Cutaneous metastasis from vulvar squamous cell carcinoma: a rare occurrence that should not be forgotten.

Vulvar cancer accounts for 5% of the female genital tract cancers. Cutaneous metastases from vulvar cancer are extremely rare and for this reason, it can be difficult to reach a diagnosis with a consequent delay in the treatment. A systematic literature review of articles on this subject was conducted through a MEDLINE-based search for articles published in English or French. To date, 16 cases (including ours unpublished) of cutaneous metastasis from vulvar cancer have been reported. Cutaneous metastasis can occur from any stage of vulvar cancer, even after a short period. Different treatments have been described but none of them seems to be more effective. In all reported cases the prognosis was very poor. Every time a vulvar cancer survivor shows a suspicious cutaneous lesion, this should be biopsied to exclude skin relapse. Impact statement Cutaneous metastases from vulvar cancer are extremely rare and due to its rarity, a standard treatment has not been established yet. Cutaneous metastasis can occur from any stage of vulvar cancer, even after a short period. In all the reported cases, the prognosis was very poor. Every time a vulvar cancer survivor shows a suspect cutaneous lesion, this should be biopsied to exclude skin relapse.

LYMPHA Technique to Prevent Secondary Lower Limb Lymphedema.

BACKGROUND: Inguinofemoral lymphadenectomy carries a high risk of lower limb lymphedema. This report describes the feasibility of performing multiple lymphatic-venous anastomoses (MLVA) after inguinofemoral lymph node completion (LYMPHA technique) and the possible benefit of LYMPHA for preventing lymphedema. METHODS: Between February, 2011 and October, 2014, 11 patients with vulvar cancer and 16 patients with melanoma of the trunk requiring inguinofemoral lymphadenectomy underwent lymph node dissection and the LYMPHA technique. Blue dye was injected into the thigh 10 min before surgery. Lymphatics afferent to the blue nodes were used to perform MLVA using a collateral branch of the great saphenous vein. RESULTS: The mean age of patients in the vulvar cancer group was 52 years (range, 48-75 years). The melanoma group comprised seven men and nine women with a mean age of 41 years (range, 37-56 years). Of the 16 patients, 5 with vulvar cancer underwent bilateral inguinofemoral lymphadenectomy, whereas the remaining 6 patients with vulvar cancer and all 16 patients with melanoma of the trunk had unilateral node dissection. All the patients were treated by the LYMPHA technique. No lymphocele or infectious complications occurred. Transient lower-extremity edema occurred for one melanoma patient (6.25 %), which resolved after 2 months, and permanent lower-extremity edema occurred for one patient (9 %) with vulvar cancer. CONCLUSIONS: The LYMPHA technique appears to be feasible, safe, and effective for the prevention of lower limb lymphedema, thereby improving the patient's quality of life and decreasing health care costs.

Feasibility and outcome of vaginal paravaginal repair using the Capio suture-capturing device.

INTRODUCTION AND HYPOTHESIS: This investigation describes the feasibility and outcome of vaginal paravaginal repair (VPVR) performed using the Capio suture-capturing device. METHODS: This prospective study included 36 women with paravaginal fascial defects, symptomatic stage II to IV anterior vaginal wall prolapse, and uterine prolapse equal or more than stage 2. VPVR was performed using the Capio device. In addition, anterior colporrhaphy, posterior colporrhaphy, and vaginal hysterectomy were performed. RESULTS: The mean time required to perform the VPVR was 12.9 min (range, 11-18 min). The median blood loss during the VPVR was 35 ml (range, 20-65 ml). There were no major intraoperative complications. At 2-year follow-up, the rate of recurrent anterior vaginal wall prolapse (stage ≥ 2) was 8.6%. CONCLUSIONS: VPVR performed using the Capio device is associated with minimal dissection of the tissues, blood loss, and operating time and has low recurrence rate at 2-year follow-up.

Systematic review and meta-analysis on the impact of the levonorgestrel-releasing intrauterine system in reducing risk of ovarian cancer.

BACKGROUND: Ovarian carcinoma (OC) is one of the most widespread tumors in the world and is characterized by low survival rates. OBJECTIVE: To determine whether the levonorgestrel-releasing intrauterine system (LNG-IUS) can prevent OC. SEARCH STRATEGY: The literature until December 2020 were systematically reviewed according to the PRISMA Statement for Reporting Systematic Reviews (PROSPERO: CRD42019137957). SELECTION CRITERIA: Studies assessing the impact of LNG-IUS on the risk of OC were included. DATA COLLECTION AND ANALYSIS: Data were extracted independently by two authors to ensure accuracy and consistency. MAIN RESULTS: A total of 34 323 records were obtained, of which three satisfied the inclusion criteria. In total, 1687 events of OC in a population of 20 461 311 person-years were considered. Data pooling revealed that the use of LNG-IUS did not confer a lower risk of OC relative to the never-use of LNG-IUS, with an estimated odds ratio of 0.66 (95% confidence interval 0.41-1.08; I2  = 84%; P = 0.002). CONCLUSION: The meta-analysis did not demonstrate a preventive role of LNG-IUS on OC. However, it was carried out on a few papers, and a definitive conclusion on the topic still cannot be drawn. Further studies are indicated in the future to define the impact of LNG-IUS on OC. The meta-analysis carried out on three papers did not demonstrate a preventive role of the levonorgestrel-releasing intrauterine device on ovarian cancer.

Neoadjuvant Chemotherapy Followed by Radical Surgery versus Concurrent Chemo-Radiotherapy in the Treatment of Locally Advanced Cervical Cancer: A Multicenter Retrospective Analysis.

OBJECTIVES: This study aims to evaluate oncological outcomes in women affected by locally advanced cervical cancer (LACC) treated by neoadjuvant chemotherapy before radical surgery (NACT + RS) or concurrent chemo-radiotherapy (CCRT). METHODS: This was a multicenter retrospective analysis of data related to women with LACC (FIGO stage IB2-IVA), who were treated by NACT + RS or CCRT between November 2006 and January 2018. The first endpoints were the evaluation of disease-free survival (DFS) and overall survival (OS); univariate and multivariate analyses were performed for identifying the prognostic factors independently associated with these oncological outcomes. RESULTS: Overall, 106 women were included in the analysis; 55 of them (51.9%) underwent NACT + RS and 51 (48.1%) CCRT, respectively. Patients in the NACT + RS group had a significant better five-year DFS and five-year OS than those in the CCRT group (77.4% vs. 33.4%, p < .001 and 93.8% vs. 56.5%, p = .003). In the multivariate analyses, treatment choice (NACT + RS or CCRT) was the only independent prognostic factor for predicting both DFS (HR = 3.954; 95 CI = 1.898-8.236; p < 0.001) and OS (HR = 5.330; 95 CI = 1.563-18.178; p = 0.008). CONCLUSIONS: This retrospective study demonstrated an improved survival outcome for patients undergoing NACT + RS compared with those undergoing CCRT. Our findings seem to support the use of NACT before RS as an effective alternative option to CCRT standard therapy.

Neoadjuvant chemotherapy and vaginal radical trachelectomy for fertility-sparing treatment in women affected by cervical cancer (FIGO stage IB-IIA1).

OBJECTIVES: The aim of the present report is to support the feasibility and the safety of a new fertility-sparing treatment in young women affected by bulky cervical cancer. METHODS: Between February 2007 and October 2010, seven patients presenting large IB-IIA1 tumors (30-45 mm) were scheduled for conservative treatment. All patients underwent neoadjuvant chemotherapy (NACT) followed by laparoscopic pelvic lymphadenectomy and vaginal radical trachelectomy (VRT). RESULTS: One patient presented hematological toxicity during NACT (grade 3). All patients showed complete disappearance of tumor (n=4/7) or partial response (a 50% or more decrease in total tumor size, n=3/7) to neoadjuvant treatment, and they were all treated with pelvic lymphadenectomy and VRT. Additional treatment (interstitial brachytherapy) was offered to only one woman because of a persistent parametrial tumoral lesion. After a mean follow up of 22 months (range 5-49), no relapse was observed. To date, only one woman in our study attempted to conceive and she is currently pregnant. CONCLUSIONS: Neoadjuvant chemotherapy for fertility sparing treatment is an innovative approach which is potentially quite interesting for many young women affected by bulky cervical cancer. These women, i.e. those with tumors larger than 2 cm (2-5 cm), are traditionally not offered fertility sparing treatment, thus the preliminary data we report here might have a promising impact. Nevertheless, for these patients it may be suitable to use the more radical, and time-tested, conservative surgical approach to allow for a complete and conservative excision of the residual tumor after neoadjuvant treatment. Studies with a larger number of patients and adequate follow-up are required to validate this conservative approach and to define clearly the good indications for this treatment.

Efficacy and safety of prolonged-release hyaluronic acid derivative vaginal application in the postpartum period: a prospective randomised clinical trial.

INTRODUCTION: In puerperium, the hypoestrogenic state induced by delivery and subsequently sustained by lactation may lead to vaginal dryness, burning, and itching sensation, contributing to the onset of sexual dysfunction. MATERIAL AND METHODS: This was a prospective, randomized, controlled, open-label study (NCT04560283) for evaluating the effects of application of a prolonged-release hyaluronic acid derivative vaginal gel in restoring sexual function during the postpartum period. Eighty-five patients were randomized to apply prolonged-release Hydeal-D 0.2% vaginal gel (Fidia Farmaceutici, Abano Terme, Italy; n = 43) every three days for 12 consecutive weeks or expectant management (n = 42). RESULTS: Women undergoing treatment had a more elevate increase in Female Sexual Function Index (FSFI) total score (+15.1 ± 11.9 vs +6.5 ± 8.9, p < 0.001) and a higher decrease in vaginal pH (-1.2 ± 0.7 vs -0.2 ± 1.1; p < 0.001). Moreover, the proportion of vaginal smears with maturation index (VMI) >65 was significantly higher in patients treated (80.6% vs 35.3%; p = 0.004). Edinburgh Postnatal Depression Scale (EPDS) decreased significantly in both groups with no inter-group difference (p = 0.459). Only two cases (4.8%) of moderate vaginal burning sensation were reported in patients undergoing local vaginal therapy. CONCLUSIONS: The results of our study demonstrated that hyaluronic acid derivative vaginal gel (Hydeal-D) was able to improve sexual function of puerperal women in the short-term treatment.KEY MESSAGEIn the puerperium, the hypoestrogenic state induced by delivery and subsequently sustained by lactation may lead to vaginal dryness, burning, and itching sensation, contributing to the onset of sexual dysfunction.Hydeal-D is a prolonged-release hyaluronic acid derivative characterised by elevated resistance to enzymatic breakdown. During puerperium, its local application may improve the vaginal microenvironment by ensuring a better migration and proliferation of cells involved in local tissue repair.Among puerperal women, Hydeal-D vaginal gel causes a significant improvement of sexual function, including desire, arousal, and lubrification, compared to expectant management. Furthermore, it leads to a decrease in vaginal pH and an increase of the trophic status of vaginal epithelium.

Pre- and post-operative work-up in patients affected by early cervical cancer and eligible for fertility-sparing treatment: role of MRI with saline hydrocolpos.

Nowadays young women affected by early invasive uterine cervical cancer (stage IA2-IB1) may be offered a fertility-sparing treatment: the radical trachelectomy with pelvic lymph node dissection. This procedure consists in surgical removal of cervix uteri, proximal parametrial tissue, and vaginal cuff. The morphology and the functions of corpus uteri are preserved. Women candidates for trachelectomy must be closely selected. Gynecologist oncologist needs an imaging modality that can accurately value the tumoral diameter and which can demonstrate proximal extension of tumor to ensure surgical clear resection margins (especially the cranial one). Magnetic resonance imaging (MRI) is a very useful examination in pre-operative study of women affected by early cervical cancer. The aim of this study is to evaluate the role of MRI with hydrocolpos about pre- and post-operative work-up in women eligible for fertility-sparing treatment.

Transobturator adjustable tape (TOA) in female stress urinary incontinence associated with low maximal urethral closure pressure.

PURPOSE: To determine the success rate of transobturator adjustable tape (TOA, Agency for Medical Innovations, A.M.I., Austria) in stress urinary incontinent patients with maximal urethral closure pressure (MUCP) < or =20 cm H(2)O compared to those with MUCP >20 cm H(2)O. MATERIALS AND METHODS: In this retrospective study, all female patients with a diagnosis of stress urinary incontinence underwent TOA, from September 2005 to August 2007. All patients had preoperative multichannel urodynamic tests (cystometry, urethral profile and uroflowmetry). During September 2008, patients were contacted by telephone and the validated short forms of the Urogenital Distress Inventory (UDI-6) questionnaire and the Incontinence Impact Questionnaire (IIQ-7) were administered. RESULTS: The chart review identified 146 patients (125 with MUCP >20 cm H(2)O and 21 with MUCP < or =20 cm H(2)O) who had undergone TOA and who met the inclusion criteria. Of these, 121 patients (82.9%) were contacted by telephone. Results showed a very good quality of life (score 0-7 in the IIQ-7) in 95.9% of patients. Only two (1.6%) patients had persistent significant urine leakage related to physical activity. In the MUCP < or =20 cm H(2)O group, 90% of patients could be considered as being very satisfied, with a very good quality of life. CONCLUSION: With the TOA procedure, the obturator route could be used to treat patients with urinary incontinence and also with low MUCP.

Borderline ovarian tumours: management in the era of fertility-sparing surgery.

Borderline ovarian tumours (BOTs) are ovarian neoplasms characterised by epithelial proliferation, variable nuclear atypia and no evidence of destructive stromal invasion. BOTs account for approximately 15% of all epithelial ovarian cancers. Due to the fact that the majority of BOTs occur in women under 40 years of age, their surgical management often has to consider fertility-sparing approaches. The aim of this mini-review is to discuss the state of the art of fertility-sparing surgery for BOTs with a specific focus on the extent of surgery, post-operative management and fertility.

Prexasertib: an investigational checkpoint kinase inhibitor for the treatment of high-grade serous ovarian cancer.

Introduction Patients with high-grade serous ovarian cancer (HGSOC) have a poor prognosis, and current chemotherapy regimens for treating advanced disease are far from satisfactory. Prexasertib (LY2606368) is a novel checkpoint kinase inhibitor (CHK) under investigation for the treatment of HGSOC. Data from a recent phase II trial showed promising efficacy and safety results for treating wild-type BRCA HGSOC. Areas covered This article reviews the available data on the pharmacokinetics, pharmacodynamics, clinical efficacy, and safety of prexasertib in the treatment of HGSOC. Expert opinion Until now, prexasertib demonstrated clinical activity in phase I and II clinical trial for treating wild-type BRCA HGSOC, whereas its promising efficacy as monotherapy and combined with olaparib in BRCA-mutated HGSOC has been preliminary evidenced only in phase I studies. Compared to other drugs of the same class, prexasertib showed a better tolerability profile, causing moderate hematological toxicity. Further studies are needed to confirm efficacy and safety profiles of prexasertib in combined regimens. New early clinical trials may investigate prexasertib administered with programmed cell death ligand 1 (PD-L1) and PI3 K inhibitors due to the preclinical evidence of a synergic action.

Metals contained and leached from rubber granulates used in synthetic turf areas.

The aim of this study was to quantify metals contained in and leached from different types of rubber granulates used in synthetic turf areas. To investigate the total content of metals, ca 0.5 g of material was added with HNO(3), HF and HClO(4) and microwave digested with power increasing from 250 W to 600 W. Leachates were prepared by extraction of about 5.0 g of material at room temperature for 24 h in an acidic environment (pH 5). Leaching with deionized water was also performed for comparison. Aluminium, As, Ba, Be, Cd, Co, Cr, Cu, Hg, Fe, Li, Mg, Mn, Mo, Ni, Pb, Rb, Sb, Se, Sn, Sr, Tl, V, W and Zn were quantified by high-resolution inductively coupled plasma mass spectrometry (HR-ICP-MS) and ICP optical emission spectrometry (ICP-OES). Results indicated that the developed method was accurate and precise for the multi-element characterization of rubber granulates and leachates. The total amount and the amount leached during the acidic test varied from metal to metal and from granulate to granulate. The highest median values were found for Zn (10,229 mg/kg), Al (755 mg/kg), Mg (456 mg/kg), Fe (305 mg/kg), followed by Pb, Ba, Co, Cu and Sr. The other elements were present at few units of mg/kg. The highest leaching was observed for Zn (2300 microg/l) and Mg (2500 microg/l), followed by Fe, Sr, Al, Mn and Ba. Little As, Cd, Co, Cr, Cu, Li, Mo, Ni, Pb, Rb, Sb and V leached, and Be, Hg, Se, Sn, Tl and W were below quantification limits. Data obtained were compared with the maximum tolerable amounts reported for similar materials, and only the concentration of Zn (total and leached) exceeded the expected values.

Complete response in a patient with gynecological hidradenocarcinoma treated with exclusive external beam radiotherapy and brachytherapy: a case report.

Hidradenocarcinoma (HC) is a very rare disease. This case report illustrates a successful treatment of a 60-year-old woman with vulvo-vaginal localization of hidradenocarcinoma treated with external beam radiotherapy delivered by helical tomotherapy with a simultaneous integrated boost (SIB), followed by brachytherapy. External beam radiotherapy dose prescription was 50.4 Gy in 28 fractions, five fractions per week to whole pelvis (planning target volume 1 - PTV1), 60.2 Gy in 28 fractions to SIB1 (fundus of uterus and right inguinal node), and 58.8 Gy in 28 fractions to SIB2 (lower/middle third of vagina, paraurethral region and right inguinal lymph nodes). Brachytherapy dose prescription was 28 Gy in 4 fractions for cervix, fundus of uterus and upper third of vagina (HR-CTV1), and 22 Gy in 4 fractions to middle third of vagina and paraurethral region (HR-CTV2). D90 for whole treatment was 91.9 Gy and 86.0 Gy for HR-CTV1 and HR-CTV2, respectively. Patient remained 12-months disease-free without treatment related side effects.

Transvaginal sonohysterographic evaluation of uterine malformations.

OBJECTIVE: The aim of this study was to assess the diagnostic value and the usefulness of sonohysterography (SHG) in the detection of uterine anomalies, compared with other diagnostic methods. STUDY DESIGN: From January 2002 to December 2003, we collected 54 patients with a history of primary or secondary infertility or repeated spontaneous abortion and with a clinically or sonographically suspected abnormal uterus. All patients had previously undergone hysterosalpingography (ISG). All patients were examined by standard transvaginal ultrasound. Sonohysterography was then carried out by the intrauterine injection of an isotonic saline solution. Suspected uterine anomalies were also confirmed by hysteroscopy (HS) and/or laparoscopy. RESULTS: Sonohysterography was able to detect all the anomalies. The sensitivity and specificity of sonohysterography were the same as for hysteroscopy. However, there was no significant difference between the diagnostic capabilities of the methods analyzed. CONCLUSIONS: Transvaginal sonohysterography with saline solution is a low-cost, easy, and helpful examination method for uterine malformations. We propose that sonohysterography should be performed for the primary investigation of infertility and repeated miscarriages.

Selection of patients with high risk endometrial cancer for surgical staging according to the evaluation of pre- and intraoperative risk factors.

BACKGROUND: The aim of this paper was to assess the accuracy of frozen sections histological examination and preoperative CA-125 to select patients with high risk endometrial cancer. METHODS: We reviewed women with type I endometrial cancer treated from January 2011 through January 2013 at the same university hospital. Preoperative CA-125 and intraoperative frozen sections were analyzed to select patients at high risk for metastases, according to Mayo Clinic algorithm. All patients underwent hysterectomy with bilateral adnexectomy. High risk patients underwent complete surgical staging. Respectively, we compared the accuracy of CA-125, frozen sections, and an algorithm combining Ca-125 plus frozen sections, with permanent sections histology as positive control. χ2 test, Landis and Koch kappa statistics (k), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were determined for each variable. RESULTS: One hundred seventy-two women were included. CA-125 levels, using 8.3 U/ml as cut-off value, showed 63.4% sensitivity, 51.6% specificity, 84.7% PPV, 25.0% NPV, 61.1% accuracy, and a low kappa statistics (k=0.106, P<0.125). Frozen sections demonstrated 97.3% sensitivity, 100% specificity, 100% PPV, 90.0% NPV, 97.8% accuracy and an optimal kappa statistics (k=0.934, P<0.001). The algorithm combining CA-125 with frozen sections showed 99.1% sensitivity, 48.1% specificity, 88.8% PPV, 92.9% NPV, 89.2% accuracy, and a satisfactory kappa statistics (k=0.578, P<0.001). CONCLUSIONS: We proved the utility of Mayo algorithm even in a different institution. Combining CA-125 plus frozen sections doesn't look like advantageous compared to frozen sections alone.

The network of the Italian laboratories: a proficiency test on the quantification of trace elements in serum.

A proficiency test on the quantification of Al, Cu, Mn, Se and Zn in serum was carried out to verify the performance of about 30 regional laboratories of the network of Italian laboratories. The exercise consisted of four runs in which the laboratories were free in choosing analytical methods to determine trace elements in freeze-dried animal serum. Laboratories performances were evaluated by the study of statistical functions as Coefficients of Variation (CV), Youden plot and Z-score value. As for Al, the results were generally characterized by good accuracy and precision, in spite of the low levels of the element (5-7 microg l(-1)). Copper determination had some problems only at low concentration (about 160 microg l(-1)--first run), in which an elevated number of anomalous data were found. Better data were achieved for Zn, for which anomalous values were mainly stragglers than outliers. Due to the low number of data for Mn (concentrations from 0.6 to 60 microg l(-1)) and Se (concentration from 45 to 106 microg l(-1)), a restricted statistical treatment was applied; for these elements high CV values were found (range from 30 to 80%). The results of this trial confirmed that participation in a proficiency test represents a benefit for all analytical laboratories. In fact, with few exceptions, most of the participants improved their performances in terms of Z-score values.