Histologic Subtypes in Endometriosis-Associated Ovarian Cancer and Ovarian Cancer Arising in Endometriosis: A Systematic Review and Meta-Analysis

The definition of the association between ovarian cancer and endometriosis was first reported by Sampson in 1925. He identified the following criteria: (a) clear evidence of endometriosis in proximity to the tumour, (b) exclusion of a metastatic tumour to the ovary, (c) presence of tissue resembling endometrial stroma surrounding epithelial glands. The naming of these cancers is "endometriosis-associated ovarian cancer" (EAOC). Scott proposed an additional stringent criterion: evidence of histological transition from endometriosis to cancer is to define "ovarian cancer arising in endometriosis" (OCAE). The aim of this systematic review is to analyse the distribution of different ovarian cancer histotypes in EAOC and OCAE to understand their similarities and differences. A total of 31 studies were included. Four studies added data for both EAOC and OCAE. Twenty-three studies were selected for EAOC, with a total of 800 patients, and 12 studies were selected for OCAE, with a total of 375 patients. The results show no significant differences in the distribution of histotypes in the two populations analysed. Clear cell carcinoma (CCC) and endometrioid carcinoma (EC) were the most common subtypes and were less frequent in EAOC compared to OCAE; the odd ratios were 0.58 (0.26-1.29) and 0.65 (0.33-1.26) respectively, although the difference was not statistically significant. The other histotypes were present in small proportions. This analysis shows that the histological profiles of EAOC and OCAE are similar, suggesting a similar aetiopathological mechanism, which requires further research to investigate whether EAOC and OCAE may be in the same way but at different points of the process to malignancy or have different pathways of progression to malignancy.

Cancer mortality patterns in selected Northern and Southern African countries

BACKGROUND

Non-communicable diseases have been rapidly increasing in African countries. We provided updated cancer death patterns in selected African countries over the last two decades.

METHODS

We extracted official death certifications and population data from the WHO and the United Nations Population Division databases. We computed country- and sex-specific age-standardized mortality rates per 100 000 person-years for all cancers combined and ten major cancer sites for the periods 2005-2007 and 2015-2017.

RESULTS

Lung cancer ranked first for male cancer mortality in all selected countries in the last available period (with the highest rates in Réunion 24/100 000), except for South Africa where prostate cancer was the leading cause of death (23/100 000). Prostate cancer ranked second in Morocco and Tunisia and third in Mauritius and Réunion. Among Egyptian men, leukemia ranked second (with a stable rate of 4.2/100 000) and bladder cancer third (3.5/100 000). Among women, the leading cancer-related cause of death was breast cancer in all selected countries (with the highest rates in Mauritius 19.6/100 000 in 2015-2017), except for South Africa where uterus cancer ranked first (17/100 000). In the second rank there were colorectal cancer in Tunisia (2/100 000), Réunion (9/100 000) and Mauritius (8/100 000), and leukemia in Egypt (3.2/100 000). Colorectal and pancreas cancer mortality rates increased, while stomach cancer mortality rates declined.

CONCLUSION

Certified cancer mortality rates are low on a global scale. However, mortality rates from selected screening detectable cancers, as well as from infection-related cancers, are comparatively high, calling for improvements in prevention strategies.

Could the contraceptive counselling improve contraceptive choice after abortion? A multicentric study to evaluate patients' perception

INTRODUCTION

24 % of abortion in Italy are repeated procedure. The cause of repeated abortion can be traced back to the inadequacy of the contraceptive counseling during the previous admission or to the adoption of an ineffective contraception method. This study aims to evaluate the Italian situation on the perceived quality of contraceptive counselling by patients undergoing abortion. The second aim is to verify if the chosen methods were available for immediate start.

STUDY DESIGN

Multicentric, prospective, non-interventional, non-randomized, non-pharmacological clinical observational study. We analyzed anonymous questionnaires on contraceptive counseling and LARC (Long Acting Reversable Contraceptives) availability and SARC (Short Acting Reversable Contraceptives) prescription at hospital discharge, distributed to women who requested abortion.

RESULTS

1074 participants on 15 hospitals through Italy. 82 % of the interviewees reported that they had received correct information regarding contraception. 74 % of the patients who chose LARC methods reported to have them inserted at the time of abortion. 73 % of women who had chosen a SARC method stated that they had received the prescription before discharge. After contraceptive counselling, we reported a significative reduction of "none or natural methods use" and a significant increase of SARC and LARC use compared to before the abortion.

CONCLUSION

Contraceptive counselling could allow a better contraceptive choice in patient who required abortion and we hope that future strategies will implement LARC choice. We think that a greater availability of LARC at an affordable price at the time of abortion could improve LARC choice. In case of SARC choice, we have to implement the prescription at hospital discharged.

Return rate following a live birth obtained with ART: frequency and determinants

PURPOSE

To understand how often couples return to ART centres for a second child.

METHODS

Retrospective monocentric cohort study including women who had a first live birth with IVF. The primary objective was to assess the rate of those returning for a second child within five years of the previous pregnancy. The secondary aim was to disentangle the determinants of this rate.

RESULTS

A total of 374 patients were included, of whom 188 returned (50%, 95% CI 45-55%). Among those who did not return (n = 186), four (2%) referred to another ART Center and 24 were unreachable. Of the 158 contacted subjects that did not refer for ART, 53 (34%, 95% CI 27-41%) conceived naturally, 57 (36%, 95% CI 29-44%) abandoned their intent of parenthood, and 48 (30%, 95% CI 24-38%) unsuccessfully attempted natural conception. These 48 women (13%) who expressed interest in a second child but did not undergo ART were compared to those seeking a second pregnancy through ART. Baseline characteristics were similar except for an older age (Median 36, IQR: 34-38 vs 34, IQR: 32-36, p = 0.001). Additionally, in terms of IVF cycle characteristics, women who did not return were more likely to achieve their first pregnancy with a fresh transfer rather than a frozen transfer (75% vs 59%, p = 0.05). They also had a higher number of retrieved oocytes (Median 10, IQR: 7-13 vs 9, IQR: 5-12) and less frequently cryopreserved embryos (27% vs 52%, p = 0.003).

CONCLUSION

The proportion of couples who have conceived with ART and who are interested in having a second child is high. Our results underline the importance of paying more attention to the number of intended children, as this information could influence clinical management.

Does preterm birth increase the initiation of antidepressant use during the postpartum? A population-based investigation

Background

Preterm birth may affect maternal mental health. We explored the relationship between preterm birth and the risk of initiating antidepressant use during the year after birth.

Methods

We conducted a population-based investigation using regional healthcare utilization databases. The exposure considered was preterm birth. The outcome was having at least one prescription for antidepressant medications during the year after birth. We used a log-binomial regression model including terms for maternal age at birth, nationality, educational level, parity, modality of conception, modality of delivery, use of other psychotropic drugs, and diabetes to estimate relative risk (RR) and 95% confidence intervals (CI) for the association between preterm birth and the initiation of antidepressant use. In addition, the absolute risk differences (ARD) were also computed according to the timing of birth.

Results

The cohort included 727,701 deliveries between 2010 and 2020 in Lombardy, Northern Italy. Out of these, 6,522 (0.9%) women had at least one prescription for antidepressant drugs during the year after birth. Preterm births were related to a 38% increased risk of initiation of antidepressant use during the year after birth (adjusted RR = 1.38; 95% CI: 1.25-1.52) for moderate to late preterm and to 83% (adjusted RR = 1.83; 95% CI: 1.46-2.28) for extremely and very preterm. Excluding women with only one antidepressant prescription, the association was consistent (adjusted RR = 1.41, 95%CI: 1.23-1.61 for moderate to late preterm and adjusted RR = 1.81, 95% CI: 1.31-2.49 for extremely and very preterm). Also, excluding women who used other psychotropics, the association remained consistent (adjusted RR = 1.39, 95%CI: 1.26-1.54 and adjusted RR = 1.91, 95% CI: 1.53-2.38, respectively for moderate to late and extremely and very preterm).

Conclusion

Women who delivered preterm may have an excess risk of initiation of antidepressant consumption during the first year after birth.

Hypertension and risk of endometrial cancer: a pooled analysis in the Epidemiology of Endometrial Cancer Consortium (E2C2)

BACKGROUND

The incidence rates of endometrial cancer (EC) are increasing, which may partly be explained by the rising prevalence of obesity, an established risk factor for EC. Hypertension, another component of metabolic syndrome, is also increasing in prevalence, and emerging evidence suggests that it may be associated with the development of certain cancers. The role of hypertension independent of other components of metabolic syndrome in the etiology of EC remains unclear. In this study we evaluated hypertension as an independent risk factor for EC and whether this association is modified by other established risk factors.

METHODS

We included 15,631 EC cases and 42,239 controls matched on age, race, and study-specific factors from 29 studies in the Epidemiology of Endometrial Cancer Consortium. We used multivariable unconditional logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) to evaluate the association between hypertension and EC and whether this association differed by study design, race/ethnicity, body mass index, diabetes status, smoking status, or reproductive factors.

RESULTS

Hypertension was associated with an increased risk of EC (OR=1.14, 95% CI:1.09-1.19). There was significant heterogeneity by study design (Phet<0.01), with a stronger magnitude of association observed among case-control vs. cohort studies. Stronger associations were also noted for pre-/peri-menopausal women and never users of postmenopausal hormone therapy.

CONCLUSIONS

Hypertension is associated with EC risk independently from known risk factors. Future research should focus on biologic mechanisms underlying this association.

IMPACT

This study provides evidence that hypertension may be an independent risk factor for EC.

Neovagina creation methods in Müllerian anomalies and risk of malignancy: insights from a systematic review

PURPOSE

This systematic review aims to provide a data synthesis about the risk of neovaginal cancer in women with Müllerian anomalies and to investigate the association between the adopted reconstructive technique and the cancer histotype.

METHODS

PubMed, MEDLINE, Embase, Scopus, ClinicalTrials.gov and Web of Science databases were searched from inception to March 1st, 2023. Studies were included if: (1) only women affected by Müllerian malformations were included, (2) the congenital defect and the vaginoplasty technique were clearly reported, (3) the type of malignancy was specified.

RESULTS

Literature search yielded 18 cases of squamous cell carcinoma and two cases of vaginal intraepithelial neoplasia 3 (VAIN 3). Of these, 3 had been operated on according to the Wharton technique, 8 according to the McIndoe technique, 3 with a split-skin graft vaginoplasty, 2 according to the Davydov technique, 2 with a simple cleavage technique, 1 according to the Vecchietti technique and 1 with a bladder flap vaginoplasty. A total of 17 cases of adenocarcinoma and 1 case of high-grade polypoid dysplasia were also described. Of these, 15 had undergone intestinal vaginoplasty, 1 had been operated on according to the McIndoe technique and 1 had undergone non-surgical vaginoplasty. Finally, 1 case of verrucous carcinoma in a woman who had undergone a split-skin graft vaginoplasty, was reported.

CONCLUSION

Although rare, neovaginal carcinoma is a definite risk after vaginal reconstruction, regardless of the adopted technique. Gynaecologic visits including the speculum examination, the HPV DNA and/or the Pap smear tests should be scheduled on an annual basis.

Ovarian Torsion in a Young Adolescent with Rokitansky Syndrome

A case report of a premenarcheal patient with ovarian torsion and mullerian agenesis is presented. A 12-year-old prepubertal girl is presented with severe right lower quadrant abdominal pain and mild rebound. Laparoscopy showed mullerian agenesis and twisted right adnexa. Detorsion and cystectomy of the right ovary were done, and the ovary was fixed to the pelvic sidewall. The postoperative course was uneventful. An association between the lax attachment of the adnexa and torsion may be a contributing factor in this condition.

Histological Features of Neovaginal Epithelium after Vaginoplasty in Mayer-Rokitansky-Küster-Hauser Syndrome

OBJECTIVE

To analyze the features of the epithelia coating neovaginas after vaginoplasty in women affected by Mayer-Rokitansky-Küster-Hauser syndrome STUDY DESIGN: We conducted a retrospective analysis of prospectively collected data. Women affected by Rokitansky syndrome who underwent neovaginal biopsy after vaginoplasty (McIndoe surgery, intestinal vaginoplasty, Vecchietti surgery, and Davydov surgery) were included. Macroscopic mucosal features were assessed through clinical examination and the Schilling test. Each biopsy specimen was prepared for examination by light microscopy and in some cases by scanning electron microscopy (SEM).

RESULTS

Thirty-six patients (4 McIndoe, 2 intestinal vaginoplasty, 14 Vecchietti, and 16 Davydov) were included. All biopsies were performed without complications. In McIndoe's neovaginas, the mucosal microscopic features were similar to normal skin, with large areas of preserved epithelium, heterogeneous presence of dermal papillae, and superficial keratinization. The characteristics of the intestinal neovagina's surface were similar to those of a sigmoid colon, with well-shaped glands, cylindrical cells, and a secreting mucosa. In Vecchietti neovaginas, the surface the epithelium was flat and multilayered, highly similar to that of a normal vagina, with the presence of glycogen and superficial desquamation. On medium SEM magnification evaluation, the epithelium presented flattened polygonal cells. Finally, in Davydov neovaginas, none of the specimens had persistent mesothelial elements. The squamous neo-epithelium had regular aspects of differentiation with the presence of glycogen. At greater SEM magnification, microridges were evident, with a regular distribution.

CONCLUSION

Each different technique of vaginoplasty leads to unique histological and structural features of the neovagina's mucosa. Knowledge of these elements must be the basis for the choice of the most appropriate intervention.

Uterine cancer deaths certified as part unspecified: an unsolved issue

OBJECTIVE

A large percentage of uterine cancer deaths worldwide are not attributed to the cervix or corpus, but classified as uterus part 'unspecified'. We provided the trend for the proportion of uterine cancer deaths certified as 'unspecified' in selected countries.

METHODS

We derived the proportions of 'unspecified' uterine cancers for 20 selected high- and middle-income countries with reliable death certification over the period 1994-2021, using official mortality data from the WHO database coded according to the 10th Revision of the International Classification of Diseases.

RESULTS

For the earliest available year, the proportion of deaths classified as 'unspecified' uterine cancers ranged from 5.8% in Mexico to 65.6% in Italy. In some countries only, this proportion decreased over time. For 10 countries the proportion of 'unspecified' uterus in the most recent available year was around 20%. The proportion of deaths at 20-44 years registered as uterus 'unspecified' was lower for all countries during the study period.

CONCLUSION

A substantial number of uterine cancer deaths worldwide coded as 'unspecified' was observed, also in high-income countries where death certification for other common neoplasms is accurate. Valid attribution of uterine cancer deaths to the cervix or corpus is feasible and should be adopted.

Probability of second live birth after first natural and medically assisted reproduction-mediated live birth: A historical cohort study

INTRODUCTION

Evidence on the role of medically assisted reproduction (MAR) in achieving the desired number of children is very limited. The aim of the current investigation was to assess the probability and the mode of conception of a second live birth according to the mode of conception of the first one.

MATERIAL AND METHODS

This historical cohort study was based on administrative data from regional healthcare databases. Women hospitalized for childbirth in Lombardy between January 1, 2007 and December 31, 2017 were identified. The probability of a second live birth up to 2021 was estimated using the Kaplan-Meier method. We calculated this probability according to the mode of conception of the first birth, and the analysis was also performed in strata of maternal age at first birth. Cox proportional hazards models were fitted to estimate the hazard ratio (HR) and 95% confidence interval (CI) of the association between mode of conception at first live birth and the probability of having a second live birth. Mothers were right-censored if they moved out of the region, died, or did not have a second live birth by the end of follow-up.

RESULTS

We identified 431 333 women who had their first live birth after a natural conception and 16 837 who had their first live birth after MAR. The probability of having a second live birth was 58.6% and 32.1%, respectively in the two groups (HR = 0.68, 95% CI: 0.66-0.70). Considering solely women who naturally conceived their first live birth, the probability to have a second child with MAR was 1.1% and to have a second child naturally 59.3%. The corresponding values were 11.5% and 25.2% in the group of women with a first MAR-mediated live birth.

CONCLUSIONS

In our cohort, one woman out of 10 having a first MAR-mediated live birth underwent MAR programs again. Considering women who had a first natural live birth, this proportion was drastically reduced. In the field of MAR, more attention should be given to the capacity of a couple to achieve the number of desired children.

Cancers attributable to overweight and obesity in Italy

BACKGROUND & AIMS

Overweight and obesity are associated with multiple cancers. We quantified the burden of cancer attributable to overweight and obesity in Italy.

METHODS

We estimated sex- and cancer site-specific population attributable fractions (PAFs) combining relative risks (from recent meta-analyses) with national obesity prevalence data (from a large sample survey conducted in 2005, to account for a 15-year lag period). Using nationwide mortality statistics and cancer registries data, we estimated the number of cancer cases and deaths attributable to overweight and obesity in Italy in 2020, based on the counterfactual scenario of a body mass index < 25 kg/m2.

RESULTS

3.6% of cancers in men and 4.0% in women in Italy were attributable to overweight and obesity, corresponding, respectively, to over 6900 and 7200 diagnoses in 2020. Attributable deaths were over 3600 in men and 2700 in women. PAFs (attributable cases) of overweight and obesity in men and women were, respectively, 38.1% (215 cases) and 21.8% (49 cases) for esophageal adenocarcinoma, 19.1% (1715 cases) and 14.5% (585 cases) for liver, 18.7% (1692 cases) and 16.7% (747 cases) for kidney, 13.7% (938 cases) and 10.1% (749 cases) for pancreatic, and 10.2% (2389 cases) and 3.4% (690 cases) for colorectal cancers. In women, PAFs were 22.3% (1859 cases) for endometrial and 5.7% (2556 cases) for post-menopausal breast cancer.

CONCLUSIONS

The cancer burden associated with overweight and obesity in Italy is considerable, but smaller compared to other high income countries, likely because of the lower prevalence of overweight and obesity in the Italian population.

Spontaneous and induced abortions in women with a diagnosis of gestational related neoplasm: a population-based linkage study in Lombardy, 2010-2020

BACKGROUND

A diagnosis of cancer during pregnancy or within one year after the end of pregnancy is a major clinical and public health issue. The current study aimed at estimating the incidence of pregnancy-associated cancer (PAC) and assessing whether the risk of abortion is increased in women diagnosed with cancer.

METHODS

This population-based cohort study used the regional healthcare utilization (HCU) databases of Lombardy, the largest region in Italy, to identify the women who delivered between 2010 and 2020. PAC were identified by oncological ICD-9-CM codes reported in the hospital discharge forms. We computed the ratio of PAC cases to the total number of pregnancies. Following a diagnosis of PAC, the prevalence ratio (PR) of abortion and the corresponding 95% confidence interval (CI), was estimated using a log-binomial model adjusted for maternal age.

RESULTS

During the study period, 926 women who gave birth (1.29 cases per 1000 births) and 341 women who had an abortion (1.52 cases per 1000 abortions) were diagnosed with PAC. Regardless of the outcome of pregnancy, the risk of PAC increased with increasing age. The rate of PAC was initially lower among births, but it came very close to the rate of PAC among abortions in the last two calendar years. The proportion of abortions among women with PAC gradually decreased from 27.7% in 2010-2012 to 18.5% in 2019-2020 (p-value < 0.001). Overall, a diagnosis of PAC was related to an approximately 10% increased risk of abortion (PR = 1.11, 95%CI:1.01-1.22). However, no association was observed in 2019-2020 (PR = 0.87, 95%CI:0.65-1.17). Considering only diagnoses made during the first trimester of pregnancy, the risk of abortion was about 2.5 times higher (PR = 2.53, 95%CI:2.05-3.11) and the risk of induced abortion was almost 4 times higher (PR = 3.71, 95%CI:2.82-4.90).

CONCLUSION

In this population the risk of abortion was about 10% higher in women with PAC than in women without PAC. However, this association tended to decrease in more recent calendar periods. This trend seemed to be influenced more by spontaneous than by induced abortions.

Fat Grafting in Vulvar Lichen Sclerosus: Long Term Follow-Up

OBJECTIVE

The rationale for the use of autologous fat grafting in the treatment of vulvar lichen sclerosus (VLS) consists in reduction of inflammation, regeneration of tissues, volume increase, and pain fiber control. The main outcome of this study was the evaluation of patients' satisfaction after treatment. Secondary outcomes included modifications in symptoms, psychosexual wellbeing, vulvar hydration, and histology after surgery.

METHODS

Eligible for this study were women aged 18-85 years with a histological diagnosis of VLS who underwent at least one autologous vulvar fat grafting at the authors' center, between 2010 and 2019. In 2021, all women underwent a clinical reevaluation, comprehensive of vulvoscopy, vulvar biopsy, and handing out of validated questionnaires.

RESULTS

Overall, 88.7% of patients declared themselves very satisfied/satisfied with the procedure. All symptoms were improved postsurgery; in particular, the difference was statistically significant for pruritus, burning, and dyspareunia ( p < .05). Sexual function was also improved at time of reevaluation, as were depressive and anxiety symptoms ( p < .05). No cases of vulvar intraepithelial neoplasia or cancer occurred during follow-up and vulvar architecture remained stable, although patients reported a significantly reduced need for topical steroids ( p < .0001). Lastly, in postoperative biopsies, inflammatory infiltrate was stable or reduced, and the distribution of elastic fibers was comparable or restored in most patients.

CONCLUSIONS

Patient satisfaction with fat grafting is detectable up to 11 years after surgery, and as such, it may represent a valid therapeutic option in selected cases of VLS.

Rokitansky Syndrome or Cervicovaginal Atresia?

STUDY OBJECTIVE

To investigate the possibility of conservative management of rudimentary uterine horns associated with vaginal agenesis.

DESIGN

Observational study on cohort of consecutive cases treated with the same criteria from 2008 to 2021.

SETTING

Two academic institutions and teaching hospitals in Milan, Italy.

PATIENTS

Eight patients with vaginal agenesis associated with rudimentary cavitated uterine horns treated by the same team and postoperatively followed.

INTERVENTIONS

All the subjects underwent the same standardized surgical procedure: laparoscopy, intraoperative ultrasound, and horn-vestibular direct anastomosis. Postoperatively vaginoscopy was performed every 6 months.

MEASUREMENTS AND MAIN RESULTS

The postoperative course was generally uneventful and the mean hospital stay was 4.3 ± 2.5 (SD) days. All the patients began to menstruate a few months after the operation. Menstrual flows were light but regular. All patients had a neovaginal length > 4 cm at 1 year postoperatively, reaching approximately 6 cm at 2 years. During the follow-up period, 5 patients were sexually active without dyspareunia. In all cases, surgery restored the continuity of the neovagina and uterine horn through the creation of a "vaginal-horn fistula tract."

CONCLUSION

In patients with vaginal agenesis associated with the presence of a uterine cavitary horn, it is possible to recover not only sexual activity but also menstrual function. The horn-vestibular anastomosis may be considered a valid, safe, and effective therapeutic option but requires accurate preoperative and intraoperative evaluation of rudimentary uterine structures.

The modest impact of assisted reproductive technology on the second birth: insights from a population-based study in Lombardy, Northern Italy

BACKGROUND

In the field of assisted reproductive technology (ART), family rate is a neglected but emerging issue. The aim of the study was to investigate the epidemiological impact of ART on the second birth during the period 2007-2020 in Lombardy, Northern Italy.

METHODS

We conducted a population-based study using administrative data from regional healthcare databases of Lombardy including first and second births occurred from 2007 to 2020. The proportion of deliveries after ART was calculated separately among first and second births. The probability of undergoing ART to achieve second birth compared to first one was estimated computing odds ratio (OR), crude and adjusted for maternal age, education, and nationality. We also assessed changes with age and calendar period.

RESULTS

We obtained a cohort including 553,190 first births and 317,976 second births. The proportion of ART babies among first and second births was 4.3% and 1.0% respectively (p < 0.001). The probability of undergoing ART to achieve second birth compared to first one, adjusted for age, education, and nationality, was 0.14 (95%CI: 0.13-0.15). The proportion of deliveries after ART increased with maternal age and along the calendar period but remained always markedly higher among first births rather than among second births.

CONCLUSION

ART played a significantly lower role in the determinism of the conception of a second birth in comparison to the conception of a first one.

Diabetes risk reduction diet and ovarian cancer risk: an Italian case-control study

PURPOSE

To investigate the relation between a diabetes risk reduction diet (DRRD) and ovarian cancer.

METHODS

We used data from a multicentric case-control study conducted in Italy, including 1031 incident ovarian cancer cases and 2411 controls admitted to hospital centres for acute non-malignant disease. Subjects' diet prior to hospital admission was collected using a validated food frequency questionnaire. Adherence to the DRRD was measured using a score based on 8 dietary components, giving higher scores for greater intakes of cereal fiber, coffee, fruit, nuts, higher polyunsaturated to saturated fatty acids ratio, lower glycemic index of diet, and lower intakes of red/processed meat, and sweetened beverages/and fruit juices. Higher scores indicated greater adherence to the DRRD. Multiple logistic regression models were fitted to calculate the odds ratios (OR) of ovarian cancer and the corresponding 95% confidence intervals (CI) for approximate quartiles of the DRRD score.

RESULTS

The DRRD score was inversely related to ovarian cancer, with an OR of 0.76 (95%CI: 0.60-0.95) for the highest versus the lowest quartile of the score (p for trend = 0.022). The exclusion of women with diabetes did not change the results (OR = 0.75, 95%CI: 0.59-0.95). Inverse associations were observed in strata of age, education, parity, menopausal status, and family history of ovarian/breast cancer.

CONCLUSION

Higher adherence to a diet aimed at reducing the risk of diabetes was inversely associated with ovarian cancer. Further evidence from prospective investigations will be useful to support our findings.

Trend of change of sperm count and concentration over the last two decades: A systematic review and meta-regression analysis

BACKGROUND

Since the 1970s, several studies found that sperm concentration (SC) and total sperm count (TSC) constantly worsened over time, mainly in high-income countries.

OBJECTIVES

To evaluate whether the decreasing trend in sperm count is continuing in Western European countries and USA, we performed a systematic review and meta-regression analysis.

MATERIALS AND METHODS

Embase and Pubmed/Medline were searched papers published in English in the 2000-2020 period limiting the search to data collected in the USA and Western European countries.

RESULTS

We identified 62 articles and pooled information on 24,196 men (range 10-2,523), collected from 1993 to 2018. Considering all the studies, random-effects meta-regression analyses showed no significant trend for SC (slope per year -0.07 mil/mL, p-value = 0.86). Negative trends of SC were detected in Scandinavian countries (slope per year -1.11 mil/mL, 95% CI: -2.40 to +0.19; p-value = 0.09), but the findings were statistically not significant. No significant trends of SC were detected in Central Europe (slope per year +0.23, 95% CI -2.51 to +2.96; p-value = 0.87), the USA (slope per year +1.08, 95% CI -0.42 to +2.57; p-value = 0.16), and Southern Europe (slope per year +0.19, 95% CI -0.99 to +1.37; p-value = 0.75). We have analyzed separately findings from studies including sperm donors, fertile men, young unselected men (unselected men, study mean age < 25 years) and unselected men (unselected men, study mean age ≥ 25 years). No significant trends of SC were observed among sperm donors (slope per year -2.80, 95% CI -6.76 to +1.17; p-value 0.16), unselected men (slope per year -0.23, 95% CI -1.58 to +1.12; p-value 0.73), young unselected men (slope per year -0.49, 95% CI -1.76 to +0.79; p-value 0.45), fertile men (slope per year +0.29, 95% CI -1.09 to +1.67; p-value 0.68).

DISCUSSION AND CONCLUSION

The results of this analysis show no significant trends in SC, in USA, and selected Western European countries.

Cancer and Pregnancy: Estimates in Italy from Record-Linkage Procedures between Cancer Registries and the Hospital Discharge Database

The aim of this study is to describe the frequency and trend of pregnancy-associated cancer (PAC) in Italy, an increasingly relevant phenomenon due to postponing age at childbirth. To this purpose, a population-based retrospective longitudinal study design based on cohorts of women aged 15-49 diagnosed with cancer and concomitant pregnancy is proposed. The study uses 19 population-based Cancer Registries, covering about 22% of Italy, and linked at an individual level with Hospital Discharge Records. A total of 2,861,437 pregnancies and 3559 PAC are identified from 74,165 women of the cohort with a rate of 1.24 PAC per 1000 pregnancies. The most frequent cancer site is breast (24.3%), followed by thyroid (23.9%) and melanoma (14.3%). The most frequent outcome is delivery (53.1%), followed by voluntary termination of pregnancy and spontaneous abortion (both 12.0%). The trend of PAC increased from 2003 to 2015, especially when the outcome is delivery, thus confirming a new attitude of clinicians to manage cancer throughout pregnancy. This represents the first attempt in Italy to describe PAC from Cancer Registries data; the methodology is applicable to other areas with the same data availability. Evidence from this study is addressed to clinicians for improving clinical management of women with PAC.

A systematic review on maternal and perinatal factors influencing breast development

BACKGROUND

A secular trend towards earlier age at menarche has been reported, but the trend in breast development is less clear. We reviewed the evidence on the relationship between in utero and early life events and breast onset/development.

METHODS

Eligible studies were identified in PubMed and Embase databases. We selected studies in which female human exposure during fetal or the first years of life was measured or estimated, and associations with breast onset or development were evaluated.

RESULTS

Of the 49 cohort studies and 5 cross-sectional studies identified, 43 provided sufficient data to assess associations. High maternal weight, primiparity, and early weight gain, were related to an increased risk of early breast onset/development in most of the studies that analysed these associations, whereas late breast onset/development was associated with preterm birth. Results were inconsistent for smoking in pregnancy, maternal hypertensive disorders, breastfeeding, diabetes, and small for gestational age. No association emerged for maternal age at delivery, alcohol drinking, and selected drug use during pregnancy, and low birth weight.

CONCLUSIONS

The results of this review show that high maternal weight, primiparity and early weight gain were associated with an increased risk of early breast onset/development. Late breast onset/development was associated with preterm birth. Breast development is a key physical marker of puberty onset, and early puberty development is linked to consequences that can reverberate throughout life. Answering the questions about the interconnections between pre/postnatal environmental exposures and their impact on puberty, represents an important area of multidisciplinary research.

Inebilizumab for neuromyelitis optica spectrum disorders in Italy: a budget impact model

BACKGROUND

The Italian National Health Service (INHS) has recently reimbursed the monoclonal antibody inebilizumab as a second line monotherapy after rituximab (RTX) use for neuromyelitis optica spectrum disorders (NMOSD) patients ≥ 18 years anti-aquaporin 4 antibody-immunoglobulin G positive, who experienced a relapse in the last year or cannot receive RTX, if incident patients. Other INHS-reimbursed drugs for NMOSD treatment are satralizumab, eculizumab and, off-label, besides RTX, ocrelizumab, tocilizumab, and immunosuppressants.

RESEARCH DESIGN AND METHODS

A 3-year (2023-2025) prevalence-based budget impact model following the INHS viewpoint compared the costs and the NMOSD attacks without (1st scenario) and with inebilizumab (2nd scenario). The epidemiology of NMOSD, and the INHS-funded healthcare resources (drugs and their administration; specialist visits; hospitalizations due to drug-related adverse events and NMOSD attacks) were obtained from the literature. One-way, threshold value and scenario sensitivity analyses investigated the robustness of the baseline findings.

RESULTS

During 2023-2025 inebilizumab saves the INHS €8,373,125.13 (1st scenario: €176,770,028.63; 2nd scenario: €168,396,903.50) and 12.74 NMOSD attacks (1st scenario: 213.94; 2nd scenario: 201.19). Sensitivity analyses confirmed the robustness of the baseline results.

CONCLUSION

Inebilizumab reduces the INHS expenditure for NMOSD drugs. Future research should explore the cost-effectiveness of inebilizumab vs other NMOSD-targeting drugs in Italy.

Adherence to the Mediterranean diet and the risk of unexpected poor response to ovarian stimulation in IVF cycles

RESEARCH QUESTION

Can preconception adherence to a Mediterranean diet influence the rate of poor response to ovarian stimulation in IVF cycles?

DESIGN

The impact of dietary habits on the success of IVF is controversial. Inconsistencies may be explained by confounders associated with the use of pregnancy as an outcome as well as by a reductionist view of diet that focuses on single components rather than on food patterns. This cross-sectional study analysed adherence to a Mediterranean diet in women with unexpected poor response to ovarian stimulation. Main inclusion criteria were: age 18-39 years, normal weight, preserved ovarian reserve and starting dose of gonadotrophins of 150-225 IU/day. Adherence to the Mediterranean diet was assessed through a Mediterranean diet score (MDS). Unexpected poor ovarian response was defined as the retrieval of ≤3 suitable oocytes.

RESULTS

A total of 296 women were included, of whom 47 (15.9%) showed an unexpected poor response. A clear dose-related association with tertiles of MDS was not observed in the univariate analysis. However, in the multivariate analysis, the risk of unexpected poor response was significantly lower for women in the second tertile of MDS compared with the first tertile (adjusted odds ratio [OR] 0.29, 95% confidence interval [CI] 0.11-0.76) and for women in the second and third tertiles, grouped together, compared with the first tertile (adjusted OR 0.34, 95% CI 0.14-0.82).

CONCLUSIONS

Low adherence to a Mediterranean diet could be a risk factor for unexpected poor ovarian response.

COVID-19 and Pregnancy: An Updated Review about Evidence-Based Therapeutic Strategies

The COVID-19 pandemic posed a significant challenge for clinicians in managing pregnant women, who were at high risk of virus transmission and severe illness. While the WHO declared in May 2023 that COVID-19 is no longer a public health emergency, it emphasized that it remains a global health threat. Despite the success of vaccines, the possibility of new pandemic waves due to viral mutations should be considered. Ongoing assessment of the safety and effectiveness of pharmacological therapies is crucial in clinical practice. This narrative review summarizes the evidence-based therapeutic strategies for pregnant women with COVID-19, considering over three years of pandemic experience. The review discusses the safety and effectiveness of various drug regimens (antivirals, anticoagulants, corticosteroids, immunoglobulins, monoclonal antibodies, and therapeutic gases) and procedures (prone positioning and extracorporeal membrane oxygenation). Drugs with contraindications, inefficacy during pregnancy, or unknown adverse effects were excluded from our evaluation. The aim is to provide healthcare professionals with a comprehensive guide for managing pregnant women with COVID-19 based on lessons learned from the pandemic outbreak.

Role of mode of induction and delivery and women's satisfaction after induction of labour at term: An observational study

This cross-sectional study aimed at evaluating the impact of different modalities of induction of labour (IOL) and delivery on levels of woman' satisfaction. All women aged 18 years or older, who underwent IOL for at-term pregnancy (≥41 weeks of gestation) in randomly selected days during the study period in 6 participating centres were eligible for the study. The questionnaire investigated women's opinion regarding information about induction, pain control, length of induction, their experience about induction, labour and delivery and their attitude towards induction in a subsequent pregnancy. Women were also asked to fill in the Italian version of the Birth Satisfaction Scale-Revised (BSS-R). A total of 300 women entered the study. The answer to the question about a "positive attitude towards induction in a subsequent pregnancy was "absolutely yes" or "yes" respectively in the 77.8%, 52.8% and 48.6% of women who were induced with oral drugs, vaginal drugs and Cook balloon (heterogeneity chi-square p = 0.05). The corresponding values for women who delivered vaginally or by caesarean section (CS) were 63.3% and 36.4% (chi-square p = 0.0009). The mean BSS-R total score was higher among women who underwent IOL with oral drugs than with vaginal drugs (p < 0.0001) or Cook Balloon (p < 0.0001), and among women who delivered vaginally than in those who delivered by CS (p < 0.0001). Women were asked "What do you think is important for a method of induction?": 47.3% (95% CI 41.7%-53.0%) of women answered that "should make the induction as painless as possible", 47.0% (95% CI 41.4%-52.7%) "should induce labour quickly", 44.3% (95% CI 38.8%-50.0%) "should be safe for baby". This study showed that vaginal delivery was associated with a higher rate of satisfaction among induced women. Considering mode of induction, oral drugs were associated with a higher level of satisfaction. Control of pain and quick induction were the most appreciated characteristics.

Risk prediction models for endometrial cancer: development and validation in an international consortium

BACKGROUND

Endometrial cancer risk stratification may help target interventions, screening, or prophylactic hysterectomy to mitigate the rising burden of this cancer. However, existing prediction models have been developed in select cohorts and have not considered genetic factors.

METHODS

We developed endometrial cancer risk prediction models using data on postmenopausal White women aged 45-85 years from 19 case-control studies in the Epidemiology of Endometrial Cancer Consortium (E2C2). Relative risk estimates for predictors were combined with age-specific endometrial cancer incidence rates and estimates for the underlying risk factor distribution. We externally validated the models in 3 cohorts: Nurses' Health Study (NHS), NHS II, and the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial.

RESULTS

Area under the receiver operating characteristic curves for the epidemiologic model ranged from 0.64 (95% confidence interval [CI] = 0.62 to 0.67) to 0.69 (95% CI = 0.66 to 0.72). Improvements in discrimination from the addition of genetic factors were modest (no change in area under the receiver operating characteristic curves in NHS; PLCO = 0.64 to 0.66). The epidemiologic model was well calibrated in NHS II (overall expected-to-observed ratio [E/O] = 1.09, 95% CI = 0.98 to 1.22) and PLCO (overall E/O = 1.04, 95% CI = 0.95 to 1.13) but poorly calibrated in NHS (overall E/O = 0.55, 95% CI = 0.51 to 0.59).

CONCLUSIONS

Using data from the largest, most heterogeneous study population to date (to our knowledge), prediction models based on epidemiologic factors alone successfully identified women at high risk of endometrial cancer. Genetic factors offered limited improvements in discrimination. Further work is needed to refine this tool for clinical or public health practice and expand these models to multiethnic populations.

ART and the forgotten siblings: a call for research

A broader definition of infertility is the incapacity to have the intended number of children. However, most literature on ART exclusively focuses on live birth as an outcome, rather than on the capacity to fully realize the reproductive wishes of the couples. This issue has probably received scant attention because the total fertility rate is below replacement levels in affluent countries, and one may simplistically assume that only a minority of couples may be interested in more than one child. This assumption, however, is unproven and presumably erroneous. Unfortunately, evidence on the rate of return in couples who conceived their first child with ART is scant and information on the intended number of children in infertile couples is lacking. In general, we plea for more research on this subject. The documentation of an intended number of children above two and a high return rate in infertile couples may lead to changes in clinical practice, such as the storage of oocytes or embryos prior to initiating embryo transfers. This could improve the chance of conceiving the second child when the couple comes back some years later. In addition, the identification of the determinants for non-return as well as those explaining the gap between the intended and the realized number of children may reveal specific barriers and possibly how to tackle them. However, at present, available evidence is insufficient to advocate any intervention. Thorough research is warranted.

Prevalence and Factors Associated With Intertwin Birth Weight Discordance Among Same-Sex Twins in Lombardy, Northern Italy

This population-based cohort study investigated the prevalence, potential risk factors, and consequences of birth weight discordance (BWD) among same-sex twins. We retrieved data from the automated system of healthcare utilization databases of Lombardy Region, Northern Italy (2007-2021). BWD was defined as 30% or more disparity in birth weights between the larger and the smaller twin. Multivariate logistic regression was used to analyze the risk factors of BWD in deliveries with same-sex twins. In addition, the distribution of several neonatal outcomes was assessed overall and according to BWD level (i.e., ≤20%, 21-29, and ≥30%). Finally, a stratified analysis by BWD was performed to assess the relationship between assisted reproductive technologies (ART) and neonatal outcomes. We identified 11,096 same-sex twin deliveries; 556 (5.0%) pairs of twins were affected by BWD. Multivariate logistic regression analysis showed that maternal age ≥35 years (OR 1.26, 95% CI [1.05,5.51]), low level of education (OR 1.34, 95% CI [1.05, 1.70]), and ART (OR 1.16, 95% CI [0.94, 1.44], almost significant due to the low power) were independent risk factors for BWD in same-sex twins. Conversely, parity (OR 0.73, 95% CI [0.60, 0.89]) was inversely related. All the adverse outcomes observed were more common among BWD pairs than non-BWD ones. Instead, a protective effect of ART was observed for most neonatal outcomes considered among BWD twins. Our results suggest that conception after ART increases the risk of developing a high disparity between the weights of the two twins. However, the presence of BWD may complicate twin pregnancies, compromising neonatal outcomes, regardless of the modality of conception.

Cancers attributable to infectious agents in Italy

OBJECTIVES

To provide an evidence-based, comprehensive assessment of the current burden of infection-related cancers in Italy.

METHODS

We calculated the proportion of cancers attributable to infectious agents (Helicobacter pylori [Hp]; hepatitis B virus [HBV] and hepatitis C virus [HCV]; human papillomavirus [HPV]; human herpesvirus-8 [HHV8]; Epstein-Barr virus [EBV]; and human immunodeficiency virus [HIV]) to estimate the burden of infection-related cancer incidence (2020) and mortality (2017). Data on the prevalence of infections were derived from cross-sectional surveys of the Italian population, and relative risks from meta-analyses and large-scale studies. Attributable fractions were calculated based on the counterfactual scenario of a lack of infection.

RESULTS

We estimated that 7.6% of total cancer deaths in 2017 were attributable to infections, with a higher proportion in men (8.1%) than in women (6.9%). The corresponding figures for incident cases were 6.5%, 6.9% and 6.1%. Hp was the first cause of infection-related cancer deaths (3.3% of the total), followed by HCV (1.8%), HIV (1.1%), HBV (0.9%), HPV, EBV and HHV8 (each ≤0.7%). Regarding incidence, 2.4% of the new cancer cases were due to Hp, 1.3% due to HCV, 1.2% due to HIV, 1.0% due to HPV, 0.6% due to HBV and <0.5% due to EBV and HHV8.

CONCLUSIONS

Our estimate of 7.6% of cancer deaths and 6.9% of incident cases that were attributable to infections in Italy is higher than those estimated in other developed countries. Hp is the major cause of infection-related cancer in Italy. Prevention, screening and treatment policies are needed to control these cancers, which are largely avoidable.

Impact of the First and Second Lockdown for COVID-19 Pandemic on Preterm Birth, Low Birth Weight, Stillbirth, Mode of Labor, and of Delivery in Lombardy, Italy

We investigated the effect of lockdown measures implemented in Lombardy on selected obstetric and perinatal outcomes. Births that occurred during the two lockdowns imposed (i.e., the first from 16 March to 2 June 2020 and the second from 3 November 2020 to 5 April 2021) and the comparison periods (i.e., the first from 16 March to 2 June 2018 and the second from 3 November 2018 to 5 April 2019) were identified using regional healthcare databases. The distribution of births according to the selected outcomes was computed and the Chi-square test was used for testing differences in the periods compared. During the two lockdowns, we observed a lower proportion of low birth weight, from 6.8% in the comparison period to 6.1% in the first lockdown (p = 0.019), and from 6.5% to 6.1% in the second one (p = 0.109). The proportion of preterm births decreased from 6.8% to 6.3% in the first lockdown (p = 0.097), and from 6.2% to 6.0% in the second one (p = 0.172). No differences in stillbirth rate emerged for both lockdowns. Induction of labor was more frequent during both lockdowns, from 28.6% to 32.7% in the first (p < 0.0001), and from 29.9% to 33.2% in the second one (p < 0.0001). Cesarean section was less frequent during the second lockdown.

Trends in the incidence of major birth defects after assisted reproductive technologies in Lombardy Region, Northern Italy

PURPOSE

The incidence of birth defects is increased in children born after assisted reproductive technologies (ART). However, changes in ART over time could influence this incidence. To investigate this issue, we present the frequency and trends of birth defects in ART and natural pregnancies in Lombardy, Northern Italy, during the period 2014-2020.

METHODS

This is a population-based study using automated system of healthcare utilization (HCU) databases. ART pregnancies included only those obtained with conventional IVF or ICSI. After identifying the total number of deliveries, the rate of newborns with birth defects was compared between natural and ART pregnancies. A logistic regression model was used to calculate the adjusted odd ratio (OR). Analyses were repeated for every calendar year.

RESULTS

Overall, 508,421 deliveries were identified, of which 14,067 (2.8%) were achieved after IVF-ICSI. A decreasing trend in birth defects over time was highlighted. The adjusted OR dropped from 1.40 (95%CI: 1.03-1.91) in 2014 to 0.92 (95%CI: 0.69-1.22) in 2020. During the study period, a significant reduction in multiple pregnancy and in the ratio of ICSI to conventional IVF was also observed, explaining at least in part the positive trend observed for birth defects.

CONCLUSION

The increased risk of birth defects in children born after IVF-ICSI is not steady over time. A decline of this risk emerged in our region. Policy changes in ART may explain this beneficial effect.

Laparoscopic Removal of Nonseparated Cavitated Horn in Unicornuate Uterus: Surgical Aspects and Long-Term follow-up

BACKGROUND

In unicornuate uterus cases, when the rudimentary horn is very close to the uterus and is firmly attached, laparoscopic surgery can be very challenging due to the danger of massive bleeding and the possiblity of damaging the healthy hemiuterus. The aim of study is to verify if the laparoscopic resection of the horn site of hematometra, when solidly attached to the unicornuate uterus, is safe and effective.

MATERIALS AND METHODS

This is a retrospective analysis of prospectively collected data in a tertiary referral centre. From 2005 to 2021, a total of 19 women were diagnosed with unicornuate uterus with cavitated noncommunicating horn (class II B). We reviewed the original documentations of the patients and created a database. The follow-up results were assessed by questionnaires answered by the patients. In all cases, the chosen treatment was: laparoscopic removal of the rudimentary horn together with the ipsilateral salpinx and reconstruction of the myometrium of the hemiuterus. Statistical Package for Social Science (SPSS) version 21.0 was used to perform data analysis. We decided to calculate continuous variables in terms of mean and standard deviation (SD) or as median and interquartile range (IQR), as appropriate. Instead, categorical variables were expressed in terms of percentage.

RESULTS

Five patients (12-18 years old) with unicornuate uterus and rudimentary horn with hematometra and broadly connected to the hemiuterus were operated laparoscopically. The surgical procedure was successfull in all cases. No major complications were recorded. Postoperative course was uneventfull. In the follow-up in all cases dysmenorrhea and pelvic pain disappeared. Three patients sought to become pregnant and have children. They had in total 4 pregnancies with 2 abortions in the 1st trimester and two pregnancies with premature births at the 34^th and 36^th weeks. No serious gestational complications were recorded and the pregnancies ended with caesarean sections due to breech presentation.

CONCLUSION

Overall, for the rudimentary horn solidly attached to the unicornuate uterus, the laparoscopic resection of the horn site of hematometra seems to be safe and effective.

Vitamin and Carotenoid Intake and Outcomes of In Vitro Fertilization in Women Referring to an Italian Fertility Service: A Cross-Sectional Analysis of a Prospective Cohort Study

BACKGROUND

Nutrition may impact reproductive health and fertility potential. The role of dietary antioxidants in affecting conception and birth outcomes is a topic of emerging interest.

METHODS

This cross-sectional analysis from a prospective cohort study aims to explore the relationship between the intake of antioxidants, vitamins, and carotenoids and the outcomes of assisted reproduction techniques. Information on the socio-demographic characteristics, health histories, lifestyle habits, and diet information of subfertile couples referred to a fertility center was obtained.

RESULTS

A total of 494 women were enrolled. According to the four IVF outcomes considered, 95% of women achieved good quality oocytes, 87% achieved embryo transfer, 32.0% achieved clinical pregnancies, and 24.5% achieved pregnancy at term. Associations were found between age and the number of good quality oocytes (p = 0.02). A moderate level of physical activity in the prior 5 years was associated with a better rate of achieving clinical pregnancy (p = 0.03). Smoking habits, alcohol intake, and caffeine consumption did not show associations with any outcome. No associations were found, even after accounting for potential confounders, with the intake of vitamins C, D, E, and α-carotene, β-carotene, beta-cryptoxanthin, lutein, and folate.

CONCLUSION

Further research is needed to understand how antioxidant intake may have a role in modulating fertility.

Maternity Blues: A Narrative Review

Puerperium is a period of great vulnerability for the woman, associated with intense physical and emotional changes. Maternity blues (MB), also known as baby blues, postnatal blues, or post-partum blues, include low mood and mild, transient, self-limited depressive symptoms, which can be developed in the first days after delivery. However, the correct identification of this condition is difficult because a shared definition and well-established diagnostic tools are not still available. A great heterogenicity has been reported worldwide regarding MB prevalence. Studies described an overall prevalence of 39%, ranging from 13.7% to 76%, according to the cultural and geographical contexts. MB is a well-established risk factor for shifting to more severe post-partum mood disorders, such as post-partum depression and postpartum psychosis. Several risk factors and pathophysiological mechanisms which could provide the foundation of MB have been the object of investigations, but only poor evidence and speculations are available until now. Taking into account its non-negligible prevalence after childbirth, making an early diagnosis of MB is important to provide adequate and prompt support to the mother, which may contribute to avoiding evolutions toward more serious post-partum disorders. In this paper, we aimed to offer an overview of the knowledge available of MB in terms of definitions, diagnosis tools, pathophysiological mechanisms, and all major clinical aspects. Clinicians should know MB and be aware of its potential evolutions in order to offer the most timely and effective evidence-based care.

High-grade vaginal intraepithelial neoplasia and recurrence risk: analysis of an Italian regional referral center series

PURPOSE

The main aim of this study was to investigate the long-term risk of disease recurrence in women treated for high-grade vaginal intraepithelial neoplasia (HG-VaIN).

METHODS

We conducted a retrospective analysis on a cohort of 82 women diagnosed with HG-VaIN between 2010 and 2021 at the "Regional Referral Center for Prevention, Diagnosis and Treatment of HPV-related Genital Disorders", Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy. All women underwent either ablative treatment (CO₂ laser ablation or electrocoagulation) or cold-knife excision.

RESULTS

In our series, the recurrence rate following treatment was 17%. The 5-year cumulative probability of recurrence was 30.4% and the median time to recurrence was 15.5 months. None of the patients progressed to invasive vaginal cancer during follow-up. A concomitant cervical or vulvar intraepithelial lesion was significatively associated with an increased risk of recurrence (p = 0.006).

CONCLUSIONS

The results of our study suggest that women with HG-VaIN are at high risk of developing disease recurrence after treatment, especially patients with a concomitant cervical or vulvar intraepithelial lesion. In these women strict monitoring is mandatory to obtain an early identification of recurrence.

Hysterectomy for cervical intraepithelial neoplasia: A retrospective observational multi-institutional study

OBJECTIVE

To analyze the clinical management, the outcomes, and the trend in hysterectomy rates (HR) in patients who underwent this procedure for cervical intraepithelial neoplasia (CIN).

METHODS

Multicentric retrospective observational study conducted on 242 patients who underwent hysterectomy for CIN between 2010 and 2020 in nine Italian institutions. Hysterectomy for invasive or micro-invasive neoplasia, sub-total hysterectomy, or trachelectomy were excluded.

RESULTS

A significant increase in the trend of HR for CIN was recorded (P = 0.002, r = 0.81; C.I. 95%: 0.415-0.949); HR increased from 0.46% in the year 2010 to 3.32% in 2020. The mortality rate was 0.4%, and 5% had operative complications. On definitive histopathology examination, a CIN of any grade was recorded in 71.5% of cases, and an occult invasive cancer in 1.24%. No pathology or CIN1 was found in 26.8% of cases, suggesting over treatment. During follow-up, a vaginal lesion was recorded in 5% of cases.

CONCLUSION

A significant increase in the number of hysterectomies performed for CIN in the last 10 years was recorded. Hysterectomy for CIN can lead to complications, risk of the onset of vaginal lesions, and risk of overtreatment, and remains, in the first instance, an unacceptable treatment, to be proposed only after adequate counseling.

A systematic review and meta-analysis on alcohol consumption and risk of endometriosis: an update from 2012

Endometriosis is a complex and chronic disease, whose multifactorial nature has encouraged a deep investigation on the role of lifestyle factors. A strong association between alcohol intake and endometriosis risk has already been shown. We aimed to confirm this association, considering the updated literature. 23 eligible studies were identified through comprehensive literature search of PubMed and EMBASE (May 2012-October 2021). A borderline statistical significance was found comparing any alcohol consumption with no consumption (unadjusted OR 1.14; 95% CI: 0.99-1.31, p = 0.06), in contrast with a previous meta-analysis. However, we confirmed the significant association between moderate alcohol intake and endometriosis (unadjusted OR 1.22, 95% CI: 1.03-1.45, p = 0.02), also performing a sensitivity analysis (unadjusted OR 1.27, 95% CI: 1.04-1.54). Our partly divergent evidence reflects the tough challenge of isolating the impact of specific factors on the natural history of multifactorial diseases. Indeed, on one hand alcohol could be adopted by patients as a self-management therapy and on the other, it could favor the disease, promoting positive feedback with inflammatory mediators and oxidative stress. Our study encourages further investigation on the role of modifiable lifestyle factors and highlights the opportunity to adopt them to prevent or at least limit endometriosis progression.

Forty-two normomenstruating adolescents with Müllerian obstructive anomalies: Presentation, pitfalls in the dagnosis and surgical management

INTRODUCTION

We analyzed the frequency, presentation and pitfalls in the diagnosis and surgical management of a large group of normomenstruating adolescents with obstructive reproductive tract anomalies.

MATERIAL AND METHODS

Retrospective analysis of prospectively collected data. Of the 143 outpatients referred for severe dysmenorrhea and persistent pelvic pain, 42 (29.3%) young women with obstructive Müllerian anomalies and regular menstrual flow were identified. These patients were divided into four groups: (1) patients with duplicate uterine cavities, obstructed hemivagina and ipsilateral renal agenesis (n = 34); (2) patients with unicornuate uterus and noncommunicating cavitated rudimentary horn (n = 5); (3) patients with accessory cavitated uterine mass (n = 2); (4) patients with partially obstructed transverse vaginal septum (n = 1). All 42 patients were conservatively treated via laparoscopy and 35/42 patients had also vaginal surgery.

RESULTS

Of the four groups, patients in groups 2 and 3 (n = 7) were conservatively managed by laparoscopy alone; for patients in groups 1 and 4 (n = 35), laparoscopy and the vaginal approach were used. Patients of group 1 were treated by resecting the obstructed vaginal septum with drainage of retained collections. In patients in group 2, surgery consisted of the removal of the rudimentary horn. Patients of group 3 were treated by the removal of myometrial neoformations. In the patient in group 4, treatment consisted of removal of the septum. All surgical procedures were successful and no major complications were recorded. Follow-up reports highlighted the disappearance of obstruction and clear improvement in pain symptoms.

CONCLUSIONS

Unilateral obstructive anomalies of the female genital tract are difficult to identify. Early diagnosis allows the preservation of reproductive activity and avoids potential complications.

A clinician’s dilemma: what should be communicated to women with oncogenic genital HPV and their partners regarding the risk of oral viral transmission?

Head and neck cancer, the sixth most common cancer worldwide, account for about 1 out of 20 malignant tumors. In recent years a reduction in the incidence of cervical cancer, but a concomitant major increase in the incidence of HPV-mediated oropharyngeal cancer caused by orogenital HPV transmission has been observed. Consequently, in wealthy countries oropharyngeal squamous-cell carcinomas (OPSCC) is now the most frequent HPV-related cancer, having overtaken cervical cancer. Without effective medical interventions, this incidence trend could continue for decades. As no specific precursor lesion has been consistently identified in the oral cavity and oropharynx, HPV vaccination is the logical intervention to successfully counteract also the rising incidence of OPSCCs. However, HPV vaccine uptake remains suboptimal, particularly in males, the population at higher risk of OPSCC. Alternative primary prevention measures, such as modifications in sexual behaviors, could be implemented based on knowledge of individual genital HPV status. Until recently, this information was not available at a population level, but the current gradual shift from cytology (Pap test) to primary HPV testing for cervical cancer screening is revealing the presence of oncogenic viral genotypes in millions of women. In the past, health authorities and professional organizations have not consistently recommended modifications in sexual behaviors to be adopted when a persistent high-risk HPV cervicovaginal infection was identified. However, given the above changing epidemiologic scenario and the recent availability of an immense amount of novel information on genital HPV infection, it is unclear whether patient counseling should change. The right of future partners to be informed of the risk could also be considered. However, any modification of the provided counseling should be based also on the actual likelihood of a beneficial effect on the incidence of HPV-associated oropharyngeal cancers. The risk is on one side to induce unjustified anxiety and provide ineffective instructions, on the other side to miss the opportunity to limit the spread of oral HPV infections. Thus, major health authorities and international gynecologic scientific societies should issue or update specific recommendations, also with the aim of preventing inconsistent health care professionals’ behaviors.

Periodontitis, female fertility and conception (Review)

Periodontal disease (PD) has been shown to increase the risk of preterm birth, preeclampsia and low birth weight. These observations have suggested that PD may also affect the early phase of pregnancy, including conception. The present study aimed to evaluate whether an association exists between oral health status and the chance of clinical pregnancy, according to the currently published literature, by performing a systematic review. The PubMed and EMBASE databases were searched from their start dates to October 2021 using the following keywords: ‘Infertility’ OR ‘conception’ OR ‘pre-pregnancy’ OR ‘time-to-pregnancy’ AND ‘periodontitis’ OR ‘periodontal disease’ OR ‘dental infection’ OR ‘gingivitis’ OR ‘odontogenic infection’ (limits: Full article, English, Human). A total of 6 papers reporting observational information on PD and spontaneous (4 studies) or medically induced conception (2 studies) were retrieved. As such, there were limited studies with different designs (randomized controlled trials and observational studies) and different settings. Moreover, in the selected studies, the ethnicity of the women was heterogeneous. According to the limited published literature, oral health might affect fertility in women. However, only results from prospective randomized trials, comparing PD treatment vs. no treatment in women seeking pregnancy, may clarify the real effectiveness of treatment in improving the conception rate.

Adherence to the World Cancer Research Fund/American Institute for Cancer Research recommendations and endometrial cancer risk: a multicentric case-control study

The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) published evidence-based recommendations for cancer prevention focusing on body weight, physical activity, and diet. Our aim is to evaluate whether adherence to the WCRF/AICR recommendations could reduce endometrial cancer risk. We used data from a multicentric, Italian hospital-based case-control study (1992-2006) including 454 endometrial cancer cases and 908 age-matched controls. Adherence to the WCRF/AICR recommendations was measured using a score (range: 0-7) based on seven components: body mass index (BMI), physical activity and five dietary items; higher scores indicated higher adherence. Odds ratios (OR) were estimated by multiple (adjusted) conditional logistic regression models including terms for major confounders and energy intake. Adherence to the WCRF/AICR recommendations was inversely related to endometrial cancer risk (OR = 0·42, 95 % confidence interval (CI) 0·30, 0·61 for the highest compared with the lowest score quartile), with a significant trend of decreasing risk with increasing adherence. An inverse association was also observed for a score including only dietary recommendations (OR = 0·67, 95 % CI 0·46, 0·96 for the highest compared with the lowest score tertile). In stratified analyses, the association was stronger among women with a normal weight, those who were older, and consequently those in post-menopause, and those with ≥ 2 children. In conclusion, high adherence to the WCRF/AICR recommendations has a favourable role in endometrial cancer risk, which is not fully explained by body weight.

The changing impact of assisted reproductive techniques on preterm birth during the period 2007-2020 in Lombardy, Northern Italy

OBJECTIVE

To assess the impact of Assisted Reproductive Techniques (ART) on the risk of preterm birth (PTB).

STUDY DESIGN

This retrospective population-based study used healthcare utilization databases of the Lombardy Region to select all the deliveries occurred between 2007 and 2020. Log-binomial regression models were fitted to estimate prevalence ratio (PR) and the corresponding 95% confidence interval (CI) of PTB among deliveries after ART. Estimates were adjusted for maternal sociodemographic features. Furthermore, the population attributable fraction was computed. All the analyses were performed for calendar period and were repeated excluding multiple births.

RESULTS

In our cohort, an increasing trend in the number of ART emerged, with an overall rate of 25.8 per 1,000 deliveries (N = 28,742). ART was positively related to PTB (aPR = 2.83, 95 % CI: 2.76-2.91) with a downward trend. Over the period study, multiple births after ART decreased (from 20.4 % to 8.4 %) and were constantly burdened by a higher number of PTB. Excluding multiple births, the association was substantially lower (aPR = 1.72, 95 % CI: 1.65-1.79) and did not describe any trend. Moreover, stratifying for type of pregnancy, the association was observed only among singletons. Finally, the proportion of PTB considered attributable to ART increased from about 2-3 % to 6 % till the 2016, then decreased.

CONCLUSION

The investigation suggested that ART was related to PTB; this association may be partly justified by the high rate of multiple births among women who conceived non spontaneously. However, excluding multiple births, ART remained associated with PTB.

Comorbidity patterns, family history and breast cancer risk: a latent class analysis

BACKGROUND

Limited evidence exists on how the presence of multiple conditions affects breast cancer (BC) risk.

METHODS

We used data from a network hospital-based case-control study conducted in Italy and Switzerland, including 3034 BC cases and 3392 controls. Comorbidity patterns were identified using latent class analysis on a set of specific health conditions/diseases. A multiple logistic regression model was used to derive ORs and the corresponding 95% CIs for BC according to the patterns, adjusting for several covariates. A second model was fitted including an additional effect of FH on the comorbidity patterns.

RESULTS

With respect to the 'healthy' pattern, the 'metabolic disorders' one reported an OR of 1.23 (95% CI 1.02 to 1.49) and the 'breast diseases' an OR of 1.86 (95% CI 1.23 to 2.83). The remaining two patterns reported an inverse association with BC, with ORs of 0.77, significant only for the 'hysterectomy, uterine fibroids and bilateral ovariectomy'. In the second model, FH was associated with an increased risk of the 'breast diseases' pattern (OR=4.09, 95% CI 2.48 to 6.74). Non-significant increased risk of the other patterns according to FH emerged.

CONCLUSION

We identified mutually exclusive patterns of comorbidity, confirming the unfavourable role of those related to metabolic and breast disorders on the risk of BC, and the protective effect of those related to common surgical procedures. FH reported an incremented risk of all the comorbidity patterns.

IMPACT

Identifying clusters of comorbidity in patients with BC may help understand their effects and enable clinicians and policymakers to better organise patient and healthcare management.

P-717 Trends in the incidence of major birth defects after Assisted Reproductive Technologies (ART) in Lombardy Region, Northern Italy

Study question

Does the association between Assisted Reproductive Technologies (ART) and birth defects change over time?

Summary answer

The increased incidence of birth defects in ART pregnancies is not steady over time. A decline of this risk emerged in most recent years.

What is known already

The incidence of birth defects is increased in pregnancies after ART. The latest meta-analysis showed that infants born following IVF-ICSI have a 40% increased risk (Zhao et al., 2020). Even if infertile women are exposed to higher risk per se, some ART related factors may also contribute. To note, ART procedures are continuously evolving, and it cannot be excluded that the magnitude of the association of ART and birth defects may have changed in recent years. We failed to identify in the literature studies reporting on the trends of birth defects in IVF-ICSI pregnancies over time.

Study design, size, duration

This is a population-based study using the automated system of healthcare utilization databases from Lombardy, a region located in Northern Italy accounting for about 10 million inhabitants. We identified deliveries occurring between January 2014 and December 2020 from women beneficiaries of the public health system using the standard discharge form and the certificate of delivery assistance. We excluded cases with incomplete information and pregnancies obtained by intrauterine insemination or ovarian hyperstimulation alone.

Participants/materials, setting, methods

The rate of newborns affected by major defects was calculated among natural and IVF-ICSI pregnancies. A logistic regression model was used to adjust for maternal sociodemographic features (i.e., age, nationality, marital status, education, and employment). Data are presented as adjusted odd ratio (aOR) and corresponding 95% Confidence Interval (CI) of major defects among IVF-ICSI pregnancies compared to natural conceptions. Analyses were repeated for every calendar year.

Main results and the role of chance

A total of 508,421 live births were included, of whom 14,067 (2.8%) were achieved with IVF-ICSI. The proportion of non-spontaneous conceptions per year progressively increased over the years, being 2.1%, 2.3%, 2.6%, 2.8%, 3.2%, 3.4% and 3.2% in 2014, 2015, 2016, 2017, 2018, 2019, and 2020, respectively (p &lt; 0.0001). Overall, 13,080 birth defects were recorded, of whom 412 occurred among ART newborns (3.1%). The risk of birth defects is increased in women undergoing ART (aOR 1.13; 95%CI:1.02-1.25), but a decreasing trend over time was highlighted. Indeed, the aOR dropped from 1.40 (95%CI: 1.04-1.91) in 2014 to 0.7 (95%CI: 0.73-1.28) in 2020 (p &lt; 0.001). During the study period, a statistically significant reduction in multiple pregnancies (p-value for trend &lt;0.0001) and in the ratio of ICSI to conventional IVF (p-value for trend &lt;0.0001) was also observed, potentially explaining the positive trend observed for birth defects.

Limitations, reasons for caution

The diagnosis of malformation is based on information detected at the time of delivery, and not during the subsequent infant’s hospitalization, or later in lifetime. Further, we have no information on pregnancies terminated early. Finally, data was collected from registries and this modality may expose the findings to some inaccuracies.

Wider implications of the findings

The increased risk of birth defects in IVF-ICSI pregnancies is not steady over time. A decline of this risk emerged in our region. Policy changes in ART may explain this beneficial effect. Evidence obtained more than one decade ago may not be valid in the modern era of IVF.

Trial registration number

not applicable

Systematic review of the effect of D‑mannose with or without other drugs in the treatment of symptoms of urinary tract infections/cystitis (Review)

Several studies, reviews and meta-analyses have documented that D-mannose use lowers the risk of recurrent urinary tract infections (UTI), but its role in the treatment of UTI/cystitis-related symptoms is unclear. In particular, no systematic review has analyzed the role of treatment with D-mannose in acute UTI/cystitis. In this paper, we systematically reviewed the published data on the effect of D-mannose, alone or in association with other compounds, on the typical symptoms of UTI/cystitis. PubMed/Medline and EMBASE databases were searched, from 1990 to January 2022, using combinations of the following keywords: ‘urinary tract infections’, ‘cystalgia’, ‘recurrent next urinary tract infection’, ‘cystitis’, ‘mannose’, ‘mannoside’, ‘D-mannose’, ‘bacteriuria’, ‘pyuria’, ‘pyelocystitis’ with the appropriate Boolean modifiers (Limits: Human, English, full article). Studies were selected for the systematic review if they were clinical studies and reported original data, the number of patients using D-mannose alone or in association with other treatments, and the number of patients with symptoms of UTI/cystitis at trial entry and after the follow-up period. A total of seven studies were identified. D-mannose was given alone in two studies, and was associated with cranberry extract, Morinda citrifolia fruit extract, pomegranate extract, fructo-oligosaccharides, lactobacilli, and N-acetylcysteine in the others. All studies reported that symptoms decreased after treatment with D-mannose. Despite the limitations of the studies, the consistent results observed among all studies give support to the general findings that D-mannose may be useful in the treatment of UTI/cystitis symptoms.