Postoperative radiotherapy in stage I/II endometrial cancer: retrospective analysis of 883 patients treated at the University of Florence.

INTRODUCTION: The efficacy of postoperative radiotherapy (RT) in the treatment of early-stage endometrial carcinoma (EC) is still under debate. This study was aimed to review the outcome and adverse effects in patients treated for EC with postoperative RT at a single center. METHODS: A total of 883 patients with pathological stages I to II EC were retrospectively analyzed. Surgery consisted of total abdominal hysterectomy and bilateral salpingo-oophorectomy, or vaginal hysteroannessiectomy in 532 patients (60.2%) with pelvic lymphadenectomy in 351 patients (39.8%). Seven hundred forty-seven patients (84.6%) underwent whole pelvic RT (WPRT) and 136 (15.4%) combined WPRT and vaginal brachytherapy (BT) boost. RESULTS: At a median follow-up of 9 years (range, 1.2-27.6 years), we observed 10.6% disease relapse. Forty-seven patients experienced local recurrence (LR), and 38 patients experienced distant metastases (DMs). At univariate analysis, age at diagnosis (P < 0.0001), stage (P < 0.04), and histological subtype (P < 0.0001) resulted in significant prognostic factors. At multivariate analysis, histotype emerged as an independent relapse predictor (P = 0.0001). Acute WPRT-related toxicity was mild; diarrhea was the most common adverse effect (19.8%). We recorded long-term adverse effects in 7.8% of the patients. CONCLUSIONS: Our study showed that patients with early-stage EC have a good outcome in overall survival and disease-free survival. In our experience, standard surgery (including hysterectomy and bilateral salpingo-oophorectomy followed by WPRT with or without BT) showed an acceptable toxicity profile.

Use of a No. 11 blade scalpel and reusable blunt trocar to establish pneumoperitoneum: description of a safe and inexpensive technique.

First access is crucial in laparoscopic surgery because of its potentially life-threatening complications. A number of procedures using a variety of instruments have been previously described; however, the safest approach remains uncertain. Herein, we describe a simple and inexpensive method for direct trocar insertion using reusable instruments that was developed over 10 years in a series of 4721 consecutive gynecologic laparoscopic procedures. Observed data revealed that the technique is feasible, rapidly performed, and safe, with a likely cost savings, using a small set of reusable instruments. This procedure should be compared with other access methods in randomized studies to confirm the observed advantages.

PCR detection rates of high risk human papillomavirus DNA in paired self-collected urine and cervical scrapes after laser CO2 conization for high-grade cervical intraepithelial neoplasia.

OBJECTIVE: To compare the PCR detection rates of high risk human papillomavirus DNA in self-collected urine and cervical scrapes during follow-up of patients treated for HG-CIN by laser CO2 conization. PATIENTS AND METHODS: 52 women who submitted to laser conization for HG-CIN were enrolled into this prospective follow-up study receiving liquid-based cytology and HR-HPV testing by PCR assay on self-collected urine and cervical scrapes before and at 3, 6 and 12 months after treatment. Diagnostic accuracy and predictive values for treatment failure were evaluated for both urinary and cervical HPV testing and follow-up cytology. RESULTS: 3 cases (5.8%) of recurrent HG-CIN occurred during follow-up. Positive margins and HR-HPV persistence resulted to significant risk factors for recurrence (p=0.01). The overall concordance on HR-HPV detection between paired urine and cervical samples was 96.6% and discord trend between agreement rates during follow-up were excluded by overall fixed-effect index (OR 1.03; 95% CI 0.62-1.70). No difference was observed comparing the three- and six-month cumulative sensitivity and NPV for recurrent disease of urinary and cervical HPV detections, with an increase of 5.6% in specificity associated with urinary testing. CONCLUSIONS: PCR detection of HR-HPV in paired urine and cervical samples during follow-up revealed an excellent concordance, suggesting a potential equivalent role of the two methods within post-treatment follow-up. In our experience HPV testing on self-collected urine was more sensitive than cytology and more specific than cervical HPV detection to predict treatment failure. Larger studies are needed to definitively establish the role of urine-based HPV testing during follow-up.

CO2 laser cylindrical excision or standard re-conization for persistent-recurrent high-grade cervical intraepithelial neoplasia (HG-CIN) in women of fertile age.

AIM: To investigate the therapeutic efficacy of cylindrical or cone-shaped excision performed by laser CO2 in the conservative management of persistent-recurrent high-grade cervical intraepithelial neoplasia (HG-CIN) in women of fertile age. PATIENTS AND METHODS: Ninety-four premenopausal patients with persistent-recurrent HG-CIN had undergone re-conization or cylindrical excision according to the time of reappearance of the disease. The length of the procedures, intra- and postoperative complications, height of the excised specimens, final histological findings and follow-up data were retrospectively evaluated. RESULTS: Fifty-five (58.5%) persistent and 39 (41.5%) recurrent cases had undergone cylindrical excision and standard re-conization respectively. All the treatments were successfully performed in an out-patient setting under local anesthesia with no differences in term of operative time, height of removed specimens, intra- and postoperative complications between the two groups. Definitive histology confirmed HG-CIN in 95.7% of the cases and FIGO Stage Ia1 cervical cancer (negative lymph vascular space involvement, LVSI) in 4.3% of the cases. The endocervical margins were involved in 3.6% of the cylindrical (persistent) and in 17.9% of the cone-shaped (recurrent) specimens (p = 0.03). The overall cure rate after a median follow-up time of 54 months (range 10-196) was 91.5%. A third excisional procedure was performed in 8 cases of persistent-recurrent HG-CIN with a disease-free subsequent follow-up of 38 months (range 6-108). CONCLUSION: Cylindrical or conical re-excision performed by CO2 laser according to the time of reappearance of the disease seems to be a promising conservative approach for persistent-recurrent HG-CIN even though further randomised prospective studies are needed to confirm the long-term efficacy and reproductive outcomes.

The incidence of obstetric anal sphincter rupture in primiparous women: a comparison between two European delivery settings.

BACKGROUND: During the last years, the incidence of obstetric anal sphincter rupture (OASR) has increased markedly in Sweden, and significantly less frequently in Italy. Our objective was to explore if different delivery management may explain the variation in OASR incidences. METHODS: In a retrospective study, data from 2,000 primiparous women in a Swedish and an Italian delivery unit were compared with respect to OASR, maternal age, gestational length, birth weight, labour induction, use of epidural analgesia (EDA) and oxytocin, vacuum extraction, episiotomy, and duration of the second stage of labour. RESULTS: Incidences of OASR were 9.2 and 0.4% in the Swedish and Italian centres, respectively. Other significant differences were noticed in maternal age, birth weight, gestational length, use of EDA, oxytocin, vacuum extraction, episiotomy, and frequency of induction. Further analysis of the Swedish population revealed a significant association between OASR and birth weight as well as vacuum extraction. The association with gestational age and duration of the second stage of labour approached significance level. However, no association could be found between OASR and maternal age, EDA, episiotomy or induction of labour. CONCLUSION: Women delivering in the Swedish setting had a 23 times higher risk of OASR. An association between OASR and birth weight, gestational age, instrumental vaginal deliveries and duration of second stage was found. These factors varied between the settings and could possibly explain the differences in OASR incidence. The importance of alternative management, such as constant midwife support and perineal protection during delivery, may be a subject for further studies.

Surveillance for endometrial cancer in women on tamoxifen: the role of liquid-based endometrial cytology - cytohistological correlation in a population of 168 women.

AIMS: The aim of this study was to evaluate the utility of liquid-based cytology for endometrial surveillance in patients receiving tamoxifen. METHODS: One hundred and sixty-eight women scheduled for hysteroscopy were enrolled in the study. The women sequentially underwent hysteroscopy, endometrial cytology and biopsy. RESULTS: Endometrial biopsy only was inadequate in 112 (67%) patients, both endometrial biopsy and cytology were inadequate in 19 (11%) patients, endometrial cytology only was inadequate in 4 (2%) patients, and both endometrial biopsy and cytology were adequate in 33 (20%) patients. Overall, endometrial biopsy was inadequate in 131 (78%) patients and endometrial cytology in 23 (14%) patients. Endometrial cytology provided sufficient material for diagnosis more often than endometrial biopsy (p < 0.05). In the series of 33 patients (20%) in whom both endometrial cytology and biopsy were adequate, there was a 100% correlation between the endometrial cytology and biopsy results. CONCLUSIONS: For the first time, this study shows the diagnostic efficacy of liquid-based endometrial cytology in the follow-up of women receiving tamoxifen. It could be applied solely or in conjunction with ultrasonography.

In situ adenocarcinoma and squamous carcinoma of uterine cervix. Pathological and immunohistochemical analysis with cytokeratin 13.

OBJECTIVES: The aim of the study was the pathological and immunohistochemical analysis of cytokeratin 13 (CK13) in intraepithelial cervical tumors. STUDY DESIGN: We studied 415 in situ squamous carcinomas and 13 in situ mucinous cervical type adenocarcinomas of the uterine cervix. All patients underwent laser cervical conization and had a follow-up ranging 12-135 months. RESULTS: 3% of the squamous carcinoma patients recurred during the follow-up period, while the percentage of recurrence of in situ adenocarcinoma patients was 7.6%. We observed positive surgical edges in 46.1% of glandular tumors, and in 5% of squamous tumors. The percentage of recurrence was high among the cases with positive borders independently from their histopathologic type (14.3% in the squamous carcinomas versus 50% in the adenocarcinomas), compared to cases with negative edges (2.3% in the squamous carcinomas versus 0% in the adenocarcinomas). We observed CK13 positive staining in cervical squamous tumors and in mucinous cervical type adenocarcinomas, while there was no positive staining in non-neoplastic cervical glandular elements. CONCLUSION: CK13 positive immunostaining among in situ squamous and in situ mucinous cervical type adenocarcinoma cases adds additional evidence to data supporting a common origin of the two lesions.

Liquid-based endometrial cytology in the management of sonographically thickened endometrium.

Liquid-based cytology represents an opportunity to re-evaluate endometrial cytology. We evaluated the accuracy of liquid-based endometrial cytology as compared to biopsy in 670 women scheduled for histeroscopy because of thickened endometrium (>4 mm), as evaluated by transvaginal sonography. Endometrial biopsy detected pathology in 41 (6%) of cases (21 of which were adenocarcinomas). Cytologic study found pathology in 62 (9%) cases (19 of which were adenocarcinomas). Two hundred ninety-one biopsies (43%) and 28 (4%) cytologies were inadequate. The sensitivity and the specificity were estimated, respectively, at 95% and 98%; the positive and negative predictive values were estimated, respectively, at 83% and 99%. Cytology provided sufficient material more often than biopsy (P < 0.01). We consider endometrial cytology an efficacious diagnostic opportunity. It could be usefully applied in association with transvaginal sonography. The combination of these procedures might reduce more invasive and expensive diagnostic procedures.

Luteinizing hormone increases human endometrial cancer cells invasiveness through activation of protein kinase A.

Endometrial cancer (EC) is a hormone-dependent cancer that currently represents the most frequent malignancy of the female reproductive tract. The involvement of steroid hormones in its etiology and progression has been reported. The possibility that even gonadotropins (GT) could play a role in the genesis and establishment of EC is supported by the fact that specific receptors for the GT luteinizing hormone/human chorionic GT (LH/hCG) have been detected in a high percentage of ECs, and their expression is apparently related to the cancer grading. However, the precise mechanisms by which GTs might exert their effect on EC is still obscure. The aim of this study was to determine the effects of LH/hCG on the invasion potential of EC cell lines and primary human EC cells. Human recombinant (hr) LH (and hCG) induced a significant increase in cell invasiveness through Matrigel-coated porous membranes in an EC human cell line Hec1A, which expresses the LH/hCG receptor. This effect turned out to depend on hrLH binding to its specific receptors and to the subsequent activation of protein kinase A (PKA). Moreover the hrLH-induced increase in Hec1A invasiveness relied upon a PKA-dependent functional activation of beta(1) integrin receptors, as well as the subsequent induction of matrix metalloproteinase-2 secretion in its active form. The same mechanisms were also found to be operative in primary EC cells. In fact, a significant percentage of primary ECs expressed the LH/hCG receptor, and hrLH addition to primary EC cells, which expressed the specific receptors produced an increase in cell invasiveness only in those tumor cells possessing the specific receptors. This effect was also dependent on PKA activity. We conclude that LH/hCG can regulate EC cells invasiveness, and this result provides a rationale for the use of inhibitors of LH secretion such as GnRH analogues in the treatment of EC.

HER-2/neu oncogene in uterine carcinosarcoma on tamoxifen therapy.

HER-2/neu is an oncogene located on chromosome 17, encoding a type 1 tyrosine kinase growth factor receptor. HER-2/neu is overexpressed in 25-30% of breast cancers, increasing the aggressiveness of the tumor. We describe HER-2/neu overexpression and her-2/neu oncogene amplification in a case of uterine carcinosarcoma occurring in a 46-year-old women who had undergone mastectomy and a 2-year postoperative treatment with tamoxifen for invasive breast cancer. This is the first study demonstrating HER-2/neu expression and her-2/neu oncogene amplification in a uterine carcinosarcoma that has developed in a patient given tamoxifen therapy. It still needs to be clarified whether HER-2/neu overexpression increases the aggressiveness of carcinosarcoma, or whether HER-2/neu has a direct role in its pathogenesis, as described in breast cancers. Our observation of the her-2/neu oncogene amplification does not shed light on the prognostic impact of uterine carcinosarcoma following tamoxifen therapy, but it may indicate the need for further studies of HER-2/neu overexpression in a larger series of uterine carcinosarcoma patients, and it may permit us to hypothesize about a therapeutic concept, including the inhibition of HER-2/neu by humanized monoclonal antibodies also in uterine carcinosarcoma patients.

Young women, cervical intraepithelial neoplasia and human papillomavirus: risk factors for persistence and recurrence.

Human papillomavirus (HPV) infection is one of the most common sexually transmitted infections (STIs) in young women. They can occur in one or multiple areas of the female genitalia. Usually, the vulva is the initial site of implantation for HPV. The purpose of our study is to evaluate the epidemiological aspects, incidence of single or multiple lesions in the lower genital tract, correlation between sexual behaviour and their localization and behaviour risk factors for persistence and recurrence of HPV lesions and cervical intraepithelial lesion (CIN) in a long-term follow-up among young women. We recruited 268 patients aged 11-21 years who previously had cytology and/or physical examination suspicious for HPV infection. The women were interviewed and asked information about lifestyle, sexual behaviour, work, personal or family history of genital warts and school attendance. We considered individuals to be 'smokers' if they smoked more than five cigarettes/day. No specific data were recorded about oral contraception, nevertheless, no woman had used oral contraceptives (OCs) for more than 2 years. Young women included in the study were between the age of 12 and 21 years who had HVP lesions after entry examinations and had undergone no treatment for HPV lesions prior to entry. Other exclusion criteria relevant to this study included cervical excisional treatment prior to entry or later. Two hundred and thirty-four young women were included in our study group. Our diagnostic schedule for a complete evaluation included exo- and endocervical cytology, colposcopy, directed biopsy and microcolpohysteroscopy. The treatment was performed with a LASER CO2 Coherent 400, model 451, with Zeiss photocolposcopy attachment. The finding that, among 126/234 (53.8%) adolescents using contraceptives, only 85 (36.3%) have used condom, the only barrier form of contraceptive effectively protecting against virus, shows a low awareness of the high risk for contracting HPV infection among young sexually active women. The sites most frequently affected in our study were vulva, perianus and perineum (194/234), 82.9% and the cervix (125/234), 53.4%. Vaginal lesions were detected only in 29/234 patients (12.3%). According to our data, in 161 patients, sexual habits, age at the first intercourse (P=0.68), frequency of intercourses (P=0.49) and number of lifetime partners (P=0.27) as well as age (P=0.26) play a role in transmission and incidence of HPV infection but not on the location of the lesions. This can be due to a coexistent clinical and subclinical multiple infection as well as a transmission via intercourse or from other sources, including tampons. Abnormal Pap test was related to HPV infection, but the low correlation with colposcopic and histological findings in this study justify the support of other examinations such as colposcopy and punch biopsy for diagnosis. Moreover, according to our data, cytology alone shows to be not suitable to exclude CIN (seven underestimated cases of CIN) and a closer correspondence were found between colposcopy and the result of histological sample after punch biopsy in CIN detection. More attention must be paid to psychological aspect of diagnoses and treatment among adolescents, more than older women as the high rate of patients lost shows in our study: 75/234 (32.05%) before LASER surgery and 55/159 (34.59%) during follow-up. International data shows that only 12-45% of sexually active adolescent girls have obtained Pap smear screening. In our study, we found no correlation between treatment failure and cigarette smoking or between the use of oral contraceptives and persistence/recurrence after LASER CO2 surgery. Because the small sample of our study group, further analyses were required.

Reproductive performance before and after abdominal myomectomy: a retrospective analysis.

OBJECTIVE: To evaluate the results of abdominal myomectomy for intramural and subserosal fibroids and to identify factors that influence the reproductive outcome after surgery. DESIGN: Retrospective analysis of a case series. SETTING: An academic department specializing in gynecologic surgery. PATIENT(S): A total of 72 women with intramural and subserosal fibroids submitted to abdominal myomectomy who wished to conceive after surgery. INTERVENTION(S): Data were collected on clinical characteristics, surgical features, and obstetric history before and after surgery. MAIN OUTCOME MEASURE(S): Conception rate, pregnancy loss, and live birth rate before and after surgery, as well as postoperative probability of conception according to selected clinical and fibroid characteristics. RESULT(S): Conception rate was 28% before myomectomy and 70% after surgery. The corresponding figures were 69% and 25% for pregnancy loss and 30% and 75% for live birth rate, respectively. Age <30 years and number of fibroids removed were the only significant and independent predictors of obstetric outcome by multivariate analysis. CONCLUSION(S): Our results suggest that abdominal myomectomy might improve reproductive outcome in patients with intramural and subserosal fibroids. The reproductive performance was particularly good when the patients were younger than 30 years and had a single myoma to remove.

Giant condyloma acuminatum or buschke-Lowenstein tumor: review of the literature and report of three cases treated by CO2 laser surgery. A long-term follow-up.

Giant condyloma acuminatum or Buschke-Lowenstein tumor (TBL) is a rare disease that arises on the male and female external genitalia. TBL arises from the confluence of multiple condylomata acuminata and it is induced a Human Papillomavirus infection. TBL presents a clinical malignancy, but it is known to be a histologically benign tumor, even if it carries a risk of malignant transformation. It is advisable to treat it early. After a review of the literature, three cases of giant condyloma acuminatum, treated by combined CO2 Laser surgery excision-vaporization and which underwent a long-term follow-up are described.

CO2 laser surgery for vulvar intraepithelial neoplasia. Excisional, destructive and combined techniques.

OBJECTIVE: To evaluate CO2 laser excision, vaporization and combined techniques for treatment of vulvar intraepithelial neoplasia (VIN). STUDY DESIGN: Thirty-nine cases of VIN 3, 15 cases of VIN 2 and 9 of VIN 1, for a total of 63 patients with histologically proven VIN, underwent laser excision or vaporization under colposcopic guidance, using local anesthesia, in an outpatient setting or after day-surgery admission. Clinical aspects, cervical intraepithelial neoplasia (CIN) and vaginal intraepithelial neoplasia (VaIN) association, types of CO2 laser treatment, follow-up, recurrences and second treatments were evaluated. RESULTS: Twenty-seven (41.3%) patients underwent laser vaporization, and 37 (58.7%) with VIN 3, underwent laser excision or the combined technique. Colposcopic and biopsy examinations of patients with VIN revealed three cases of CIN 3 and nine cases of VaIN 3; two patients had concomitant VIN 3, CIN 3 and VaIN 3. Local anesthesia, using 2% carbocaine, and outpatient or day-surgery treatments were possible in all cases. A small incidence of intraoperative complications (4.8%) and absence of postoperative complications were observed. A single session was curative in 76.9% of patients treated with laser vaporization and in 78.4% of those treated with laser excision. Eleven cases of recurrent VIN and two cases of invasive vulvar carcinoma were observed during follow-up. A second laser procedure was carred out in all cases of relapsed VIN, with an overall cure rate of 96.8% after two treatments. Radical vulvectomy associated with inguinal-femoral lymphadenectomy was performed in the two cases of invasive carcinoma. CONCLUSION: CO2 laser surgery permits treatment of VIN in an outpatient or day-surgery setting under local anesthesia with excellent cosmetic and functional results. The treatment can also be adjusted to the patient's specific needs, with the possibility of calibrating the depth of the vaporized and removed tissues. Excisional treatment is the preferred method because it permits histologic evaluation of the excised tissue and detection of possible occult early invasion.

Mini-laparotomy versus vaginal surgery for class II-III obese patients with early-stage endometrial cancer.

AIM: To compare minilaparotomic and vaginal surgery in selected obese patients with early-stage endometrial cancer at high surgical risk. PATIENTS AND METHODS: Data of 37 consecutive class II-III obese patients submitted to minilaparotomic surgery were retrospectively reviewed. Thirty-seven women matched for demographic characteristics, BMI and stage of disease submitted to vaginal surgery in the same period comprised the control group. RESULTS: No difference was observed concerning intra- and postoperative data among the two groups. The patients who were submitted to general anesthesia exhibited a larger use of supplemental drugs for pain control (p>0.01), a higher incidence of thromboembolic events (p>0.005) and a longer hospitalization (p>0.02). No statistical difference was observed in terms of pattern of recurrence, disease-free survival and overall survival between the two groups of patients. CONCLUSION: Obese patients with endometrial cancer unfit for vaginal surgery can be safely managed through mini-laparotomy with the same surgical and oncological outcomes.

Levonorgestrel-releasing intrauterine system (LNG-IUS) as an effective treatment option for endometrial hyperplasia: a 15-year follow-up study.

The levonorgestrel-releasing intrauterine system may represent an effective treatment option in >85% of endometrial hyperplasia cases, but histologic regression during and/or at the end of treatment does not assure stable recovery. We recommend periodic endometrial samplings for at least the first 2 years of follow-up and long-term clinical surveillance thereafter.

Levonorgestrel-releasing intrauterine system alone as primary treatment in young women with early endometrial cancer: case report.

Young women with polycystic ovary syndrome (PCOS) are at increased risk of endometrial adenocarcinoma (EAC) through chronic unopposed estrogen production. We describe the first case, to our knowledge, of grade 1 endometrioid EAC arising in the context of complex atypical endometrial hyperplasia in a 26-year-old woman with thrombophilia and PCOS who wished to retain fertility potential and was treated using a levonorgestrel-releasing intrauterine system alone. At first follow-up biopsy, a single focus of complex hyperplasia without atypia was documented. All specimens sampled during subsequent follow-up demonstrated inactive endometrium with pseudodecidual changes, and no ultrasonographic or magnetic resonance (MR) images exhibiting myometrial invasion or endoabdominal spread were observed. This successful outcome suggests that insertion of a levonorgestrel-releasing intrauterine system is a treatment option in selected young women with early-stage EAC who are not candidates for systemic therapy and who wish to maintain fertility potential. Close histologic follow-up is required, and immediate surgery is mandatory if endometrial cancer persists.

Carbon-dioxide laser vaporization of the Bartholin gland cyst: a retrospective analysis on 200 cases.

STUDY OBJECTIVE: To evaluate the effectiveness of carbon-dioxide laser vaporization as definitive treatment for Bartholin gland cyst. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: University teaching hospital. PATIENTS: A consecutive series of 200 patients with monolateral or bilateral Bartholin gland cyst. INTERVENTIONS: A standardized technique of cyst vaporization performed by carbon-dioxide laser in outpatient setting and local anesthesia. MEASUREMENTS AND MAIN RESULTS: Records of all patients were reviewed for anamnestic information, anatomic parameters, intraoperative and postoperative outcomes, and follow-up data. Seven patients having bilateral cyst were treated in a single session; 207 procedures were performed. The cyst mean size was 6.3 +/- 2.3 cm (95% CI 5.93-6.67). All treatments were completed in outpatient regimen and local anesthesia with a median operative time of 17 minutes (range: 7-45). Three (1.5%) cases of intraoperative major bleeding were observed. The cure rate of a single laser treatment was 95.7%. The 9 patients with recurrent disease observed during follow-up underwent carbon-dioxide laser reintervention by the same therapeutic strategy with a 100% cure rate after 2 or 3 treatments. CONCLUSION: Carbon-dioxide laser vaporization of Bartholin gland cyst represents a safe and effective procedure with complete healing and positive follow-up outcomes. Further randomized trials should be conducted to confirm these findings and to establish the best surgical strategy.

Late solitary metastasis of cutaneous malignant melanoma presenting as abnormal uterine bleeding.

We present the case of a 52-year-old woman with a history of excised cutaneous malignant melanoma complaining of abnormal uterine bleeding 11 years after initial diagnosis. Hysteroscopic examination showed an endometrial lesion with polypoid shape and endometrial biopsy was suggestive for melanoma. After a complete clinical work-up ruling out other metastatic sites, the patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Final histopathological and immunohistochemical analysis confirmed the diagnosis of endometrial melanoma with initial myometrial invasion. After a 6-month follow-up period, the patient was disease free. Even after many years of negative follow up, gynecologists should be aware of the possibility that abnormal uterine bleeding could represent the clinical expression of metastatic melanoma in order to offer a prompt diagnosis and a personalized strategy of treatment.