Annalisa Pieralli

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.

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.

Feasibility of myomectomy performed by minilaparotomy

Background. To evaluate feasibility and clinical outcomes of myomectomy performed through minilaparotomic access in a large series of consecutive patients. Methods. All patients submitted to laparotomic conservative surgery for uterine myomas through an initial minilaparotomic approach (4–8‐cm transverse skin incision) were retrospectively evaluated. Preoperative findings, surgical technique, rate of laparotomic enlargement, operative time, surgical complications and length of recovery were the main analyzed outcomes. Results. One hundred and seventy out of 212 patients experienced minilaparotomic approach for uterine myomatosis. In 97 (57.1%) multiple myomas were present (maximum, 23). The size of the largest myoma ranged from 2 to 19 cm (median 5.6). In 161 (94.7%) patients myomectomy was ended through minilaparotomic access with a mean length of skin incision of 6.2 cm (4–7.8). The correlation between severe obesity and laparotomic enlargement was statistically significant (p<0.05). The mean operative time was 57 min (32–118). One bladder intraoperative injury was successfully managed through minilaparotomic incision. Bowel or vascular complications never occurred. Estimated blood loss was not significant except in three cases (1.9%) requiring transfusion. Febrile complications were observed in nine patients (5.6%). The median postoperative stay in uncomplicated patients was 2.5 days (2–4). Conclusions. Our report supports the wide application of minilaparotomic myomectomy and suggests that more than 85% of women with fit uterine myomatosis could be successfully managed in this way with a failure rate of 5.3% in eligible patients. The main criteria of minimal invasive surgery seem to be by minilaparotomic myomectomy, which should be considered a valid option for uterine myohas conservative treatment.

Clinical utility of liquid-based cytology for the characterization and management of endometrial polyps in postmenopausal age.

The proper management of endometrial polyps still represents a clinical ongoing challenge, especially when they are asymptomatic and occasionally discovered. The aim of this study was to evaluate liquid-based endometrial cytology to manage endometrial polyps in postmenopausal age by its ability to exclude hidden premalignant and malignant changes within polyps. Three hundred fifty-nine consecutive postmenopausal patients who underwent hysteroscopic diagnosis of endometrial polyp over a 3-year period and who were scheduled for surgical removal within the three subsequent months were retrospectively evaluated. Histologic results after resection during operative hysteroscopy or during hysterectomy were compared with liquid-based cytology and endometrial biopsy obtained at the time of diagnostic hysteroscopy. Eight of 359 patients (2.2%) had malignant or premalignant polyps interpreted as benign finding at hysteroscopy. Unsatisfactory samples were higher for endometrial biopsy compared to liquid-based cytology in the whole series and in the subgroup of low-risk asymptomatic patients (P< 0.001). Endometrial biopsy and liquid-based cytology revealed a sensitivity of 62% and 87.5%, respectively and a 100% specificity. Considering the subgroup of low-risk asymptomatic patients, liquid-based cytology disclosed all the five pathologic lesions with a 100% sensitivity and specificity. In conclusion, liquid-based cytology proved to be a useful tool to establish the nature of endometrial polyps in postmenopausal patients. Complete removal of the lesion should be offered to all symptomatic patients and those with established risk factors for endometrial cancer. Conversely, a wait and see attitude should be considered in case of asymptomatic low-risk polyps with typical appearance on hysteroscopy and negative liquid-based cytology.

Vulvar paget disease: a large single-centre experience on clinical presentation, surgical treatment, and long-term outcomes.

Objective Our aim was to add information to the current literature on vulvar Paget disease by reviewing a consistent number of patients who have been all diagnosed, treated, and followed up by the same group of physicians at a single medical institution. Methods Clinical, surgical, histological, and follow-up data of 34 patients (mean [SD] age at diagnosis = 68.7 [10.1] years) with vulvar Paget disease were reviewed during a 27-year period. Results Primary symptoms were itching (76.5%) and burning (58.8%). Clinical manifestations were present for a mean (SD) of 17.8 (7.2) months before the diagnosis was made. Multifocal lesions were observed in 17 patients (50%) and were associated with a delay in diagnosis exceeding 12 months (p = .03). Of the patients, 10 (29.4%) presented a history of malignancy in other sites. Surgery with various extent of resection was performed as primary treatment in all patients. Definitive histological examination revealed positive surgical margins in 15 cases (44.1%), stromal invasion in 4 (11.7%), and associated adenocarcinoma in 2 (5.9%). Of the patients, 6 (17.6%) underwent reconstructive technique at their primary surgery or radicalization. During a mean (SD) follow-up of 76.9 (51.3) months, 15 patients (44.1%) experienced local recurrence (1 recurrence in 29.4%, 2 recurrences in 5.9%, and 3 recurrences in 8.8%). First recurrence appeared after a mean (SD) time of 45.7 (25.1) months and was associated with multifocal lesions (p = 0.005) and surgical margins involvement (p = 0.03). One patient (2.6%) died of the disease. Conclusions Vulvar Paget disease is a chronic disease with high recurrence rate and low mortality. Early diagnosis, minimal surgery with free margins, and long-term follow-up are the cornerstones of treatment.

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.

Feasibility and outcome of laser CO2 conization performed within the 18th week of gestation

The purpose of this study is to evaluate the feasibility, safety, and potential therapeutic benefit of laser CO2 conization of the cervix for in situ and minimally invasive carcinoma diagnosed during pregnancy. Twenty-six pregnant patients with biopsy-proven carcinoma in situ/cervical intraepithelial neoplasia III but colposcopically suspicious for invasion underwent laser CO2 conization during the 18th week of gestation in an outpatient setting under local anesthesia. No major intraoperative or postoperative complications occurred, and cervical cerclage was not required in any case. Two cases (7.7%) of occult FIGO stage IA1 minimally invasive cervical cancers with free surgical margins were diagnosed. Both patients delivered vaginally at term and were free of disease at postpartum follow-up. Median length of gestation was 39.1 weeks with a median birth weight of 3450 g. All 1-min Apgar scores were 8 or greater. Twenty patients (76.9%) delivered vaginally, while six patients underwent cesarean section for indications not related to the prior conization. After a mean postpartum follow-up of 18 months (range 3–42), 92.3% of patients continued to have both cytologic and colposcopic evaluations negative for persistent or recurrent disease. Two cases of persistent intraepithelial disease were successfully managed by reconization. In summary, our data suggest that laser CO2 conization performed within the 18th week of gestation is safe for both the patient and the fetus, provides reliable histologic diagnosis, and can be curative. Further studies are required to confirm the favorable risk–benefit ratio of laser CO2 conization in the management of non-reassuring cervical lesions observed in the first half of pregnancy.

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.

Large-Muscle Endometriosis Involving the Adductor Tight Compartment: Case Report

Extrapelvic endometriosis is an uncommon condition but can involve nearly every organ, resulting in a wide range of clinical manifestations. Herein, we describe the case of a 45-year-old woman not a candidate for hormonal therapy who had cyclic pain in the left thigh associated with progressive impairment of walking ability. Clinical, instrumental, and laboratory data supported the diagnosis of endometriosis involving the adductor muscles compartment associated with ovarian endometriomas. Laparoscopic bilateral salpingo-oophorectomy and local wide excision in collaboration with an experienced orthopedic oncologist were performed, and definitive histologic analysis confirmed the diagnosis of endometriosis. The patient was pain-free at 6-month follow-up and demonstrated substantial improvement in ambulation and quality of life. Large-muscle endometriosis is a rare entity that can compromise musculoskeletal integrity and decrease quality of life. In this case, surgical excision in collaboration with an orthopedic oncologist was the cornerstone of treatment.

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.