Anna Myriam Perrone

Accuracy of three-dimensional ultrasound in diagnosis and classification of congenital uterine anomalies

OBJECTIVE To assess the accuracy of three-dimensional (3D) ultrasound in the diagnosis of congenital uterine anomalies. DESIGN Prospective study. SETTING University hospital. PATIENT(S) Nulliparae with three or more consecutive miscarriages. INTERVENTION(S) All women underwent 3D transvaginal ultrasound study of the uterine cavity. MAIN OUTCOME MEASURE(S) Women with negative ultrasound findings subsequently underwent office hysteroscopy, whereas a combined laparoscopic-hysteroscopic assessment was performed in cases of suspected Müllerian anomaly. RESULT(S) A specific Müllerian malformation was sonographically diagnosed in 54 women of the 284 included in the study group. All negative ultrasound findings were confirmed at office hysteroscopy. Among the women with abnormal ultrasound findings, the presence of a Müllerian anomaly was endoscopically confirmed in all. Concordance between ultrasound and endoscopy around the type of anomaly was verified in 52 cases, including all those with septate uterus and two out of three with bicornuate uterus. CONCLUSION(S) Volume transvaginal ultrasound appears to be extremely accurate for the diagnosis and classification of congenital uterine anomalies and may conveniently become the only mandatory step in the assessment of the uterine cavity in patients with a history of recurrent miscarriage.

Cervical and hysteroscopic injection for identification of sentinel lymph node in endometrial cancer

OBJECTIVES The aims of our study were to evaluate the possibility of identifying the sentinel lymph node (SLN) in patients with endometrial cancer (EC) and to directly compare two injection techniques, cervical and hysteroscopic injection. METHODS Fifty-four patients with endometrial carcinoma, clinical stages I and II, were submitted to complete surgical staging through laparoscopy, as recommended by FIGO in 1988. For the mapping procedure the patients were divided into two groups of injection: the cervical injection group and hysteroscopic injection group. Technetium (Tc) 99m radiocolloid was used as tracer. RESULTS Intraoperative detection rate of SLN was 70% in cervical group and 65% in the hysteroscopic group (p=n.s.). In the cervical group, all patients had SLN in the pelvis only and the mean SLN removed was 18 (range 2-26). In the hysteroscopic group, all patients had SNLs in the pelvis and two patients had SLN both in the pelvis and above the bifurcation of the aorta. Mean pelvic SLN removed was 20 (range 8-42). CONCLUSIONS Our data shows that it is possible to identify the SLN in tumours of the endometrium. Both cervical and hysteroscopic techniques are feasible but the hysteroscopic procedure might represent the only method able to highlight the complete lymphatic drainage of the uterus as suggested by the presence of paraaortic positive SLN only in this group.

Effect of Long‐Term Testosterone Administration on the Endometrium of Female‐to‐Male (FtM) Transsexuals

INTRODUCTION Long term safety of testosterone (T) administration in women is still unknown. In particular few and discordant data exists on the effects of T on the endometrium. AIM The aim of this study was to investigate the effects of long-term T treatment on endometrium histology and proliferation in female to male transsexual subjects (FtM). We compared these endometria with those of young women in the proliferative phase (PM) of the cycle and with those of post menopausal women (M). METHOD Endometrial samples from 27 FtM treated with T (intramuscular injection of 100 mg Testoviron Depot /10 days for at least one year), 30 M undergoing vaginal hysterectomy, and 13 PM undergoing hysteroscopy for infertility problems were collected. Endometrial proliferation was evaluated on the basis of histopathology and expression of the proliferation marker Ki-67. Both M and PM women had not received any hormonal treatment for at least one year. MAIN OUTCOME MEASURE Circulating total testosterone (TT), estradiol (E), progesterone (P), insulin and glucose levels were measured in FtM and PM subjects. RESULTS FtM had received T for 33.6 +/- 21.3 months (mean +/- SD). In FtM subjects, histological analysis found inactive endometrium similar to the atrophic menopausal endometrium. The expression of Ki-67 in the glands, stroma and glands and stroma together was significantly (p < 0.0005) lower in FtM than in PM women and was similar in the FtM and M groups. Small polyps were detected in 5 of the 27 FtM subjects. CONCLUSIONS In conclusion our data suggest that exogenous T administration does not stimulate endometrial proliferation in FtM transsexuals and indeed may have atrophic effects.

Effects of Testosterone Undecanoate Administered Alone or in Combination with Letrozole or Dutasteride in Female to Male Transsexuals

INTRODUCTION Testosterone undecanoate (TU) has potential as androgen therapy for ovariectomized female to male (FtM) transsexual subjects; however, the long-term physiologic effects of TU treatment, the significance of testosterone (T), and the T metabolites dihydrotestosterone (DHT) and estradiol (E) on specific outcome parameters are currently unknown. AIM The aim of this study was to investigate the long-term treatment of TU with regard to bone metabolism, body composition, and lipid profile in FtM subjects, and to evaluate the relationship between observed effects and circulating levels of T, E, and DHT. MAIN OUTCOME MEASURES Circulating follicle-stimulating hormone, luteinizing hormone, T, E, DHT, and lipid concentrations were measured, as well as bone metabolism, body composition, and insulin resistance. METHODS This was a 1-year, randomized treatment, open-label, uncontrolled safety study. Fifteen ovariectomized FtM subjects from an outpatient clinic were divided into three groups to receive TU 1,000 mg alone or in combination with oral administration of letrozole (L) 2.5 mg/die or dutasteride (D) 0.5 mg/die for a period of 54 weeks. RESULTS TU alone and TU + D treatments were successful in terms of hormone adjustment, did not result in any adverse effects, and were well-tolerated. Bone mineral density decreased by an average of 0.9 g/cm(2) in the TU + L group, and the addition of D resulted in a failure to gain lean mass. CONCLUSIONS This study confirmed that TU is a successful and safe treatment for FtM subjects. These data indicate that E has an important role in bone metabolism and that DHT may play a role in muscle metabolism.

BRCA-Associated Ovarian Cancer: From Molecular Genetics to Risk Management

Ovarian cancer (OC) mostly arises sporadically, but a fraction of cases are associated with mutations in BRCA1 and BRCA2 genes. The presence of a BRCA mutation in OC patients has been suggested as a prognostic and predictive factor. In addition, the identification of asymptomatic carriers of such mutations offers an unprecedented opportunity for OC prevention. This review is aimed at exploring the current knowledge on epidemiological and molecular aspects of BRCA-associated OC predisposition, on pathology and clinical behavior of OC occurring in BRCA mutation carriers, and on the available options for managing asymptomatic carriers.

The Impairment of Sexual Function Is Less Distressing for Menopausal than for Premenopausal Women

INTRODUCTION Menopause requires psychological and physical adjustments because of the occurring significant hormonal changes. Sexuality is one of the aspects that undergoes the most profound modifications. Preliminary data suggest that sometimes women do not regard sexual changes as problematic and often readjust their life and relationship according to their new physical status. AIM The aim of our study was to evaluate sexual function and the way women feel by comparing healthy postmenopausal and premenopausal women. METHODS One hundred menopausal (M) and 100 premenopausal (pM) healthy women were asked to complete anonymous questionnaires to assess sexual function and stress related to sexual activity. MAIN OUTCOME MEASURES Female Sexual Function Index (FSFI), Female Sexual Distress Scale (FSDS) were completed by M and pM women. Results. Medium FSFI score was 20.5 +/- 9.6 and 26.4 +/- 7.7 (P < 0.0005) and medium FSDS score was 12.1 +/- 11.7 (95% CI 9.7-14.4) and 11.3 +/- 10.2 (P = 0.917) for M and pM women, respectively. Twenty-five of the 69 M women and 20 of the 31 pM women with a pathological score in the FSFI questionnaire scored higher than 15 in the FSDS (P < 0.0005). The overall prevalence of sexual dysfunction was 20% and 25% (P = 0.5) in the M and pM women. CONCLUSIONS Our data confirm that menopause is associated with changes in sexual function that may be compatible with sexual dysfunction. However, personal distress caused by these changes in sexual life appears to be lower among menopausal women (36.2%) as compared with premenopausal women (64.5%). These data suggest that medical treatment for sexual health in menopause must be highly personalized and carefully prescribed.

Mitochondrial DNA Mutation in Serous Ovarian Cancer: Implications for Mitochondria-Coded Genes in Chemoresistance

Case Report A69-year-oldwomansufferingdyspneaandwidespreadabdominal pain was admitted. Preliminary tests detected mild anemia, leukocytosis, and high levels of CA125 (2,200 U/mL). Abdominal-pelvic ultrasound scan, toraco-abdominal computer tomography (CT) and positron emission tomography (PET) indicated a gastric expansive mass together with two adherent pelvic solid masses, vascularized, strictly contiguous to bowel, omental cake, peritoneal carcinomatosis marks and ascites (Figs 1A and 1C; Figs 1E and 1G, arrows). Esophageal-gastric duodenoscopy was normal. CT-guided biopsy of the pelvic masses led to diagnose a poorly differentiated ovarian carcinoma in July 2010. A six-cycle carboplatin-paclitaxel chemotherapy was administered from August 2010 to December 2010. Radiological CT and PET at the end of the chemotherapyshowednearlycomplete response(Figs1Band1D;1Fand 1H). Diagnostic laparoscopy confirmed the absence of peritoneal carcinomatosis and suggested that surgery had become feasible. In March 2011, the patient was submitted to hysterectomy with bilateral annessiectomy, pelvic and lomboartic lymphadenectomy, omentectomy and peritoneal biopsies with complete macroscopical removal of disease. The histologicalreportshowedpersistenceofmicroscopicfociofdisease inthe ovaries (G3serouspapillaryadenocarcinoma),with lymphnodes,omentum and peritoneum free from disease. No adjuvant chemotherapy was administered because the patient had received six full courses of preoperativechemotherapyandnomacroscopicdiseasewaspresentaftersurgery. The patient was enrolled in the Mitochondria in Progression of Endometrial and Ovarian Cancer (MiPEO) study approved by the local ethical committee at S. Orsola Hospital, Bologna. Signed informed consent was obtained. She was subjected to regular follow-ups every 4 months with CT, pelvic ultrasound, and test of CA125. With the aim to characterize the residual chemoresistant ovarian cancer, hematoxylin/eosin staining showed a clear-cut oncocytic component, undetected in the prechemotherapy biopsy. Therefore, the acquisition of oncocytic change was observed exclusively in the ovarian cancer tissueresidualafterchemotherapy(Fig2).Wehavepreviouslyshownthat mitochondrial DNA (mtDNA) mutations in respiratory complex I (CI) genes are markers of oncocytic transformation, which cause CI derangement and, consequently, impairment of mitochondrial respiration. In order to understand whether mtDNA mutations and CI disassembly underlay the oncocytic phenotype, whole mtDNA sequencing was performed. Sequence analysis revealed the presence of m.10875T C missense mutation of a conserved residue (p.39Leu Pro) in the MTND4 gene encoding a CI subunit (Figs 3 and 4 [boxed in red in Fig 4]). The mutation was nearly homoplasmic, although a minor contamination withadjacentnontumortissuecouldnotbecompletelyruledout.Predictor of amino acid change pathogenic potential PolyPhen2 revealed the mutation to be probably damaging. Proof of pathogenicity was obtained through negative immunohistochemistry (IHC) staining of nuclearencoded CI subunit NDUFB8, which does not integrate within the complex when ND4 is lacking (Fig 2). In order to ascertain that the mtDNA disruptive mutation had accumulated postchemotherapy, normal and prechemotherapy tissues were screened for the same mutation, which was shown to be absent (Fig 3). In order to exclude the presence of a possible low-level heteroplasmy, a sensitive locked nucleic acid–based technique with a detection limit of 0.1% was implemented. Green squares represent standard curve samples (slope: 3.364; r 0.995; PCR efficiency: 97%). Wild-type control is circled in black and prechemotherapy sample in red. Absence of the mutation in prechemotherapy and in nontumor tissue was confirmed (Fig 5), indicating that the homoplasmic m.10875T Cwasapostchemotherapy-specificevent,consistentwiththe NDUFB8-positive staining of prechemotherapy tissue (Fig 2). Concordantly with the previously determined correlation between the occurrence of mtDNA mutations and low proliferation of oncocytic tumors, Ki67 of the postchemotherapy mass was nearly zero (Fig 6). Next, we sought to determine whether the residual mass had retained the original pro-oncogenic lesions, in order to ascertain a modifier role for the MTND4 mutation in keeping the chemoresistant clone under alow-proliferativeconstraint.Screeningofoncogenesfrequentlyinvolved in ovarian carcinogenesis, namely KRAS, BRAF, CTNNB1, PIK3CA, ERBB2 and AKT1 did not reveal mutations. Screening of tumor suppressor genes TP53 and PTEN identified a TP53 pathogenic heterozygous p.220Y C mutation both in preand postchemotherapic tissue, but not in the nontumor lymph node (Fig 7). Moreover, the homozygous TP53 p.72P R variant detected in all three samples (Fig 7) was previously reported to render TP53 a sensitive target for oncogenic protein E6 of human papilloma virus strain 16 (HPV16), occasionally associated with ovarian carcinoma. HPV16 was indeed detected both in tumor and in thenontumorlymphnodeofthepatientas it isevidentfromalignmentof detected amino acidic viral sequence (Fig 8). These data suggested cell transformation was due to the viral oncogenic properties in combination with the TP53 mutations.

Mitochondrial DNA genotyping efficiently reveals clonality of synchronous endometrial and ovarian cancers.

Simultaneous independent primary tumors of the female genital tract occur in 1–2% of gynecological cancer patients, 50–70% of which are synchronous tumors of the endometrium and ovary. Recognition of synchrony upon multiple tumors is crucial for correct prognosis, therapeutic choice, and patient management. Current guidelines for determining synchrony, based on surgical and histopathological findings, are often ambiguous and may require further molecular analyses. However, because of the uniqueness of each tumor and of its intrinsic heterogeneity, these analyses may sometimes be inconclusive. A role for mitochondrial DNA genotyping was previously demonstrated in the diagnosis of synchronous endometrial and ovarian carcinoma. We have analyzed 11 sample pairs of simultaneously revealed endometrial and ovarian cancers and have thereby applied conventional histopathological criteria, current molecular analyses (microsatellite instability, β-catenin immunohistochemical staining/CTNNB1 mutation screening), and mitochondrial DNA sequencing to distinguish separate independent tumors from metastases, comparing the performance and the informative potential of such methods. We have demonstrated that in ambiguous interpretations where histopathological criteria and canonical molecular methods fail to be conclusive, mitochondrial DNA analysis may act as a needle of balance and allow to formulate a diagnosis in 45.5% of our cases. Additional advantages of mitochondrial DNA genotyping, besides the high level of information we demonstrated here, are the easy implementation and the need for small amounts of starting material. Our results show that mitochondrial DNA genotyping may provide a substantial contribution to indisputably recognize the metastatic nature of simultaneously detected endometrial and ovarian cancers and may change the final staging and clinical management of these patients.

Electrochemotherapy can be used as palliative treatment in patients with repeated loco-regional recurrence of squamous vulvar cancer: a preliminary study

OBJECTIVE Electrochemotherapy (ECT) is an attractive treatment for solid cutaneous tumours with a good response rate (55-92%). No studies have evaluated ECT performed in vulvar cancer. The aim of our study was to evaluate the safety, local tumour efficacy and relief of symptoms of ECT treatment in patients affected by recurrence of squamocellular vulvar cancer (V-SCC) unsuitable for standard treatments. METHODS We enrolled nine patients with histological diagnosis of recurrence of V-SCC. Intravenous bleomycin was injected under general sedation after an accurate mapping of all lesions and ECT was performed. Patients were reviewed after one, three and six months. Response to therapy was evaluated using RECIST criteria and quality of life (QoL) was evaluated via questionnaires. RESULTS The median age was 84 years (range 80-90 years). The main location of recurrences was the vulva (87.5%). Multiple lesions were present in 25% of cases. No peri-operative complications were observed. Response to therapy was complete in 62.5% of patients, partial in 12.5%, no change was observed in 12.5% and progression of disease in 12.5% of patients respectively. Evaluation of symptoms showed a significant reduction of pain, bleeding, odour (p < 0.04) and urinary discomfort (p < 0.04). We observed two relapses at four and seven months after treatment. After nine months fifty percent of patients were alive. CONCLUSIONS Our preliminary study showed that ECT is a suitable procedure in elderly patients with loco-regional vulvar cancer relapses. ECT can be used as palliative therapy and the treatment relieves symptoms and improves QoL.

Hysterectomy and Bilateral Salpingoovariectomy in a Transsexual Subject without Visible Scaring.

Objective. To report on the use of laparoendoscopic single-site surgery (LESS) for the management of total hysterectomy (TH) with bilateral salpingoovariectomy (BSO) in a subject affected by gender identity disorder. Design. Case report. Setting. University Hospital. Patient(s). A 27-year-old affected by Gender Identity Disorder underwent a hysterectomy and BSO as part of surgical sex reassignment. Intervention(s). Laparoendoscopic single-site surgery access for TH and BSO. Main Outcome Measure(s). The procedure was performed without incident. The trocar placement was easy and safe, without inadvertent port removal. No vascular or visceral injuries, loss of pneumoperitoneum, or intraoperative port site bleeding occurred. Result(s). A detailed description of the technique of a single-site surgery for management of hysterectomy and BSO. Conclusion. Our case presents the first report of single-site surgery for surgical treatment of subjects affected by GID.