDLINE, Embase, and Google Scholar from 1807 to December 2022. All studies reporting the histologic diagnosis of an EA. We collected the following data: patient's age, size and location of adenomyoma, presence of endometriosis and adenomyosis, past gynecologic treatment, symptoms, diagnostic imaging, surgical intervention, alternative/adjuvant treatment, associated malignancy, and follow up.

RESULTS

Sixty-seven studies with 85 patients were included. Pain was the most frequent symptom (69.5%). Among diagnostic examinations, ultrasonography was used in 60 out of 81 reported cases, with several radiologic features described. EA was located inside the pelvis in 77.6% of patients. Adnexa were the most frequent site of the disease (24, 28.2%). History of endometriosis or adenomyosis was described in 35 patients (35, 41.2%). Uterine tissue morcellation was reported in 6 of the 85 patients (7.1%). Associated malignancy was detected in 9 out of 85 patients with available data (10.6%). There were two recurrences of disease.

CONCLUSION

Specific imaging features of EA are yet to be described in the literature. History of endometriosis and adenomyosis or uterine tissue morcellation may be suggestive of EA. Histologic examination can give a definitive diagnosis and exclude malignant transformation.

Hysteroscopic Transillumination as a Guide for Laparoscopic Excision of Rudimentary Uterine Horn: A Winning Duo

STUDY OBJECTIVE

Anatomic anomalies of the female reproductive genital tract affect approximately 5.5% of women [1]. The hemiuterus or class U4 by the European Society of Human Reproduction and Embryology / European Society for Gynaecological Endoscopy 2013 classification is a rare congenital malformation defined as a unilateral uterine development, with a contralateral part that could be either incompletely formed or absent. This class is divided into 2 subclasses depending on the presence or not of a functional rudimentary cavity (U4a/U4b) [2]. This work aimed to share our experience performing an hysteroscopic and laparoscopic combined technique to surgically manage this uterine malformation exploiting the hysteroscopic transillumination.

DESIGN

A step-by-step explanation of surgical technique with narrated video footage.

SETTING

Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero - Universitaria di Bologna" Bologna, Italy.

INTERVENTIONS

A 32-year-old woman with a symptomatic (severe dysmenorrhea and chronic pelvic pain) suspected U4a uterine malformation diagnosed at our center was scheduled for laparoscopic removal of the right uterine horn and ipsilateral salpingectomy exploiting the contemporary hysteroscopic transillumination guidance. We selected this approach to avoid possible complications owing to the anatomic anomalies that are very common in these cases [3,4]. After coagulation and section of the right round ligament at the uterine angle and opening of the right broad ligament, access to the retroperitoneum was obtained to directly visualize the entire course of ureter and the uterine artery. The right uterine artery was coagulated and sectioned at the uterus. Then, the hysteroscope was introduced to the uterine fundus and the light source brightness was increased up to 100% to allow an adequate transmural visualization of the uterine defect from the laparoscope. Once the defect edge was well highlighted, the right uterine horn was isolated and removed using a monopolar hook, taking care to preserve an adequate amount of myometrium. A double layer running suture with barbed absorbable thread (V-Loc) for reconstructive purposes was performed. The specimen was retrieved inside an endobag to allow a safe extraction. Right salpingectomy was then performed.

CONCLUSION

Considering the great anatomic variability of this condition, this type of surgery is not always simple. Indeed, the borders between the uterus and the rudimentary uterine horn are often not perfectly recognizable; this can lead to accidental removal of healthy myometrium and increase the risk of perioperative bleeding [5]. In our experience, the combined hysteroscopic and laparoscopic combined technique allows the surgeon to better delimit the borders of the hemiuterus, providing a more conservative and safer surgery. Hysteroscopic transillumination offers the possibility to modulate the radicality in the resection of the rudimentary horn and in the final treatment of dysmorphism. VIDEO ABSTRACT.

Adenomyosis and endometriosis in adolescents and young women with pelvic pain: prevalence and risk factors

BACKGROUND

The aim of this study was to evaluate the prevalence of ultrasound diagnosis of adenomyosis and endometriosis in young women complaining of pelvic pain and to find the symptoms and clinical characteristics associated with these diseases in young women.

METHODS

Cross-sectional study, including 100 young women (14-24 years) with a history of chronic pelvic pain. Women were asked detailed medical hystory and pain symptoms scores (Visual Analogue Scale) and underwent gynecological examination and ultrasound evaluation.

RESULTS

The prevalence of endometriosis and adenomyosis in young women amounted to 25.0% and 46.0%, respectively. A significant correlation was found between ovarian endometriosis and adenomyosis. Dysmenorrhea and dyspareunia were risk factors for adenomyosis. Dyschezia, dyspareunia, chronic pelvic pain, presence of sonographic soft markers suggestive of pelvic adhesions, being a worker and having a previous surgery were risk factors for endometriosis. Young women (20-24 years) had a higher incidence of both adenomyosis and endometriosis than adolescents (14-19 years).

CONCLUSIONS

Our outcomes strengthen the hypothesis of a progressive and common course of the natural history of endometriosis, which initially may manifest with symptoms, then with signs of pelvic adhesions and finally as adenomyosis, ovarian endometriomas or deep infiltrating endometriosis.

Horizontal versus vertical direction of posterior vaginal wall suture after eradication of rectovaginal endometriosis: A multicenter study

OBJECTIVE

To compare safety and effectiveness of two-different directions of suturing the posterior vaginal breach (horizontal [Ho] vs vertical [Ve]) in women undergoing recto-vaginal endometriosis (RVE) nodule resection.

METHODS

A multicenter, retrospective, observational, cohort study was performed including all women of reproductive age undergoing RVE nodule resection between March 2013 and December 2018 at our tertiary centers. Patients included in the present study were divided into two groups based on the direction in suturing the posterior vaginal fornix defect, for comparisons in terms of rate of postoperative complications, pain relief, pain and anatomical recurrence, and length of hospital stay. Univariate comparisons were performed adopting the t test or the Mann-Whitney test for continuous data and the chi-square test or the Fisher exact test for categorical data, with a significant P value set to <0.05.

RESULTS

A total of 101 women were included: 67 in the Ho-group and 34 in the Ve-group. The two groups did not significantly differ in length of hospital stay (6.7 ± 6.9 vs 6.6 ± 3.3 days; P = 0.95), overall postoperative complications (32.8% vs 14.7%; P = 0.05), pain recurrence (35.8% vs 26.5%; P = 0.34) and anatomical recurrence rate (19.4% vs 23.5%; P = 0.62). Conversely, grade III complications were significantly more common in the Ho-group than in the Ve-group (22.7% vs 20%, P = 0.009), while pain relief in terms of deep dyspareunia, dyschezia, dysuria and chronic pelvic pain was more consistent in the Ve-group patients (P = 0.04, 0.04, 0.05, 0.004, respectively).

CONCLUSION

In symptomatic women undergoing RVE nodule resection, Ho suturing of the vaginal breach appears more commonly associated with severe postoperative complications and a worse pain control.

Diagnostic Accuracy of Ultrasound in the Diagnosis of Uterine Leiomyomas and Sarcomas

BACKGROUND

Differential diagnosis between uterine leiomyomas and sarcomas is challenging. Ultrasound shows an uncertain role in the clinical practice given that pooled estimates about its diagnostic accuracy are lacking.

OBJECTIVES

To assess the accuracy of ultrasound in the differential diagnosis between uterine leiomyomas and sarcomas.

DATA SOURCES

A systematic review was performed searching 5 electronic databases (MEDLINE, Web of Sciences, Google Scholar, Scopus, and ClinicalTrial.gov) from their inception to June 2023.

METHODS OF STUDY SELECTION

All peer-reviewed observational or randomized clinical trials that reported an unbiased postoperative histologic diagnosis of uterine leiomyoma or uterine sarcoma that also comprised a preoperative ultrasonographic evaluation of the uterine mass.

TABULATION, INTEGRATION, AND RESULTS

Sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and area under the curve on summary receiver operating characteristic were calculated for each included study and as pooled estimate, with 95% confidence interval (CI); 972 women (694 with uterine leiomyomas and 278 with uterine sarcomas) were included. Ultrasound showed pooled sensitivity of 0.76 (95% CI, 0.70-0.81), specificity of 0.89 (95% CI, 0.87-0.92), positive and negative likelihood ratios of 6.65 (95% CI, 4.45-9.93) and 0.26 (95% CI, 0.07-1.0) respectively, diagnostic odds ratio of 23.06 (95% CI, 4.56-116.53), and area under the curve of 0.8925.

CONCLUSIONS

Ultrasound seems to have only a moderate diagnostic accuracy in the differential diagnosis between uterine leiomyomas and sarcomas, with a lower sensitivity than specificity.

Not All Bad Comes to Harm: Enhanced Recovery After Surgery for Rectosigmoid Endometriosis

STUDY OBJECTIVE

To assess the impact of implementing an enhanced recovery after surgery (ERAS) protocol on the length of hospitalization in women undergoing laparoscopy for rectosigmoid deep infiltrating endometriosis (DIE).

DESIGN

A retrospective cohort study.

SETTING

An academic referral center for endometriosis and minimally invasive gynecologic surgery.

PATIENTS

Women aged between 18 and 50 years scheduled for laparoscopic excision (shaving, full-thickness anterior wall resection, segmental resection) of rectosigmoid endometriosis between February 2017 and February 2023.

INTERVENTIONS

We divided patients into 2 groups (non-ERAS and ERAS) based on the timing of surgery (before or after March 5, 2020). Starting from this day, restrictions were issued to limit the spread of the coronavirus disease 2019 pandemic, inducing our group to implement an ERAS protocol for patients hospitalized after surgery for posterior DIE.

MEASUREMENTS AND MAIN RESULTS

We included 579 patients in the analysis, 316 (54.6%) in the non-ERAS group and 263 (45.4%) in the ERAS group. In the ERAS group, we observed a shorter length of hospital stay (5.8 ± 3.1 days vs 4.8 ± 2.9 days; p <.001) and lower complications rates (33, 12.5% vs 60, 19.0%; p = .04), despite a decreased frequency of conservative surgical approaches (shaving procedures 121 vs 196; p <.001). Repeated surgery or hospital readmissions owing to postdischarge complications were infrequent, with no significant differences between the 2 groups. The multiple linear regression analysis strengthened our results given the higher prevalence of bowel resection surgeries (both full-thickness anterior wall or segmental), showing that patients managed with a multimodal protocol had an overall reduction of hospital stay by 1.5 days.

CONCLUSION

The implementation of an ERAS program in patients undergoing laparoscopic surgery for DIE is associated with a significant reduction in hospital stay, without an increase in perioperative or postoperative complication rates.

Effects of Pelvic Floor Muscle Physiotherapy on Urinary, Bowel, and Sexual Functions in Women with Deep Infiltrating Endometriosis: A Randomized Controlled Trial

Background and Objectives: Endometriosis is a chronic and recurrent disease defined as the presence and proliferation of endometrial glands and stroma outside the uterine cavity. It affects up to 6-10% of women of reproductive age and can be classified into superficial, ovarian, and deep infiltrating endometriosis (DIE). Deep infiltrating endometriosis can be associated with pain symptoms and pelvic floor muscle hypertone. Moreover, it may be responsible of bowel, urinary, and sexual dysfunctions with impairment of women's quality of life. Few studies have investigated the role of physiotherapy in women with DIE. Here, we aimed first to evaluate the effects of pelvic floor physiotherapy (PFP) on urinary, bowel, and sexual functions. Secondly, we aimed to evaluate the effects of ultrasound visual feedback during PFP on pelvic floor and subjective modifications in the frequency of sexual intercourse. Materials and Methods: This randomized controlled trial was conducted between June 2018 and December 2019 at our tertiary center. Nulliparous women with DIE and superficial dyspareunia were enrolled. At first examination, levator hiatal area (LHA) assessed with 3D/4D transperineal ultrasound, pain symptoms, urinary, bowel, and sexual functions were evaluated. Then, women were randomly assigned to no intervention (control group) or treatment with five individual sessions of PFP (experimental group), and after four months women underwent a second examination. Urinary, bowel, and sexual functions were assessed with validated questionnaires at first and second examinations. In particular, the Bristol Female Lower Urinary Tract Symptoms questionnaire was used to evaluate urinary symptoms, the Knowles-Eccersley-Scott-Symptom questionnaire to assess the presence of constipation, and the Female Sexual Function Index to investigate sexual function. Study outcomes were the comparisons among groups in terms of differences in actual changes in median of questionnaire scores between first and second examinations. Results: Thirty women (17 in the experimental group and 13 in the control group) completed the study. No significant differences were found between the two groups regarding urinary, bowel, and sexual functions, although women in the experimental group showed a tendency towards an improvement in constipation symptoms. Conclusion: In women with DIE, PFP does not appear to affect urinary, bowel, and sexual functions. Therefore, despite the improvement in superficial dyspareunia, chronic pelvic pain, and PFM relaxation with high treatment satisfaction, women should be informed about the unclear impact of PFP on urinary, bowel, and sexual functions. Larger studies are necessary to further investigate the impact of PFP on these functions.

Endometriosis in the time of internet: how web navigation affects women with endometriosis

OBJECTIVES

Patients often search for health-related information on the internet allthough this trend may have some benefits, it also has some risks, such as misinformation. The aim of this study is to evaluate how Internet information seeking affect the level of anxiety in patients with endometriosis.

MATERIALS AND METHODS

This prospective observational study was conducted at our outpatient clinic between March 2019 and December 2020. We enrolled We enrolled all patients with a confirmed sonographic diagnosis of endometriosis who had sought information about the disease prior to our visit. We divided them into two groups based on the source of information (Internet only vs multiple sources). Before the visit, we asked women to fill-in validated questionnaires about anxiety, such as the Generalized Anxiety Disorder-7 (GAD) and the Spielberg State Trait Anxiety Inventory (STAI- Y6) and the Endometriosis Health Profile (EHP) - 5. After the visit, the STAI-Y6 was resubmitted to each woman.

RESULTS

We enrolled 200 women who filled-in the questionnaires: 46 reported the Internet as the only source of information, 52 sought information also from medically qualified sources, 74 consulted only healthcare professionals, and 28 resorted to medical journals. Women who used the Internet as their exclusive source of information were younger on average and their STAI-Y6 score after the visit was significantly lower compared to other group (34.1 ± 11.5 vs 42.1 ± 14.7, p = .001). Moreover, the difference between the STAI-Y6 scores before and after our assessment was higher in these women (-18.3 ± 14.7 vs -10.3 ± 16.5, p = .003).

CONCLUSIONS

Women who sought information online were younger, had lower levels of state trait anxiety after our medical evaluation, and a had a greater reduction in anxiety levels after our examination compared to women who consulted other sources to learn more about endometriosis.KEY MESSAGESWomen using only Internet are younger than those who use other sources of information.Women who researched symptoms online showed higher pre-examination anxiety levels.Patients with severe pain symptoms consulted both the internet and professionals.

Molecular Signature of Endometrial Cancer with Coexistent Adenomyosis: A Multicentric Exploratory Analysis

Adenomyosis has been associated with better survival outcomes in women with endometrial cancer. However, although the endometrial cancer patients' risk stratification has been revolutionized by molecular findings, the impact of the molecular signature on the favorable prognosis of endometrial cancer patients with coexistent adenomyosis is unknown. The aim of our study was to compare the prevalence of molecular groups at poor and intermediate prognosis between endometrial cancer patients with and without coexistent adenomyosis. A multicentric, observational, retrospective, cohort study was performed to assess the differences in the prevalence of p53-abnormal expression (p53-abn) and mismatch repair protein-deficient expression (MMR-d) signatures between endometrial cancer patients with and without coexistent adenomyosis. A total of 147 endometrial cancer patients were included in the study: 38 in the adenomyosis group and 109 in the no adenomyosis group. A total of 37 patients showed the MMR-d signature (12 in the adenomyosis group and 25 in the no adenomyosis group), while 12 showed the p53-abn signature (3 in the adenomyosis group and 9 in the no adenomyosis group). No significant difference was found in the prevalence of p53-abn (p = 1.000) and MMR-d (p = 0.2880) signatures between endometrial cancer patients with and without coexistent adenomyosis. In conclusion, the molecular signature does not appear to explain the better prognosis associated with coexistent adenomyosis in endometrial cancer patients. Further investigation of these findings is necessary through future larger studies.

Effects of Low Luteinizing Hormone Serum Levels on Oocyte Retrieval, Fertilization Rate, and Embryo Quality during Controlled Ovarian Stimulation: Results from a Prospective Cohort Analysis

OBJECTIVES

Luteinizing hormone (LH) plays a key role in normal follicular development and oocyte maturation in controlled ovarian stimulation. LH stimulates the proliferation and differentiation of theca cells for the secretion of androgens, synergistically increasing estrogen production. This study aimed to investigate the effects of low LH concentrations on oocyte retrieval, fertilization, and embryo development in patients undergoing in vitro fertilization/intracytoplasmic sperm injection.

DESIGN

We prospectively (ClinicalTrials ID: NCT05755529) analyzed patients undergoing in vitro fertilization/intracytoplasmic sperm injection, subdividing them into three groups according to their age. Serum LH levels were evaluated on day 3, during stimulation (day 10) and before ovulation induction (day 12).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Forty-three consecutive women were scheduled for IVF and received ovarian stimulation with follitropin alfa (Gonal F, Merck Serono, Germany) and ganirelix (Fyremaldel, Sun Pharma, Italy). Statistical analysis was performed with InStat 3.10, GraphPad software, San Diego, CA, USA. Normal distribution was tested by the Shapiro-Wilk test. Continuous variables were expressed as the mean and standard deviation. Categorical variables are expressed as frequencies and percentages.

RESULTS

Our data analysis suggests that serum LH levels progressively decrease during controlled ovarian stimulation, and this effect is more evident in the early phase of this procedure. From this perspective, circulating LH levels may significantly decrease during the late follicular phase due to the negative feedback of ovarian hormones from multiple follicular developments or after the suppressive effects of gonadotropin-releasing hormone antagonists.

LIMITATIONS

Although our study confirms that exogenous LH can be considered a strategy in women with reduced LH levels during ovarian stimulation to improve oocyte quality and reproductive outcome, the generalizability of the results is limited by the low number of participants enrolled.

CONCLUSIONS

Exogenous LH may be considered a strategy in women with a decrease in LH levels during ovarian stimulation to improve oocyte quality and reproductive outcome.

Dienogest alone or dienogest combined with estrogens in the treatment of ovarian endometriomas, that is the question. A retrospective cohort study

PURPOSE

to compare the effects of Dienogest 2 mg (D) alone or combined with estrogens (D + ethinylestradiol 0.03 mg, D + EE; D + estradiol valerate 1-3 mg, D + EV) in terms of symptoms and endometriotic lesions variations.

METHODS

This retrospective study included symptomatic patients in reproductive age with ultrasound diagnosis of ovarian endometriomas. Medical therapy for at least 12 months with D, D + EE or D + EV was required. Women were evaluated at baseline visit (V1) and after 6 (V2) and 12 months (V3) of therapy.

RESULTS

297 patients were enrolled (156 in the D group, 58 in the D + EE group, 83 in the D + EV group). Medical treatment leaded to a significant reduction in size of endometriomas after 12 months, with no differences between the three groups. When comparing D and D + EE/D + EV groups, a significant decrease of dysmenorrhea was detected in the D group than in D + EE/D + EV group. Conversely, the reduction of dysuria was more significative in the D + EE/D + EV groups rather than in the D group. Regarding tolerability, treatment associated side effects were reported by 16.2% patients. The most frequent one was uterine bleeding/spotting, significantly higher in the D + EV group.

CONCLUSION

Dienogest alone or associated with estrogens (EE/EV) seems to be equally effective in reducing endometriotic lesions mean diameter. The reduction of dysmenorrhea was more significative when D was administered alone, while dysuria seems to improve more when D is associated with estrogens.

Prevalence of sonographic signs in women with uterine sarcoma: a systematic review and meta-analysis

OBJECTIVE

To assess the prevalence of sonographic signs in women with uterine sarcoma.

MATERIALS AND METHODS

A systematic review and meta-analysis were performed. Five electronic databases were searched from inception to June 2022 for all studies allowing calculation of the prevalence of sonographic signs in women with uterine sarcoma. Pooled prevalence with 95% confidence intervals was calculated for each sonographic sign and was a priori defined as "very high" when it was ≥ 80%, "high" when it ranged from 80% to 70%, and less relevant when it was ≤ 70%.

RESULTS

6 studies with 317 sarcoma patients were included. The pooled prevalence was: · 25.0% (95%CI:15.4-37.9%) for absence of visibility of the myometrium. · 80.5% (95%CI:74.8-85.2%) for solid component. · 78.3% (95%CI:59.3-89.9%) for inhomogeneous echogenicity of solid component. · 47.9% (95%CI:41.1-54.8%) for cystic areas. · 80.7% (95%CI:68.3-89.0%) for irregular walls of cystic areas. · 72.3% (95%CI:16.7-97.2%) for anechoic cystic areas. · 54.8% (95%CI:34.0-74.1%) for absence of shadowing. · 73.5% (95%CI:43.3-90.9%) for absence of calcifications. · 48.7% (95%CI:18.6-79.8%) for color score 3 or 4. · 47.3% (95%CI:37.0-57.8%) for irregular tumor borders. · 45.4% (95%CI:27.6-64.3%) for endometrial cavity not visualizable. · 10.9% (95%CI:3.5-29.1%) for free pelvic fluid. · 6.4% (95%CI:1.1-30.2%) for ascites. · 21.2% (95%CI:2.1-76.8%) for intracavitary process. · 81.5% (95%CI:56.1-93.8%) for singular lesion..

CONCLUSION

Solid component, irregular walls of cystic areas, and singular lesions are signs with very high prevalence, while inhomogeneous echogenicity of solid component, anechoic cystic areas, and absence of calcifications are signs with high prevalence. The remaining signs were less relevant.

Race and ethnicity reporting in endometrial cancer literature

OBJECTIVES

There is evidence that there are differences in survival outcomes among patients with endometrial cancer of different ethnic groups. We aimed to assess the quantity and quality of race/ethnicity reporting in the literature on endometrial cancer published from January 2020 to December 2020.

METHODS

In this systematic review, electronic searches of PubMed, MEDLINE, Web of Sciences, Scopus, and Cochrane Library databases were performed for all articles published in 2020. A total of 3330 articles were reviewed, of which 949 (35%) peer-reviewed human-based articles focusing on endometrial cancer were included. Non-research-focused articles, review articles, meta-analyses, case reports, and non-human studies were excluded. We analyzed the proportion of studies reporting race/ethnicity and assessed the quality of reporting with regard to the adherence to the International Committee of Medical Journal Editors (ICMJE) recommendations. We evaluated the influence of study characteristics on race/ethnicity reporting and compared articles published in journals which adhere to the ICMJE recommendations against those that did not explicitly state that they did.

RESULTS

Of the 949 (28.5%) included articles, 166 (17.5%) reported race/ethnicity of patients, with low quality of reporting. The reporting rate of race/ethnicity was similar when comparing articles from ICMJE and non-ICMJE journals (62 (20.4%) vs 104 (16.1%); p=0.11), prospective versus retrospective studies (53 (22.7%) vs 113 (15.8%); p=0.02), and national versus international studies (147 (17.5%) vs 19 (17.4%); p=0.99). Studies performed in the WHO region of Americas were significantly more consistent in reporting race compared with other regions (119 (44.7%) vs 23 (6.8%) European, 2 (7.4%) Eastern Mediterranean, 21 (7.1%) Western Pacific, 0 (0%) South-East Asia; p<0.001). Female corresponding authors were significantly more consistent in reporting race than male authors (94 (22.5%) vs 72 (13.6%); p<0.001).

CONCLUSIONS

Human-based articles focusing on endometrial cancer have a low frequency and quality of race/ethnicity reporting, even in journals claiming to follow ICMJE recommendations.

Comparison between vaginal and laparoscopic cerclage in women with mid-trimester pregnancy loss or history of spontaneous preterm delivery

BACKGROUND

Women with unfavorable obstetric history can benefit from prophylactic cerclage ("history indicated") which can be performed vaginally or transabdominally with laparoscopic techniques. The aim of our study is to evaluate the effectiveness in the prevention of preterm birth of the vaginal technique and of the minimally invasive laparoscopic technique in women with an unfavorable obstetric history.

METHODS

This was a retrospective cohort study examining elective cerclages performed in women with adverse obstetrics history. The primary outcome was rate of early preterm and second trimester deliveries while other outcomes analyzed were surgical complications, the time needed for cerclage procedures, live birth rate, gestational age at delivery, birth weight, Apgar score.

RESULTS

Data from 64 women were analyzed; among them, 14 underwent a laparoscopic procedure (22%) while 50 a vaginal cerclage (78%). The two groups were homogeneous in terms of demographic characteristics, but of course differed significantly in terms of obstetrics history, as well as for the surgical indications of cerclage procedures. The rate of early preterm deliveries and second trimester miscarriage were the same in the vaginal and laparoscopic group (8%), comparable to what was reported in literature. The operative time was longer in the laparoscopic group, but with similar duration of the hospital stay. We reported no intraoperative complications in both groups.

CONCLUSIONS

As the laparoscopic procedure, usually reserved for women with a previous failed vaginal cerclage, has been proved to be equally safe and effective, it may could be proposed to a wider group of women. Prospective randomized studies are needed to provide new and conclusive data about this topic.

Corded and hyalinized endometrioid carcinoma: Summary of clinical, histological, immunohistochemical and molecular data

Corded and hyalinized endometrioid carcinoma (CHEC) represents a potential pitfall for pathologists. This study aimed to provide a complete overview of all clinicopathological and molecular features of CHEC. Electronic databases were searched for all published series of CHEC. Clinical, histological, immunohistochemical and molecular data about CHEC were extracted and pooled. Six studies with 62 patients were identified; mean age was 49.8 years (range 19-83). Most cases showed FIGO stage I (68%), low grade (87.5%), and a favorable outcome (78.4%), with "no specific molecular profile" (NSMP). A subset of cases showed high-grade features (12.5%), p53 abnormalities (11.1%) or mismatch repair (MMR) deficiency (20%) and occurred at an older age (mean age>60 years). Common features of CHEC were: superficial localization of the corded component (88.6%), squamous/morular differentiation (82.5%), nuclear β-catenin accumulation (92%), partial/total loss of CKAE1/AE3 (88.9%), estrogen receptor (95.7%) and e-cadherin (100%), stromal changes such as myxoid (38.5%), osteoid (24%) and chondroid (4.5%), CTNNB1 mutations (57.9%), and POLE-wild-type (100%); 24.4% of cases showed lymphovascular space invasion. A minority of cases (16.2%) showed poor outcome despite a low-grade, NSMP phenotype; the molecular basis for the aggressiveness of these cases is still undefined. Further studies are necessary in this field.

Predictive factors of sentinel lymph node failed mapping in endometrial carcinoma patients: a systematic review and meta-analysis

OBJECTIVE

In endometrial carcinoma patients, sentinel lymph node bilateral mapping fails in 20-25% of cases, with several factors affecting the likelihood of detection. However, pooled data about predictive factors of failure are lacking. The aim of this systematic review and meta-analysis was to assess the predictive factors of sentinel lymph node failed mapping in endometrial cancer patients undergoing sentinel lymph node biopsy.

METHODS

A systematic review and a meta-analysis was performed searching all studies assessing predictive factors of sentinel lymph node failed mapping in apparent uterine-confined endometrial cancer patients undergoing sentinel lymph node biopsy through the cervical injection of indocyanine green. The associations between sentinel lymph node failed mapping and predictive factors of failure were assessed, calculating the odds ratio (OR) with 95% confidence intervals.

RESULTS

Six studies with a total of 1345 patients were included. Compared with patients with sentinel lymph node bilateral successful mapping, patients with sentinel lymph node failed mapping showed: OR 1.39 (p=0.41) for body mass index >30 kg/m²; OR 1.72 (p=0.24) for menopausal status; OR 1.19 (p=0.74) for adenomyosis; OR 0.86 (p=0.55) for prior pelvic surgery; OR 2.38 (p=0.26) for prior cervical surgery; OR 0.96 (p=0.89) for prior Cesarean section; OR 1.39 (p=0.70) for lysis of adhesions during surgery before sentinel lymph node biopsy; OR 1.77 (p=0.02) for indocyanine green dose <3 mL; OR 1.28 (p=0.31) for deep myometrial invasion; OR 1.21 (p=0.42) for International Federation of Gynecology and Obstetrics (FIGO) grade 3; OR 1.89 (p=0.01) for FIGO stages III-IV; OR 1.62 (p=0.07) for non-endometrioid histotype; OR 1.29 (p=0.25) for lymph-vascular space invasion; OR 4.11 (p<0.0001) for enlarged lymph nodes; and OR 1.71 (p=0.022) for lymph node involvement.

CONCLUSION

Indocyanine green dose <3 mL, FIGO stage III-IV, enlarged lymph nodes, and lymph node involvement are predictive factors of sentinel lymph node failed mapping in endometrial cancer patients.

Laparoscopic entry techniques: Which should you prefer?

BACKGROUND

Despite a debate spanning two decades, no consensus has been achieved about the safest laparoscopic entry technique.

OBJECTIVES

To update the evidence about the safety of the main different laparoscopic entry techniques.

SEARCH STRATEGY

Six electronic databases were searched from inception to February 2021.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing different laparoscopic entry techniques were included.

DATA COLLECTION AND ANALYSIS

Entry-related complications and total time for entry were compared among the different methods of entry calculating pooled odds ratios (ORs) and mean differences, with 95% confidence intervals (CIs); P < 0.05 was considered significant.

MAIN RESULTS

In total, 25 RCTs (6950 patients) were included. Complications considered were vascular, visceral and omental injury, failed entry, extraperitoneal insufflation, bleeding and infection at the trocar site bleeding, and incisional hernia. Compared to direct trocar, the OR for Veress needle was significantly higher for omental injury (OR 3.65, P < 0.001), for failed entry (OR 4.19, P < 0.001), and for extraperitoneal insufflation (OR 5.29, P < 0.001). Compared to the open method, the OR for Veress needle was significantly higher for omental injury (OR 4.93, P = 0.001), for failed entry (OR 2.99, P < 0.001), for extraperitoneal insufflation (OR 4.77; P = 0.04), and for incisional hernia. Compared to the open method, the OR for direct trocar was significantly lower for visceral injury (OR 0.17, P = 0.002) and for trocar site infection (OR 0.27, P = 0.001).

CONCLUSIONS

The direct trocar method may be preferred over Veress needle and open methods as a laparoscopic entry technique since it appears associated to a lower risk of complications.

Conservative surgery versus colorectal resection for endometriosis with rectal involvement: a systematic review and meta-analysis of surgical and long-term outcomes

PURPOSE

The optimal surgical approach for removal of colorectal endometrial deposits is unclear. Shaving and discoid excision of colorectal deposits allow organ preservation but risk recurrence with associated functional issues and re-operation. Formal resection risks potential higher complications but may be associated with lower recurrence rates. This meta-analysis compares peri-operative and long-term outcomes between conservative surgery (shaving and disc excision) versus formal colorectal resection.

METHODS

The study was registered with PROSPERO. A systematic search was performed on PubMed and EMBASE databases. All comparative studies examining surgical outcomes in patients that underwent conservative surgery versus colorectal resection for rectal endometrial deposits were included. The two main groups (conservative versus resection) were compared in three main blocks of variables including group comparability, operative outcomes and long-term outcomes.

RESULTS

Seventeen studies including 2861 patients were analysed with patients subdivided by procedure: colorectal resection (n = 1389), shaving (n = 703) and discoid excision (n = 742). When formal colorectal resection was compared to conservative surgery there was lower risk of recurrence (p = 0.002), comparable functional outcomes (minor LARS, p = 0.30, major LARS, p = 0.54), similar rates of postoperative leaks (p = 0.22), pelvic abscesses (p = 0.18) and rectovaginal fistula (p = 0.92). On subgroup analysis, shaving had the highest recurrence rate (p = 0.0007), however a lower rate of stoma formation (p < 0.00001) and rectal stenosis (p = 0.01). Discoid excision and formal resection were comparable.

CONCLUSION

Colorectal resection has a significantly lower recurrence rate compared to shaving. There is no difference in complications or functional outcomes between discoid excision and formal resection and both have similar recurrence rates.

Application of Deep Learning Model in the Sonographic Diagnosis of Uterine Adenomyosis

BACKGROUND

This study aims to evaluate the diagnostic performance of Deep Learning (DL) machine for the detection of adenomyosis on uterine ultrasonographic images and compare it to intermediate ultrasound skilled trainees.

METHODS

Prospective observational study were conducted between 1 and 30 April 2022. Transvaginal ultrasound (TVUS) diagnosis of adenomyosis was investigated by an experienced sonographer on 100 fertile-age patients. Videoclips of the uterine corpus were recorded and sequential ultrasound images were extracted. Intermediate ultrasound-skilled trainees and DL machine were asked to make a diagnosis reviewing uterine images. We evaluated and compared the accuracy, sensitivity, positive predictive value, F1-score, specificity and negative predictive value of the DL model and the trainees for adenomyosis diagnosis.

RESULTS

Accuracy of DL and intermediate ultrasound-skilled trainees for the diagnosis of adenomyosis were 0.51 (95% CI, 0.48-0.54) and 0.70 (95% CI, 0.60-0.79), respectively. Sensitivity, specificity and F1-score of DL were 0.43 (95% CI, 0.38-0.48), 0.82 (95% CI, 0.79-0.85) and 0.46 (0.42-0.50), respectively, whereas intermediate ultrasound-skilled trainees had sensitivity of 0.72 (95% CI, 0.52-0.86), specificity of 0.69 (95% CI, 0.58-0.79) and F1-score of 0.55 (95% CI, 0.43-0.66).

CONCLUSIONS

In this preliminary study DL model showed a lower accuracy but a higher specificity in diagnosing adenomyosis on ultrasonographic images compared to intermediate-skilled trainees.

Diagnostic and prognostic value of Bcl-2 in uterine leiomyosarcoma

BACKGROUND

Uterine leiomyosarcoma (uLMS) may show loss of expression of B-cell lymphoma-2 (Bcl-2) protein. It has been suggested that Bcl-2 loss may both be a diagnostic marker and an unfavorable prognostic marker in uLMS.

OBJECTIVE

To define the diagnostic and prognostic value of Bcl-2 loss in uLMS through a systematic review and meta-analysis.

METHODS

Electronic databases were searched from their inception to May 2020 for all studies assessing the diagnostic and prognostic value of Bcl-2 loss of immunohistochemical expression in uLMS. Data were extracted to calculate odds ratio (OR) for the association of Bcl-2 with uLMS vs leiomyoma variants and smooth-muscle tumors of uncertain malignant potential (STUMP), and hazard ratio (HR) for overall survival; a p value < 0.05 was considered significant.

RESULTS

Eight studies with 388 patients were included. Loss of Bcl-2 expression in uLMS was not significantly associated with a diagnosis of uLMS vs leiomyoma variants and STUMP (OR = 2.981; p = 0.48). Bcl-2 loss was significantly associated with shorter overall survival in uLMS (HR = 3.722; p = 0.006). High statistical heterogeneity was observed in both analyses.

CONCLUSION

Loss of Bcl-2 expression appears as a significant prognostic but not diagnostic marker in uLMS. The high heterogeneity observed highlights the need for further research and larger studies.

Postoperative morphologic changes of the isthmocele and clinical impact in patients treated by channel-like (360°) hysteroscopic technique

OBJECTIVE

To evaluate the changes in (1) residual myometrial thickness (RMT), (2) cesarean scar defect (CSD) size, and (3) clinical symptoms, before and after channel-like (360°) hysteroscopic resection for the treatment of CSD.

METHODS

A single-center, observational, prospective, cohort study was carried out enrolling all symptomatic patients of childbearing age, diagnosed with CSD and routinely scheduled for channel-like (360°) hysteroscopic resection from July 2020 to July 2021 at the Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Univeristaria di Bologna. University of Bologna, Italy. The primary outcome was the difference in mean RMT before and after the procedure. Secondary outcomes were the differences before and 4 months after the surgery in: (1) CSD size measured by transvaginal ultrasound, (2) visual analog scale (VAS) scores for the symptoms, and (3) abnormal uterine bleeding (AUB) rate. Lastly, patients' satisfaction was assessed by the global impression of improvement (PGI-I) score.

RESULTS

We found a significant difference before and after the procedure in: (1) mean RMT (+2.0 mm; P < 0.001); mean size of the CSD (base: +1.6 mm; height: -2.5 mm; transverse diameter: -3.2 mm; volume: -263.7 mm³ ; P < 0.001); (2) mean VAS score for dyspareunia (-5.84; P < 0.001), dysmenorrhea (-8.94; P < 0.001), pelvic pain (-2.94; P < 0.001); (3) AUB rate (91% vs. 3%; P < 0.001). Lastly, the mean PGI-I score ± SD was 1.7 ± 0.9.

CONCLUSION

Channel-like (360°) hysteroscopic resection for the treatment of patients with symptomatic CSD may lead to an increase in RMT, decrease in CSD, and improvement of symptoms after the procedure, with high patient satisfaction.

Prevalence and Risk Factors of Central Sensitization in Women with Endometriosis

STUDY OBJECTIVE

To assess prevalence of central sensitization (CS) and its association with demographic and clinical factors in patients with endometriosis.

DESIGN

Single-center, observational, cross-sectional study.

SETTING

Tertiary center.

PATIENTS

Consecutive patients with endometriosis referred to the center from January 15, 2022, to April 30, 2022.

INTERVENTIONS

For each enrolled patient, demographic and clinical data were collected, and the presence of CS was measured using the CS Inventory questionnaire (score ≥40).

MEASUREMENTS AND MAIN RESULTS

Primary study outcome was CS prevalence, and secondary study outcomes were the associations between demographic and clinical factors and CS. The 95% confidence intervals for CS prevalence were obtained with Bayesian-derived Jeffreys method, and the associations between CS and demographic and clinical factors were evaluated with the chi-square test and Fisher's exact test, where appropriate. The variables significantly associated with CS were then included in a multivariable logistic regression model. The significance level was set at .05 for all analyses. During the study period, 285 eligible women were enrolled. CS prevalence was 41.4% (95% confidence interval, 35.8-47.2). At univariable analysis, infertility, moderate to severe pain symptoms (except for dyschezia), altered bowel movements, posterolateral parametrium involvement, hormonal therapy failure (HTF), and most of central sensitivity syndromes were significantly associated with CS occurrence. Multivariable analysis only confirmed the significant association of CS with moderate to severe chronic pelvic pain, posterolateral parametrium involvement, HTF, migraine or tension-type headache, irritable bowel syndrome, and anxiety or panic attacks.

CONCLUSION

CS has a high prevalence in patients with endometriosis, especially in those with moderate to severe chronic pelvic pain, posterolateral parametrium involvement, HTF, and 3 central sensitivity syndromes (i.e. migraine or tension-type headache, irritable bowel syndrome, anxiety or panic attacks). Given the association with HTF, identifying CS through CS Inventory might be useful to counsel the patient and to choose multimodal treatment.

Integration of Molecular Data in the Prognostic Stratification and Management of Endometrial Carcinoma

In the last years, the TCGA-based molecular classifier have been progressively integrated in the management of endometrial carcinoma. While molecular assays are increasingly available across pathology laboratories, the additional costs will expectedly be compensated by a reduction in overtreatments and a prevention of recurrences. The additional time might be shortened by assessing molecular markers on biopsy specimens. Retrospective data suggest that the molecular classifier will have a major impact of on the risk stratification, with many patients having their risk class down- or upstaged based on POLE mutations or p53 abnormalities, respectively. However, there are still several issues to be resolved, such as the prognostic value of the TCGA classifier in each FIGO stage, or the type of adjuvant treatment most suitable for each molecular group. Other issues regard the prognostic stratification of the mismatch repair-deficient and "no specific molecular profile" groups, which currently follows the same criteria; however, the former seems to be prognostically consistent regardless of FIGO grade and histotype, whereas the latter appears highly heterogeneous. Numerous clinical, histological, immunohistochemical and molecular markers have been proposed to refine the TCGA classification, but their prognostic value is still undefined. Hopefully, prospective data collected in the next years will help resolving these issues.

Impact of the COVID-19 pandemic on ovarian tissue cryopreservation planning in the Bologna clinical center

Introduction

Treatment of patients with COVID-19 has been a priority by competing with the treatment of any other disease due to limited hospital resources. The current pandemic situation has focused the attention of healthcare providers around the world away from all other non-emergency health problems, including oncofertility. The aim of the study was to evaluate the repercussions of the COVID-19 pandemic on the activity levels of ovarian tissue cryopreservation (OTC) in the our center.

Methods

The study analyzed the number of patients treated for OTC in our center during three periods: pre-pandemic period: March 2019-February 2020, pandemic period: March 2020-February 2021 and post-pandemic period: March 2021-February 2022.

Results

In our center routine hospital operation was completely reorganized, allowing only urgent interventions. Continuing to urgently preserve fertility during the pandemic required rapid changes to our standard practices for the care of these vulnerable patients. Despite the modifications, there was no difference in the number of OTC performed among the periods analyzed. Similarly, the number of patients who did not perform OTC was the same over the three years analyzed.

Discussion

Despite the local and national restructuring of care to conserve resources and protect the community, it is significant to continue offering fertility-sparing treatment to cancer patients. This emphasis on the importance of preserving fertility despite the pandemic further highlights the essential and urgent nature of this procedure.

The use of near-infrared imaging with indocyanine green in the ovarian tissue transplantation: a case report

The request for fertility preservation has consistently increased in recent years. To our knowledge this case report is the first to describe the application of near-infrared intraoperative imaging using indocyanine green (NIR-ICG) during ovarian tissue transplantation (OTT), to assist surgeon choosing the site of implantation of ovarian fragments. OTT was performed in a 42-year-old woman using NIR-ICG to evaluate the vascularisation of peritoneal area as the site of implantation for the ovarian graft. we believe this new approach could be useful in identifying the best reimplantation site.

Accuracy of cytological examination of Tao brush endometrial sampling in diagnosing endometrial premalignancy and malignancy

Although Tao brush has become one of the most studied and used endometrial cytological samplers, concerns remain about the adequacy of the cytological sample compared with definitive histology. We aimed to assess accuracy of cytological examination from Tao brush sampling in diagnosing endometrial premalignancy and malignancy through a systematic review and meta-analysis. Seven electronic databases were searched from January 2000 to July 2021 for all studies which allowed assessment of accuracy of Tao brush in diagnosing endometrial premalignancy and malignancy. We calculated sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-), diagnostic odds ratio (DOR) and area under the curve (AUC) on summary receiver operating characteristic (SROC) curve. Five studies with 774 patients were included. In diagnosing endometrial premalignancy and malignancy, cytological examination from Tao brush endometrial sampling showed pooled sensitivity of 0.95 (95% CI, 0.90-0.98), specificity of 0.92 (95% CI, 0.90-0.94), LR+ of 12.73 (95% CI, 3.94-41.18), LR- of 0.09 (95% CI, 0.05-0.18), DOR of 184.84 (95% CI, 24.37-1401.79), AUC of 0.9757 (standard error: 0.013). In conclusion, cytological examination from Tao brush seems to have a high diagnostic accuracy and might be proposed as both screening and diagnostic tool. However, further studies are necessary to confirm these findings.

Clinical, laboratory and ultrasonographic risk factors for uterine artery arteriosclerosis: insights for uterus transplantation

OBJECTIVE

To assess uterine artery arteriosclerosis prevalence in women undergoing total hysterectomy for benign diseases, and any associations between clinical, laboratory, and ultrasound factors and uterine artery arteriosclerosis occurrence.

METHODS

A single center, observational, prospective, cohort study was performed enrolling all symptomatic patients scheduled for total hysterectomy from May to December 2021. Our outcomes were: uterine artery arteriosclerosis prevalence and the difference in clinical, laboratory, and ultrasonographic factors between patients with and without uterine artery arteriosclerosis.

RESULTS

Forty women were included. Uterine artery arteriosclerosis prevalence was 70%. Body mass index (BMI) (P = 0.04) and triglycerides (P = 0.04) were significantly higher in patients with uterine artery arteriosclerosis than in patients without; while high-density lipoprotein (HDL) (P = 0.02) was significantly lower. Uterine arteries with arteriosclerosis showed higher peak systolic velocity (PSV) values compared with vessels without arteriosclerosis (P = 0.05).

CONCLUSIONS

Uterine artery arteriosclerosis shows a high prevalence in women undergoing total hysterectomy for benign diseases. Higher BMI, serum triglycerides, and PSV, and lower serum HDL appear as risk factors for uterine artery arteriosclerosis.

The impact of hysterectomy on oncological outcomes in postmenopausal patients with borderline ovarian tumors: A multicenter retrospective study

Data about the oncological outcomes in women with borderline ovarian tumor (BOT) undergoing uterine-sparing surgery without ovarian preservation are poor. We aimed to assess the oncological outcomes in women with BOT undergoing uterine-sparing surgery without ovarian preservation. A multi-center observational retrospective cohort study was performed including all consecutive postmenopausal patients who underwent surgical treatment for BOT at three tertiary level referral centers for gynecologic oncology from January 2005 to December 2016. Patients were divided into two groups for comparisons: patients undergoing hysterectomy (hysterectomy group) and patients undergoing uterine-sparing surgery (no hysterectomy group). Study outcomes were disease-free survival (DFS), overall survival (OS), disease-specific survival (DSS) and surgical complications rate. Ninety-eight patients were included: 44 in the hysterectomy group and 54 in the no hysterectomy group. The 5- and 10-year DFS rates were 97.7% (95% CI: 84.9–99.7) and 92.3% (95% CI: 69.7–98.2), in the hysterectomy group, and 86.8% (95% CI: 74.3–93.5) and 86.8% (95% CI: 74.3–93.5), in the no hysterectomy group, respectively, without significant differences (p=0.16). Hazard ratio for DFS was 0.26 (95% CI: 0.06–1.68) for the hysterectomy group. The 5- and 10-year OS rates were 100.0% (95% CI: -) and 100.0% (95% CI: -), in the hysterectomy group, and 98.2% (95% CI: 87.6–99.7) and 94.4% (95% CI: 77.7–98.7), in the no hysterectomy group, respectively, without significant differences (p=0.23). No significant difference in complication rate was reported among the groups (p=0.48). As hysterectomy appears to not impact survival outcomes of women with BOT, it might be avoided in the surgical staging.

Impact of ovarian preservation on survival for women with endometrial carcinoma

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

Primary objective will be to evaluate the impact of ovarian preservation on survival outcomes of women with endometrial cancer, while secondary objectives will be to evaluate the impact of ovarian preservation on adverse events and quality of life (QoL).

TCGA Molecular Prognostic Groups of Endometrial Carcinoma: Current Knowledge and Future Perspectives

The four TCGA-based molecular prognostic groups of endometrial carcinoma (EC), i.e., POLE-mutant, mismatch repair (MMR)-deficient, p53-abnormal, and “no specific molecular profile” (NSMP), have recently been integrated into ESGO-ESTRO-ESP guidelines. The POLE-mutant and MMR-deficient groups are associated with high mutational load, morphological heterogeneity, and inflammatory infiltration. These groups are frequent in high-grade endometrioid, undifferentiated/dedifferentiated, and mixed histotypes. POLE-mutant ECs show good prognosis and do not require adjuvant treatment, although the management of cases at stage >II is still undefined. MMR-deficient ECs show intermediate prognosis and are currently substratified based on clinicopathological variables, some of which might not have prognostic value. These groups may benefit from immunotherapy. P53-mutant ECs are typically high-grade and often morphologically ambiguous, accounting for virtually all serous ECs, most carcinosarcomas and mixed ECs, and half of clear-cell ECs. They show poor prognosis and are treated with chemoradiotherapy; a subset may benefit from HER2 inhibitors or PARP inhibitors. The NSMP group is the most frequent TCGA group; its prognosis is highly variable and affected by clinicopathological/molecular factors, most of which are still under evaluation. In conclusion, the TCGA classification has improved diagnosis, risk stratification, and management of EC. Further studies are needed to resolve the points of uncertainty that still exist.

Is preoperative ultrasound tumor size a prognostic factor in endometrial carcinoma patients?

Objective

We aimed to assess the prognostic value of preoperative ultrasound tumor size in EC through a single center, observational, retrospective, cohort study.

Methods

Medical records and electronic clinical databases were searched for all consecutive patients with EC, preoperative ultrasound scans available to ad hoc estimate tumor size, and a follow-up of at least 2-year, at our Institution from January 2010 to June 2018. Patients were divided into two groups based on different dimensional cut-offs for the maximum tumor diameter: 2, 3 and 4 cm. Differences in overall survival (OS), disease specific survival (DSS) and progression-free survival (PFS) were assessed among the groups by using the Kaplan–Meier estimator and the log-rank test.

Results

108 patients were included in the study. OS, DSS and PFS did not significantly differ between the groups based on the different tumor diameter cut-offs. No significant differences were found among the groups sub-stratified by age, BMI, FIGO stage, FIGO grade, lymphovascular space invasion status, myometrial invasion, lymph nodal involvement, histotype, and adjuvant treatment.

Conclusions

Preoperative ultrasound tumor size does not appear as a prognostic factor in EC women.

Sonographic Assessment of Uterine Biometry for the Diagnosis of Diffuse Adenomyosis in a Tertiary Outpatient Clinic

Background: to compare several uterine biometric parameters at transvaginal ultrasound (TVUS) between adenomyosis and non-adenomyosis uteri and evaluate their role for the diagnosis of diffuse adenomyosis. Methods: prospective observational study conducted between the 1 February 2022 and the 30 April 2022. In this case, 56 patients with TVUS diagnosis of adenomyosis were included. A 1:1 ratio age and parity-matched group of non-adenomyosis patients was selected. We compared sonographic uterine biometric parameters (longitudinal (LD), anteroposterior (APD) and transverse (TD) diameters, volume, simple and complex diameter ratios) and investigated their diagnostic performance. Results: all sonographic parameters were significantly different between the study groups, except for TD/(LD+APD). Optimal cut-off values of APD and LD/APD showed the best sensitivity and specificity. APD diameter equal or superior to 39.5 mm (95% CI, 36.2–42.8) had sensitivity of 0.70 (95% CI, 0.57–0.80), specificity of 0.71 (95% CI, 0.59–0.82) and accuracy of 0.75 (95% CI, 0.66–0.84). LD/APD equal or inferior to 2.05 (95% CI, 1.96–2.13) showed sensitivity and specificity of 0.70 (95% CI, 0.57–0.80) each and accuracy of 0.72 (95% CI, 0.62–0.81). Conclusions: several biometric uterine parameters at TVUS in fertile-aged women were statistically different between adenomyosis and non-adenomyosis uteri, though their optimal cut-off values showed low accuracy in diagnosing adenomyosis.

The social media effect: the impact of fake news on women affected by endometriosis. A prospective observational study

OBJECTIVES

Our purpose was to evaluate women's awareness of endometriosis and their ability to identify fake news about endometriosis on the internet. The second outcome was to identify those characteristics which make women more likely to believe in fake news.

STUDY DESIGN

This prospective observational study was conducted at our academic outpatient clinic for endometriosis and pelvic pain. We enrolled 172 patients referred to our Center due to the suspicion of endometriosis, who were asked to fill in a two-part questionnaire. The first part included socio-demographic information, the evaluation of anxiety status (STAI Y6 and GAD-7), and endometriosis related-symptoms (EHP-5). The second part of the questionnaire was about fake news: women were asked whether they had encountered six different statings when searching the Internet, and to judge the likelihood that those 6 topics were true.

RESULTS

76.3% of patients found fake news about endometriosis online. Higher STAI-Y6 scores were associated with a higher risk of finding fake news about endometriosis (OR 1.05, 95% C.I. 1.01-1.09, p = 0.013). More than half of patients who came across the news regarding the impossibility of obtaining pregnancy for women affected by endometriosis considered this news moderately or highly credible, 6% of them even considered it completely plausible. No demographic characteristics were associated with thehigher perceived plausibility of the fake news.

CONCLUSION

Gynecologists should be aware that some hot topics concerning endometriosis are widely talked about on the web and that many statements found online have no scientific base. Through this knowledge physicians could more easily engage patients by acquiring important insight into their main concerns and doubts, and could provide women with reliable and correct information regarding their disease, dissipating doubts and misconceptions.

P-746 Clinical, laboratory and ultrasonographic risk factors for uterine artery arteriosclerosis: insights for uterus transplantation

Study question

What is the uterine artery arteriosclerosis prevalence in women undergoing total hysterectomy for benign diseases?

Summary answer

Uterine artery arteriosclerosis shows a prevalence of 70% in women undergoing total hysterectomy for benign diseases.

What is known already

Arteriosclerosis is defined as a chronic inflammatory disease involving arteries triggered by endothelial dysfunction. The presence of uterine artery arteriosclerosis might identify uteri to be excluded for uterus transplantation. Just one article assessed frequency of UAA in women scheduled for hysterectomy. The Authors observed UAA lesions, from intimal thickness to complex plaque, in all patients; but these data have not been validated in other study populations.

Study design, size, duration

This is a single center, observational, prospective, cohort study, carried out in a tertiary academic center from December 2020 to May 2021. Forty-two consecutive symptomatic patients refuse/ contraindications/intolerance to medical therapy and scheduled for total hysterectomy were enrolled in the study. Exclusion criteria were virgo patients and patients with specimen removal requiring morcellation. Women underwent preoperative assessment of medical history, gynecological examination, transvaginal ultrasound scan and serum tests.

Participants/materials, setting, methods

Two-cm length segments of ascending branch of uterine arteries specimens were harvested at a level of the internal cervical os, then divided, fixed in formalin and then embedded in paraffin. Serial sections were obtained with a thickness of 4 micron. Clinical data and serum tests were collected during preoperative evaluation for each patient. Transvaginal ultrasound was performed. We evaluated PI, RI and PSV as markers of vascular stenosis.

Main results and the role of chance

Forty women were included in the analyses. UAA prevalence was 70%. Among clinical and laboratory factors, means ± SD of body mass index (p = 0.04), total cholesterol (p = 0.03), and triglycerides (p = 0.049) were significantly higher in patients with UAA compared to patients without UAA. On the contrary, HDL mean ± SD (p = 0.02) was significantly lower in patients with UAA than those without UAA. Regarding ultrasonographic factors, uterine arteries with UAA showed higher PSV values compared to vessels without UAA (p = 0.04).

Limitations, reasons for caution

A potential limitation of the present study is the small sample size and the enrollment of women affected by uterine diseases requiring surgery. However, we considered unethical to provide histological data in a cohort of patients with regular uterus, thus not requiring hysterectomy.

Wider implications of the findings

To our knowledge, our study may be the first to evaluate the correlation between both clinical, laboratory and ultrasonographic factors and the presence of UAA. Our findings might direct future studies aiming to improve UTx outcomes.

Trial registration number

Not applicable

Histological Prognostic Factors of Endometrial Cancer in Patients with Adenomyosis: A Systematic Review and Meta-Analysis

BACKGROUND

A better endometrial cancer (EC) prognosis in patients with coexistent adenomyosis has been hypothesized based on a different prevalence of favorable EC histological prognostic factors. However, pooled risk of EC unfavorable histological prognostic factors in patients with adenomyosis has never been calculated.

OBJECTIVES

We aimed to assess the risk of EC unfavorable histological prognostic factors in patients with adenomyosis.

METHODS

All studies with data about histological prognostic factors of EC in patients with and without adenomyosis were included. Relative risk for each unfavorable histological prognostic factor of EC, such as nonendometrioid histotype, FIGO grade 3, FIGO stage II-IV, lymphovascular space invasion (LVSI), and deep myometrial invasion, was calculated in patients with adenomyosis compared to patients without adenomyosis.

RESULTS

Seven studies with 4,439 patients were included in the quantitative analysis. EC patients with adenomyosis showed a pooled RR of 0.77 (p = 0.05) for nonendometrioid histotype, 0.55 (p < 0.00001) for FIGO grade 3, 0.60 (p = 0.005) for FIGO stage II-IV, 0.75 (p = 0.004) for LVSI, and 0.65 (p = 0.001) for deep myometrial invasion.

CONCLUSION

EC patients with adenomyosis have a significantly decreased risk for unfavorable histological prognostic factors of EC compared to EC patients without adenomyosis. Such findings might explain the supposed better EC prognosis in patients with adenomyosis.

Malignant epithelioid neoplasm of the ileum with ACTB-GLI1 fusion mimicking an adnexal mass

BACKGROUND

Malignant epithelioid neoplasm with ACTB-GLI1 fusion are considered different from the more common pericytic lesions, such myopericytoma, because they have a spectrum of different genetic abnormalities. They appear to pursue a benign clinical course in young adults, although in sporadic cases lymph node metastasis were described. The categorization of this new type of tumor may also lead to new therapeutic strategies, because they might be sensitive to SHH pathway inhibitors.

CASE PRESENTATION

The case involves a 72-years-old multiparous woman who accessed our department after an incidental finding of a right adnexal mass of 43 mm with contrast-enhancement on a control computed tomography scan made for suspected diverticulitis. Our intervention was a detailed ultrasound description of the suspected neoplasm; a diagnostic laparoscopy and the contextual laparotomic removal of abdominal mass; its histological and immunohistochemical analysis. Our main outcome measure is the definition and future recognition of new pathologic entity called malignant epithelioid neoplasm with ACTB-GLI1 fusion.

CONCLUSIONS

We described for the first time the ultrasound characteristic of this type of lesion using standardized terminology and we believe that it may be the first step to improve the acknowledgement of this novel pathologic entity defined as malignant epithelioid neoplasm with GLI-1 fusions.

Clinicopathological Features Associated with Microsatellite Instability/Mismatch Repair Deficiency in Uterine Carcinosarcoma: A Quantitative Systematic Review

INTRODUCTION

Recent studies suggested that microsatellite instability/mismatch repair deficiency (MSI/MMR-d) might define a clinicopathologically distinct subset of uterine carcinosarcomas (UCSs).

OBJECTIVE

The aim of this study was to compare clinicopathological features between MSI/MMR-d and microsatellite-stable/mismatch repair-proficient (MSS/MMR-p) UCSs.

METHODS

A quantitative systematic review was performed by searching electronic databases from January 2000 to January 2021. All studies assessing MSI/MMR status in UCS were included. Odds ratio (OR) with a significant two-tailed p value <0.05 was used to assess the association of MSI/MMR-d with clinicopathological features.

RESULTS

Eleven studies with 783 patients were included. MSI/MMR-d was directly associated with endometrioid (pure: p < 0.001; pure + mixed: p < 0.001), undifferentiated/dedifferentiated (p < 0.001), and clear cell carcinoma component (p = 0.046), and inversely associated with age >60 (p = 0.034), serous carcinoma component (pure: p < 0.001; pure + mixed: p < 0.001), heterologous sarcoma component (p = 0.027), TP53-mutation/p53-abnormal expression (p < 0.001), and recurrence (p < 0.001). MSI/MMR-d showed no significant association with advanced FIGO stage (OR = 1.259; p = 0.517), low-grade carcinoma component (pure: p = 0.596; pure + mixed: p = 0.307), mixed carcinoma component (p = 1), and proportion of patients "dead of disease" (p = 0.352), "alive with disease" (p = 1) or with "no evidence of disease" (p = 0.458).

CONCLUSION

MSI/MMR-d UCSs show younger age, more common endometrioid, undifferentiated or clear cell carcinoma component, and less common serous carcinoma component, heterologous sarcoma component, and TP53 mutation than MSS/MMR-p UCSs. Given the discrepancy between recurrence rate and oncologic outcomes at the last follow-up, further studies are necessary to define whether MSI/MMR-d UCSs have better prognosis.

Cost-effectiveness analysis of ovarian tissue cryopreservation and transplantation for preservation of fertility in post-pubertal oncological women submitted to high-risk gonadotoxic chemotherapy

OBJECTIVE

To study the economic impact of ovarian tissue cryopreservation and transplantation (OTC) in post-pubertal patients who underwent high-risk gonadotoxic chemotherapy.

METHODS

A decision tree model was used to determine the live birth rate and cost-effectiveness of OTC versus non-OTC. The incremental cost-effectiveness ratio (ICER) was calculated. A sensitivity analysis was performed under the assumption that the costs of ovarian cortex retrieval, cryopreservation, and storage for patients with cancer might be covered by the national health system or health insurance.

RESULTS

Patients had the greatest probability of achieving live birth after high-risk chemotherapy when they underwent OTC versus non-OTC. Although cryopreservation of ovarian tissue results in higher live birth rates, it is always more expensive. Cost-effectiveness increases when the majority of patients completes the path of tissue cryopreservation plus transplantation after 5 years.

CONCLUSION

Although OCT has been demonstrated as a procedure for effective fertility preservation in fertility-age women with cancer, no cost-effectiveness analysis has been performed until now. This model could help healthcare systems to allocate coverage for OCT.