Ultrasound Appearance of Intravascular Uterine Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP): A Case Report.

A 43-year-old patient with a history of uterine fibromatosis was referred to our hospital for menometrorrhagia and pelvic pain. At the pelvic ultrasound, a highly-vascularized myometrial lesion in volumetric increase was described. An elongated, solid, hypoechoic, painless, and highly vascularized left parauterine mass was identified. On histological examination, a uterine smooth muscle tumor of uncertain malignant potential (STUMP) with intravascular invasion of the left uterine vein was diagnosed. The adnexa and peritoneum were free of disease. On a retrospective evaluation of the ultrasound images, we noticed that the intravascular lesion showed sonographic features comparable to the original mass. Moreover, the Color Doppler (CD) analysis revealed an interrupted blood flow within the left uterine vein. In this case, the ultrasound proved to be an accurate diagnostic tool. When inhomogeneous uterine masses are suspected, and a parauterine/paraadnexal mass surrounded by irregular vessels are identified, the sonographer should take into account a risk of intravascular invasion. The patency of uterine and ovarian vessels should be accurately evaluated, to guide a tailored patient surgical approach.

A misleading case of Müllerian anomaly: fibroid degeneration and growth involving nonfunctional, noncommunicating rudimentary horn.

OBJECTIVE: To report a rare, misleading fibroid degeneration involving a nonfunctional, noncommunicating horn in a woman with a unicornuate uterus. Although the presence of a functional rudimentary horn may lead to signs and symptoms that recommend its removal, nonfunctional cases are rarely reported, and because of their apparent functional inactivity, the need for their removal has not yet been reported. No previous report showed the possibility of a degenerative process in a nonfunctional rudimentary horn causing patient discomfort. DESIGN: This is a step-by-step narrated video showing a unique case of fibroid degeneration and growth of a nonfunctional, noncommunicating rudimentary horn in a unicornuate uterus (American Society for Reproductive Medicine classification 2021) and its surgical management. SETTING: University academic hospital. PATIENT(S): A 48-year-old White nulliparous premenopausal woman was referred to our institution because of abdominal pain and an enlarging adnexal mass. Her personal history showed primary infertility with a previous diagnosis of unicornuate uterus. Given the possibility of ectopic ureters in these occurrences, complete computed tomography was performed, and no genitourinary alterations were found. Preoperative imaging (ultrasound evaluation, computed tomography, and magnetic resonance imaging) provided a provisional diagnosis of a suspicious ovarian fibroma. INTERVENTION(S): Considering the patient's age, lack of desire for pregnancy, and volumetric increase in the adnexal mass, a laparoscopic intervention to perform mass removal and prophylactic bilateral salpingectomy was planned. The patient was counseled about the low risk of an underlying malignant transformation. Therefore, the decision to remove the intact mass via a minilaparotomy at the end of the surgery was shared. Once the abdominal cavity was entered, the right unicornuate uterus was found in anatomical continuity with the ipsilateral broad ligament, fallopian tube, and ovary. These structures were wholly attached to the right pelvic wall. On the other side, cranially compared with the right hemiuterus, a roundish myoma-like mass was detected in direct connection with the left broad ligament, fallopian tube, and ovary. In light of a changed intraoperative finding, amputation of the left rudimentary horn and prophylactic bilateral salpingectomy were performed. MAIN OUTCOME MEASURE(S): Showing the fibroid degeneration and growth of a nonfunctional, noncommunicating rudimentary horn in a unicornuate uterus (American Society for Reproductive Medicine classification 2021) treated laparoscopically. RESULT(S): Laparoscopic removal of the uterine horn was successful, and no intraoperative and postoperative complications occurred. The patient was in good health at the 6-month follow-up visit. The histopathological examination confirmed the fibroid degeneration and absence of the endometrium. CONCLUSION(S): The lack of symptomatic cases of rudimentary nonfunctional horns reported in the literature led gynecologists to consider them a silent Müllerian anomaly. This unique case demonstrates that even nonfunctional rudimentary horns can undergo symptomatic transformation processes requiring surgery. This information may be helpful for more comprehensive counseling of women and for considering the possibility of this occurrence in the diagnostic workup of misleading Müllerian anomalies. With this in mind, surgical treatment can also be better planned as the technical aspects change compared with what is expected for an adnexal pathology.

Atypical Endometrial Hyperplasia and Concurrent Cancer: A Comprehensive Overview on a Challenging Clinical Condition.

The present review regarding atypical endometrial hyperplasia (AEH) focused on the main debated factors regarding this challenging clinical condition: (i) predictive variables of occult endometrial cancer (EC); (ii) the rate of EC underestimation according to different endometrial sampling methods; and (iii) the appropriateness of lymph node status assessment. When cancer is detected, approximately 90% of cases include low-risk EC, although intermediate/high-risk cases have been found in 10-13% of women with cancer. Older age, diabetes, high BMI, and increased endometrial thickness are the most recurrent factors in women with EC. However, the predictive power of these independent variables measured on internal validation sets showed disappointing results. Relative to endometrial sampling methods, hysteroscopic endometrial resection (Hys-res) provided the lowest EC underestimation, ranging between 6 and 11%. Further studies, including larger sample sizes of women undergoing Hys-res, are needed to confirm these findings. These data are urgently needed, especially for female candidates for conservative treatment. Finally, the evaluation of lymph node status measured on 660 of over 20,000 women showed a lymph node positivity of 2.3%. Although there has been an increase in the use of this procedure in AEH in recent years, the present data cannot recommend this option in AEH based on a cost/risk/benefit ratio.

HPV-Negative Adenocarcinomas of the Uterine Cervix: From Molecular Characterization to Clinical Implications.

Cervical cancer is the fourth most common cancer in women. It is the leading cause of female deaths in developing countries. Most of these cervical neoplasms are represented by squamous lesions. Cervical adenocarcinoma causes about a quarter of cervical cancers. In contrast to squamous lesions, cervical glandular disease is HPV-negative in about 15-20% of cases. HPV-negative cervical adenocarcinomas typically present in advanced stages at clinical evaluation, resulting in a poorer prognosis. The overall and disease-free survival of glandular lesions is lower than that of squamous lesions. Treatment options require definitive treatments, as fertility-sparing is not recommended. Moreover, the impact of HPV vaccination and primary HPV screening is likely to affect these lesions less; hence, the interest in this challenging topic for clinical practice. An updated review focusing on clinical and molecular characterization, prognostic factors, and therapeutic options may be helpful for properly managing such cervical lesions.

Is Dual Mobility Total Hip Arthroplasty Surgery More Aggressive than Hemiarthroplasty when Treating Femoral Neck Fracture in the Elderly? A Multicentric Retrospective Study on 302 Hips.

INTRODUCTION: Bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) are validated treatments for displaced femoral neck fractures (DFNFs). BHA seldomly needs conversion to THA, but the latter has higher dislocation rate in FNFs. Dual Mobility THA offers a reduced dislocation rate and eliminates the risk of conversion. This study looks for differences between BHA and DMTHA in terms of surgical time, blood loss and transfusion, dislocation rate, mortality, and thromboembolic events. MATERIAL AND METHODS: All patients were ≥75yo. Recorded data included use of anticoagulant/antiplatelet drugs, ASA, operative time, intra-operative complications, pre/post-operative hemoglobin values, transfusions, hospitalization time, DVT/PE, glomerular filtration rate, Charlson Comorbidity Index (CCI), dislocation at 60 days, and mortality at 30 days and 6 months. A secondary analysis compared the subgroups in different age range (75-85 and ≥ 86yo). RESULTS: In the cohort of 302 DFNF (93 BHA and 209 DMTHA) differences in mean age, CCI, and ASA score were significant. Once divided by age, the subgroups resulted comparable in terms of age and CCI, with no significant difference. A significant difference in surgical times showed DMTHA being an average 12 minutes longer than BHA. Significant was the ΔHB in the DMTHA subgroup which resulted lower compared to the BHA one. Difference in mean number of post-operative transfusion were not statistically significant. CONCLUSIONS: From our data, DMTHA did not lead to an increase in mortality, morbidity, bleeding, or dislocation rate when compared to BHA and could be considered as treatment of choice for DFNFs especially in healthy and active patients.