Clinical and ultrasonographic characteristics of pregnancy-related enhanced myometrial vascularity: prospective cohort study.

OBJECTIVES: To assess the ultrasonographic, epidemiological, clinical and evolutive characteristics of enhanced myometrial vascularity (EMV) following a first-trimester termination of pregnancy (TOP) or management of non-viable pregnancy. METHODS: This prospective study included women who underwent follow-up ultrasound examination 5-6 weeks after a first-trimester TOP or after management of a first-trimester non-viable pregnancy at the University Hospital Polyclinic San Martino of Genoa between March 2021 and March 2022. EMV was characterized using two- and three-dimensional ultrasound and Virtual Organ Computer-aided Analysis. Ultrasonographic diagnosis of EMV was made when an unusual, tortuous myometrial vessel structure, with high-velocity blood flow, protruding towards the endometrium was observed, while an abnormal junctional zone, absent endometrial midline and heterogeneous endometrium supported the diagnosis. Patients with EMV underwent expectant management with planned ultrasonographic follow-up every 2 weeks until resolution. RESULTS: During the study period, 305 women underwent TOP, of whom 132 attended the initial follow-up 5-6 weeks later, at which 52 were diagnosed with EMV. Ninety-six women were managed for a non-viable pregnancy, of whom 32 presented for follow-up, at which six had a diagnosis of EMV. Thus, overall, 164 of 401 women were included in the study and EMV was identified in 58 (35%) of these. The prevalence of EMV 5-6 weeks after a TOP was therefore between 52/305 (17%) and 52/132 (39%), and that after management of a non-viable pregnancy was between 6/96 (6%) and 6/32 (19%). Bleeding/pelvic pain was present in half (29/58) of the women with EMV, and serum human chorionic gonadotropin was detectable in 29% (17/58) at the first follow-up examination. At ultrasound assessment, all cases with EMV presented abundant tortuous myometrial vessels with high-velocity flow projecting from the myometrium towards the endometrium, along with non-uniform heterogeneous endometrium in 97% of cases, which often (67% of these) contained cystic areas, absence of the endometrial midline in 98% of cases and an abnormal junctional zone in 97% of cases (64% interrupted, 33% irregular). Most (67%) women with EMV were parous and 90% of them had undergone TOP rather than management for a non-viable pregnancy. Medical management of the TOP or non-viable pregnancy was more frequent in women with than those without EMV (93% vs 77%, P = 0.023). Multiple regression analysis showed the risk of EMV to be increased following TOP vs non-viable pregnancy (odds ratio (OR), 3.67 (95% CI, 1.16-11.56), P = 0.026) and in parous compared with nulliparous women (OR, 2.95 (95% CI, 1.45-6.01), P = 0.002). All women with EMV underwent expectant management. Eleven women did not return for subsequent follow-up examinations and did not present to our outpatient or emergency facilities, so were lost to further follow-up. Spontaneous resolution of the lesion was observed within 7-16 weeks after the procedure in 96% (45/47) of the remaining cases. Two women chose to undergo surgery for pelvic discomfort, and histology showed the presence of neovessels mixed with retained chorionic villi. CONCLUSION: EMV is a transient and common finding 5-6 weeks following first-trimester TOP or management of non-viable pregnancy. TOP and being parous are risk factors for EMV. Expectant management of EMV is appropriate, because, in almost all cases, this resolves spontaneously, without complications, within 2-4 months. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

The sentinel lymph node biopsy for breast cancer over the years.

The sentinel lymph node biopsy (SLNB) has progressively substituted complete axillary lymph node dissection (CALND), and has dramatically changed breast surgery impact on women's psychophysical wellness, reducing surgical morbidity while granting an adequate nodal staging. The present authors have seen a gradual improvement in the technique in order to reduce both surgical time and the number of interventions required, in particular with the intraoperative histological examination of sentinel node. Anyway, there is still great debate about the predictability of axillary nodal status in case of negative SLNB, as well as in case of positive one. Therefore, the authors reviewed the SLNB history and discussed its controversial points.

Isolated axillary nodal swelling and cancer of unknown primary.

INTRODUCTION: The literature reports rare cases of isolated axillary lymph node metastasis from cancer of unknown primary (CUP). The authors reviewed the prevalence and outcome of patients with isolated axillary nodal swelling suspicious for malignancy affected or not by isolated axillary node metastasis from CUP. MATERIALS AND METHODS: The authors collected data about 65 patients presented with isolated axillary lymph node swelling who underwent axillary lymph node excisional biopsy for malignancy suspicion, between January 2005 and December 2011, in the absence of any specific diagnosis. RESULTS: Histological examination revealed a metastatic infiltration by an occult solid cancer in 16 cases (24%), ten of which were occult breast cancers. Histological patterns and molecular markers allowed in all cases of occult cancer a probable identification of the primary tumor site, while a definitive diagnosis was possible only in the 56.25% of cases (9/16). The prognosis of these patients was very poor with a five-year overall survival of 28%, and thus very similar to patients affected by Stage IV overt breast cancer. CONCLUSIONS: Among occult malignancies presenting with sole axillary lymph node metastasis, breast cancer remains the more probable primary cancer, but many other sites should be taken into consideration by negative breast imaging. Positron-emission tomography computed tomography (PET-CT) resulted helpful in the primary site detection, but has nonetheless a margin of failure. Occult breast cancers behave very similar to Stage IV overt breast cancers, and should be treated accordingly.

New surgical trends in breast cancer treatment: conservative interventions and oncoplastic breast surgery.

AIM: From radical mastectomy by Halstedt to quadrantectomy by Veronesi, surgical treatment of breast cancer has become more and more conservative in order to preserve women quality of life. We analyzed the evolution of breast interventions through a nine-year period. METHODS: We collected data about all breast surgery interventions performed between 2002 and 2010 in our Department Of Surgery, focusing on patients' age, tumor histology, TNM classification, hormonal status, intervention radicality on the breast and axilla, and eventual plastic surgery. Data were analyzed by R (version 2.14.2), considering significant P<0.05. RESULTS: A total of 3320 breast surgery interventions were performed on 2300 patients. Absolute yearly number of interventions has strongly increased with the introduction of the mammography screening (291 to 430). Conservative breast surgery (55% to 62%) and skin-sparing mastectomy (1% to 8%) have been performed more frequently in premenopausal patients, and significantly increased in time, with a consequent decrease of classical radical mastectomy (38 to 15%) but an increase of margins widening after primary surgery (2% to 6%). Sentinel lymph node biopsy is mostly replacing complete axillary lymph node dissection (93% to 31%). Skin-glandular reshaping progressively increased (up to 20%) as also breast reconstruction (23% to 40%), which since 2008 has been performed also in women older than 75 years, while flaps have been used in strictly selected patients. CONCLUSION: Conservative surgery represents the target of current breast cancer treatment where possible, and skin-sparing mastectomy an interesting alternative to classical one when radicality is required. Sentinel lymph node biopsy has replaced complete axillary lymph node dissection by clinically negative nodal status. Breast reshaping and reconstruction are increasing in every age group, including women older than 75 years.

Breast-feeding and benign breast disease.

Benign breast disease (BBD) is very common among women in their fertile age, but its correlation with breast reproductive function remains unclear. Our study aimed to investigate the relation between BBD and breast-feeding. We collected data on 105 women with BBD and 98 controls, focusing on their reproductive history and breast-feeding. We analysed data by R (version 2.12.1) considering p < 0.05 as significant. The results showed that fibroadenoma represented the most frequent BBD (55%), followed by fibrocystic changes (19%), intraductal papilloma (6%) and inflammatory breast disorders (5%). The mean age was 31.5 years (± 6.1), BMI 21.2 kg/m² (± 3.4) and age at menarche 13.0 years (± 1.5). Duration of breast-feeding was not significantly different between controls and BBD types (p = NS). Selecting women with fibroadenoma breast-feeding duration directly correlated with the number of benign lesions (p < 0.05), which remains significant also by multivariate analysis. It was concluded that there seemed to be no difference in breast-feeding among BBDs types, but lactation may influence the number of fibroadenomas. Moreover, prospective studies would better define the correlation between lactation and BBDs.

Fertility in women survivors of hematological malignancies: what is the real role of GnRH analogue treatment?

PURPOSE OF INVESTIGATION: The aim of this study was to evaluate the ovarian function in women who received or not gonadotropin-releasing hormone (GnRH) analogue co-treatment compared to the control group that did not receive it. MATERIALS AND METHODS: This study analyzed 124 patients affected by hematological diseases between 1998 and 2007. The data were analyzed using R (v 2.9.1). RESULTS: In the women treated with GnRH analogue, the authors found 33% post-treatment secondary amenorrhea and 6% had a pregnancy post-treatment, while in the other group the prevalence were respectively 49% and 4% (p n.s.). Moreover, in multivariate analysis the authors found bone marrow transplantation to be a risk factor for secondary amenorrhea, while the association of chemotherapy with radiotherapy was a protective factor (p < 0.05). Finally, none of the considered factors were predictive of pregnancy achievement post-treatment. CONCLUSIONS: The authors found no statistical evidence to support that Gn-RH analogue treatment preserves ovarian follicular reserve during hematologic cancer treatment, but more evidence must be obtained.

Risk factors for chronic pelvic pain in a cohort of primipara and secondipara at one year after delivery: association of chronic pelvic pain with autoimmune pathologies.

AIM: Over genetic and obsteteric factors, also autoimmunity may be involved in female chronic pelvic pain (CPP) pathogenesis. Our study aims to determinate the prevalence of CPP after one year from delivery, and to investigate the possible influence on CPP of concomitant autoimmune conditions. Methods. We selected a cohort of caucasian primipara and secondipara who delivered in our clinic in 2006. We collected personal, clinical and obstetric data, and asked them about pelviperineal painful symptoms. Results. Mean maternal age is 35.52 years (±4.70), 27.65% of women delivered by cesarean section, 61.04% spontaneously and 11.32% by operative assistance, with partoanalgesia in 10.39% of cases, episiotomy in 41.19%, vaginoperineal tears in respectively 14.10% I degree, 11.13% II degree and 0.93% III-IV degree; 43.60% of women have ever undergone abdominopelvic surgery, 32.84% by laparotomy-laparoscopy, 7.05% by hysteroscopy, 5.01% limited to perineum. Chronic autoimmune diseases affect 78.48% of women, allergies 7.79%, rheumatic pathologies 1.3%, autoimmune endocrinopathies 71.8%; 26.53% of women report pelviperineal painful symptoms, being already present in 2.23% of cases, 12.43% generalised pelvic pain, 4.27% bladder pain, 2.60% vulvodynia, 17. 07% dyspareunia. By monovariate analysis CPP results influenced by III-IV degree vaginoperineal tears, operative assistance, preexisting CPP, previous and actual urinary incontinence, previous abdominopelvic surgical interventions and chronic rheumatic pathologies. Furthermore, rheumatic disease, operative assistance and previous CPP are predictive factors for CPP in the postpartum (AUC=58.10%). Conclusion. Delivery may highlight CPP symptoms in predisposed women affected by chronic autoimmune pathologies.

[Intrauterine growth restriction and pregnancy outcome]. / Ritardo di accrescimento intrauterino e outcome della gravidanza.

AIM: This prospective study was performed to evaluate perinatal outcome and maternal risk factors in pregnancies complicated by fetal intrauterine growth restriction (IUGR). METHODS: A total of 3 537 women pregnant with a singleton gestation were enrolled in the study: 219 of these pregnancies were complicated by fetal growth restriction (6.2%). Statistical analysis was performed using Wilcoxon test, Kruskall-Wallis test, c2 analysis of variance and ANOVA test. Statistical significance was set at P-value <0.05. Correlations were calculated by Spearman's coefficient. RESULTS: Ethnic group, physical demanding work, maternal smoking, alcohol abuse do not seem to be associated with lower birth weight and worse Apgar score. Sonographic assessment of fetal weight obtained by Hadlock's formula underestimate real newborn's weight. The difference between estimate weight and real weight is statistically significant. Women with intrauterine growth restriction underwent caesarean sections more often than women with appropriate fetal growth selected as controls (P<0.05). CONCLUSION: In conclusion, the obstetrician must recognize and accurately diagnose inadequate fetal growth and attempt to determine its cause (especially placental factors) in order to reduce fetal and maternal risks and establish the appropriate clinical management, timing and mode of delivery. If the growth-restricted fetus is identified and appropriate management instituted, perinatal mortality can be reduced.