Imaging modalities in fertility preservation in patients with gynecologic cancers.

Fertility preservation is an integral component of clinical decision-making and treatment design. However, the selection criteria on imaging for patients eligible for fertility preservation is still unclear. The present review aimed to summarize the main findings reported in both the literature and international guidelines on the role of imaging in the selection of patients for fertility preservation. A search strategy was developed and applied to PubMed, Scopus, Web of Science, and EMBASE to identify previous citations reporting imaging and fertility preservation in patients with gynecological cancer. We also retrieved the published guidelines on the eligibility criteria for fertility-sparing treatment of gynecological neoplasms. A description of the internal multidisciplinary guidelines, clinically in use in our institution, is provided with representative clinical cases. The literature review revealed 1291 articles and 18 of these were selected for the analysis. Both ultrasound and MRI represented the primary imaging methods for selecting patients for fertility preservation in cervical and endometrial cancers. Eligibility criteria of fertility-sparing management in patients with cervical cancer were: tumor size <2 cm, tumor distance from the internal os >1 cm, and no parametrium invasion. For patients with endometrial cancer, these included no myometrial and cervical stroma invasion. Both ultrasound and MRI play a key role in characterizing adnexal masses. These modalities provide a useful tool in identifying small ovarian lesions, thus key in the surveillance of patients after fertility sparing surgery. However, efficacy in excluding disease beyond the ovary remains limited. This review provides an update of the literature and schematic outline for the counseling and management of patients with the desire for fertility preservation.

Management of ASC-US/HPV positive post-menopausal woman.

BACKGROUND: The aim of our study was to determine which diagnostic course is best to identify women at risk of CIN2+ among post-menopausal women with cytological diagnosis of ASCUS METHODS: We selected women who had been post-menopausal for at least one year , and who had completed the entire diagnostic-therapeutic course that they had undertaken. The sample was divided into two arms: in the first arm, we considered 146 ASCUS positive women who had undergone the HPV test, colposcopy and then underwent more detailed diagnostics by means of LEEP or a scraping of the cervical canal. The second arm was made up of 124 ASCUS positive women who had undergone a vaginal administration of estriolo, the HPV test and colposcopy. Estriol was administered for 5 weeks: the first week one vaginal suppository every evening, the other four weeks the administration was twice a week. Then, the patients underwent colposcopy. In cases of positivity a biopsy was carried out, the patients positive for CIN2+ at the biopsy underwent excisional therapy using LEEP and were followed up. The patients, who were negative at colposcopy or with histological diagnosis of CIN1, were examined again at 1 year. RESULTS: In the first arm the HPV test had an SE of 94%, an SP of 68%, NPV of 99%, and PPV of 28%. The PPV is very low because of the elevated percentage of false positives that the HPV test gave (71%). In the second arm the HPV test maintained its high SE (100%), an SP of 74%, a NPV of 100%, and a PPV of 43%. The use of estrogen increased the specificity of the test. CONCLUSION: It is important to say that the second arm indicates the use of local estrogen therapy only for ASCUS/HPV positive postmenopausal women. Therefore, the HPV test should be used as the first diagnostic possibility in cases of ASCUS in post-menopausal women, associating local estrogen therapy only with HPV positive women.

Overexpression of E6/E7 mRNA HPV Is a Prognostic Biomarker for Residual Disease Progression in Women Undergoing LEEP for Cervical Intraepithelial Neoplasia 3.

The risk of overtreatment or not treating an occult carcinoma exists in women at risk of residual disease after a LEEP excision for CIN3. Our goal was to discover an efficient method to select patients requiring a second LEEP from those requiring a FU only through an mRNA-detection test. In a population of 686 women undergoing a LEEP excision for CIN 3, we selected 285 women at risk of residual disease and subjected them to a search for E6/E7 mRNA HPV. The women with negative mRNA were subjected to a follow up, while the women with positive mRNA were subjected to a second LEEP. The histological examination of the second cone revealed 120 (85.7%) cases of residual disease in the mRNA-positive women: 40 cases of CIN2, 51 cases of CIN3, 11 cases of squamous microinvasive carcinoma, 7 cases of squamous carcinoma, 9 cases of AIS (adenocarcinoma in situ) and 2 cases of adenocarcinoma. Among the mRNA-negative women undergoing a follow up, there were only five cases of residual disease. During the follow-up period of about 6 years, we witnessed the regression of the residual disease and the elimination of the virus, just as predicted by the negative result of the mRNA test. Testing patients for E6/E7 mRNA allowed us to identify women with residual disease (CIN2+) and treat them appropriately.

Robotic-assisted laparoscopic cervicouterine anastomosis in a patient with agenesis of the uterine isthmus.

OBJECTIVE: To demonstrate the surgical management of agenesis of the uterine isthmus. DESIGN: Stepwise description of robotic-assisted laparoscopic cervicouterine anastomosis. SETTING: Academic medical center. PATIENT(S): A 27-year-old nulligravida with primary amenorrhea and cyclic pelvic pain. INTERVENTION(S): The patient underwent a robot-assisted cervicouterine anastomosis using the following surgical steps: adhesiolysis of the right ovary from the rudimentary uterine horn; vesicouterine peritoneal fold dissection and mobilization of the cervical canal; the opening of the cervical canal and dilatation with Hegar dilators; longitudinal incision of the lower third of the anterior uterine wall up to the endometrial cavity; insertion of a 14 Ch Foley catheter, not inflated, fixed to the cervix with a suture and removed after 7 days; and closure of the cervicouterine breach with a double-layer Vicryl suture. Informed consent was obtained from the patient for the use of video and images. MAIN OUTCOME MEASURE(S): After 3 months, the patency of the anastomosis site was assessed via hysteroscopy. Subsequent follow-up was performed by referring physicians. RESULT(S): Postoperatively, anatomic continuity was restored and the patient was menstruating with regular monthly cycles; furthermore, cyclic pelvic pain was relieved. Few cases of this condition have been reported in the literature and, currently, surgical treatment of agenesis of the uterine isthmus is controversial, with some treatments including laparoscopic-assisted uterocervical anastomosis using a stent to prevent restenosis, primary cervicouterine anastomosis by laparotomy performed with a Foley catheter in the cervical canal, and anastomosis of the uterine isthmus agenesis. However, to our knowledge, we are the first to use a robotic approach. Preservation of reproductive function and symptom relief represent the goals of the surgery. Therefore, hysterectomy cannot be considered as a treatment option. However, after a cervicouterine anastomosis procedure, the normal uterine morphology cannot be achieved; cyclic abdominal pain may remain after surgical treatment. In this case, an alternative surgical approach, such as hysterectomy, can be considered. CONCLUSION(S): Robotic-assisted treatment of this uncommon müllerian anomaly is feasible and may be an alternative to hysterectomy in individuals who wish to preserve fertility. Follow-up is needed to evaluate fertility and reproductive function.

Incidental Diagnosis of Pseudomyxoma Peritonei: A Case Report.

Pseudomyxoma peritonei (PMP) is a rare clinical condition characterized by disseminating gelatinous ascites within the peritoneal cavity with mucinous implants on peritoneal surfaces. We present the case of a patient incidentally diagnosed after laparoscopy: definitive diagnosis after the histological examination was PMP. A 37-year-old female patient with a medical history of infertility and mild pelvic pain was found to have several collections in the pelvis and an amount of free fluid into the Douglas pouch at ultrasound examination. The patient underwent laparoscopic surgical exploration. Peritoneal biopsies and appendectomy were performed. Histological examination was about a low-grade appendiceal mucinous tumor limited to the mucosa without submucosal infiltration with perforation of the wall and deposit of periappendicular acellular mucin. The patient was discharged in good health and referred to an oncological peritoneal center where cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) were performed. In conclusion, PMP is an uncommon disease within the abdomen, characterized by a mucinous tumor that produces progressive mucinous ascites. It is characterized by various non-specific symptoms and signs and difficult imaging diagnoses. Histological diagnosis is a determinant to establish the therapy that can differ significantly, depending on the stage of the disease.

O potencial transformador do comum em saúde / The transformative potential of health as a Commons / El potencial transformador de lo común en salud

RESUMO A Itália foi um dos países participantes do projeto de pesquisa-ação multicêntrica do Movimento pela Saúde dos Povos (Peoples's Health Movement), chamado 'Engajamento da Sociedade Civil para a Saúde para Todos' (Civil Society Engagement for Health for All). A equipe italiana, um coletivo chamado Grup-pa, realizou várias atividades participativas de pesquisa-ação, incluindo, em uma primeira fase, um mapeamento de grupos ativos em áreas ligadas à determinação social da saúde e à promoção da saúde, através de entrevistas individuais e coletivas. Em uma segunda fase, três oficinas públicas, estruturadas em torno do intercâmbio de práticas, focalizaram-se em temas-chave surgidos durante a primeira fase. Um importante construto originado deste trabalho, centrado em torno da co-construção do conhecimento experiencial do comum em saúde, foi denominado 'práticas do comum em saúde'. O foco nas práticas não é meramente estratégico (produzir sinergias e alianças), mas inerentemente político (conceber a participação como um valor) e ligado à saúde e à manutenção da saúde (dos indivíduos; da comunidade). O conceito de 'práticas do comum em saúde' pretende tornar visível uma área de transformações contínuas em novos espaços criados pelos movimentos sociais e em ações mais tradicionais em defesa dos serviços públicos existentes, abordando a saúde como uma questão sociopolítica. Neste ensaio, esboça-se uma reflexão em torno de seis palavras-chave que lhe são centrais: comum, cuidado, tecnologia, eficácia, sustentabilidade, instituição.

ABSTRACT Italy was a participating country in the People's Health Movement multi-centred action-research project (Civil Society Engagement for Health for All). The Italian team, a collective named Grup-pa, undertook several participatory action-research activities including, in a first phase, a mapping of groups active in fields linked to the social determination of health and health promotion, through individual and collective interviews. In a second phase, three public workshops, structured around the exchange of practices, focused on key themes emerged from phase one. A major construct originated from this work, centred around the co-construction of experiential knowledge on health as a commons, has been named 'health commons practices'. The focus on practices is not merely strategic (producing synergies and alliances), but inherently political (conceiving participation as a value) and connected to health and staying healthy (as individuals; as a community). The construct of 'health commons practices' is meant to make visible an area of ongoing transformations in new spaces created by movements and in more traditional actions in defence of existing public services, addressing health as a socio-political issue. In this essay, we sketch the reflection around six keywords that are central to it: commons, care, technology, efficacy, sustainability, institution.

RESUMEN Italia fue uno de lo países que participó en el proyecto de investigación-acción multicentrico (Compromiso de la Sociedad Civil para la Salud para Todos) del People's Health Movement (Movimiento para la Salud de los Pueblos). El grupo italiano, un colectivo llamado Grup-pa, llevó a cabo varias actividades de investigación-acción participativas incluyendo, en una primera fase, un mapeo de los grupos activos en ámbitos vinculados a la determinación social de la salud y la promoción de la salud, mediante entrevistas individuales y colectivas. En una segunda fase, se organizaron tres talleres públicos, estructurados alrededor del intercambio de prácticas, se centraron en temas clave surgidos en la primera fase. Un constructo importante originado en este trabajo, centrado en la co-construcción de los conocimientos experienciales sobre salud en común, ha sido denominado 'prácticas de lo común en salud'. El enfoque en las prácticas no es meramente estratégico (para la producción de sinergias y alianzas), sino intrínsecamente político (concibiendo la participación como un valor) y conectado con la salud y el mantenerse saludable (sea individualmente que como comunidad). La construcción de 'prácticas de lo común en salud' pretende hacer visible un área de transformaciones que se están gestando en nuevos espacios creados por los movimientos y en acciones más tradicionales en defensa de los servicios públicos existentes, abordando la salud como una cuestión sociopolítica. En este ensayo, esbozamos la reflexión en torno a seis palabras clave que son centrales para ella: común, cuidado, tecnología, eficacia, sostenibilidad, institución.

O potencial transformador do comum em saúde / The transformative potential of health as a Commons / El potencial transformador de lo común en salud

RESUMO A Itália foi um dos países participantes do projeto de pesquisa-ação multicêntrica do Movimento pela Saúde dos Povos (Peoples's Health Movement), chamado 'Engajamento da Sociedade Civil para a Saúde para Todos' (Civil Society Engagement for Health for All). A equipe italiana, um coletivo chamado Grup-pa, realizou várias atividades participativas de pesquisa-ação, incluindo, em uma primeira fase, um mapeamento de grupos ativos em áreas ligadas à determinação social da saúde e à promoção da saúde, através de entrevistas individuais e coletivas. Em uma segunda fase, três oficinas públicas, estruturadas em torno do intercâmbio de práticas, focalizaram-se em temas-chave surgidos durante a primeira fase. Um importante construto originado deste trabalho, centrado em torno da co-construção do conhecimento experiencial do comum em saúde, foi denominado 'práticas do comum em saúde'. O foco nas práticas não é meramente estratégico (produzir sinergias e alianças), mas inerentemente político (conceber a participação como um valor) e ligado à saúde e à manutenção da saúde (dos indivíduos; da comunidade). O conceito de 'práticas do comum em saúde' pretende tornar visível uma área de transformações contínuas em novos espaços criados pelos movimentos sociais e em ações mais tradicionais em defesa dos serviços públicos existentes, abordando a saúde como uma questão sociopolítica. Neste ensaio, esboça-se uma reflexão em torno de seis palavras-chave que lhe são centrais: comum, cuidado, tecnologia, eficácia, sustentabilidade, instituição.

ABSTRACT Italy was a participating country in the People's Health Movement multi-centred action-research project (Civil Society Engagement for Health for All). The Italian team, a collective named Grup-pa, undertook several participatory action-research activities including, in a first phase, a mapping of groups active in fields linked to the social determination of health and health promotion, through individual and collective interviews. In a second phase, three public workshops, structured around the exchange of practices, focused on key themes emerged from phase one. A major construct originated from this work, centred around the co-construction of experiential knowledge on health as a commons, has been named 'health commons practices'. The focus on practices is not merely strategic (producing synergies and alliances), but inherently political (conceiving participation as a value) and connected to health and staying healthy (as individuals; as a community). The construct of 'health commons practices' is meant to make visible an area of ongoing transformations in new spaces created by movements and in more traditional actions in defence of existing public services, addressing health as a socio-political issue. In this essay, we sketch the reflection around six keywords that are central to it: commons, care, technology, efficacy, sustainability, institution.

RESUMEN Italia fue uno de lo países que participó en el proyecto de investigación-acción multicentrico (Compromiso de la Sociedad Civil para la Salud para Todos) del People's Health Movement (Movimiento para la Salud de los Pueblos). El grupo italiano, un colectivo llamado Grup-pa, llevó a cabo varias actividades de investigación-acción participativas incluyendo, en una primera fase, un mapeo de los grupos activos en ámbitos vinculados a la determinación social de la salud y la promoción de la salud, mediante entrevistas individuales y colectivas. En una segunda fase, se organizaron tres talleres públicos, estructurados alrededor del intercambio de prácticas, se centraron en temas clave surgidos en la primera fase. Un constructo importante originado en este trabajo, centrado en la co-construcción de los conocimientos experienciales sobre salud en común, ha sido denominado 'prácticas de lo común en salud'. El enfoque en las prácticas no es meramente estratégico (para la producción de sinergias y alianzas), sino intrínsecamente político (concibiendo la participación como un valor) y conectado con la salud y el mantenerse saludable (sea individualmente que como comunidad). La construcción de 'prácticas de lo común en salud' pretende hacer visible un área de transformaciones que se están gestando en nuevos espacios creados por los movimientos y en acciones más tradicionales en defensa de los servicios públicos existentes, abordando la salud como una cuestión sociopolítica. En este ensayo, esbozamos la reflexión en torno a seis palabras clave que son centrales para ella: común, cuidado, tecnología, eficacia, sostenibilidad, institución.