Specialista in Ginecologia e Ostetricia
1. Fetal Diagn Ther. 2020;47(3):171-181. Epub 2019 Oct 8.
The Utility of the Congenital Pulmonary Airway Malformation-Volume Ratio in the
Assessment of Fetal Echogenic Lung Lesions: A Systematic Review.
Although relatively uncommon, the incidence of fetal echogenic lung lesions - a
heterogeneous group of anomalies that includes congenital pulmonary airway
malformations (CPAM) and bronchopulmonary sequestrations (BPS) - has increased
recently. Two decades ago, the CPAM-volume ratio (CVR) was first described as a
tool to predict the development of hydrops, with this outcome found to be
unlikely in fetuses with CVRs of ≤1.6 cm2. Since then, no clear international
consensus has evolved as to the optimal CVR thresholds for the prediction of
fetal/neonatal outcomes. This systematic review aimed to assess all original
research studies that reported on the predictive utility of the CVR. Potentially
relevant papers were identified through searching for citations of the paper that
originally described the CVR, in addition to keyword searches of electronic
databases. Fifty-two original research papers were included in the final review.
Of these, 34 used the CVR for descriptive purposes only, 5 assessed the validity
of established thresholds in different populations, and 13 proposed new
thresholds. The evidence identified in this review would suggest that a threshold
much lower than 1.6 cm2 is likely to be of greater utility in most populations
for many outcomes of perinatal relevance. For neonatal outcomes (mostly
respiratory compromise at birth), a CVR on the initial ultrasound scan ranging
from 0.5 to 1.0 cm2 appears to have the greatest predictive value. Although a
number of studies concurred that 1.6 cm2 was a useful threshold for the
prediction of hydrops, many others were unable to assess this due to the rarity
of this complication. For this reason, thresholds as low as 0.4 cm2 may be more
useful for the prediction of a broader range of fetal concerns, including
mediastinal shift and fluid collections. Further large-scale studies are required
to determine the true utility of this well-established index.
2. Int J Clin Exp Med. 2015 Jun 15;8(6):9805-9. eCollection 2015.
Could Harmonic Scalpel (Ultracision®) be considered the best device in surgical
treatment of vulvar cancer of patients with implanted pace-maker? Proposal and
rationale.
Vulvar cancer (VC) represents about 4% of gynecologic malignancies, its incidence
increases with age and peak incidence is found between 70-79 years. In cases of
locally advanced disease surgery is often required and radical vulvectomy, with
or without mono-bilateral inguino-femoral lymphadenectomy, is standard
management. Various devices have been implemented in gynecological surgery in an
attempt to minimize or avoid frequent intra/postoperative complications linked to
energy use, unfortunately the majority of these devices require monopolar or
bipolar energy. Ultracision® represents a unique surgical device capable of
performing both cutting and coagulation at different intensities without use of
electric energy. The use of Ultracision® in the radical treatment of VC has
advantages both in terms of intraoperative and postoperative complications
responsible for the reduction of surgical time and blood loss, complete tissue
removal according to oncological criteria, diminished desensitization of
peripheral areas and reduction of wound complications. These advantages have been
widely demonstrated and contribute to making Ultracision® a cost-effective option
in the routine treatment of patients affected by vulvar cancer especially when
considering its safety in cardiopathic patients with implanted pacemaker. If the
impressive results achieved in radical vulvar surgery will be confirmed, scalpel
use could be proposed as routine for surgery of the routinely in surgical
approach of vulvar and perineal area, in both benign and malignant disease.
3. Reprod Sci. 2015 Oct;22(10):1289-96. Epub 2015 Apr
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Intrauterine Morcellator Devices: The Icon of Hysteroscopic Future or Merely a
Marketing Image? A Systematic Review Regarding Safety, Efficacy, Advantages, and
Contraindications.
The aim of this study was to analyze all available evidence regarding the use of
intrauterine morcellator (IUM), for treatment of the most prevalent intrauterine
benign lesions, compared to both traditional resectoscopy and conventional
outpatient operative hysteroscopy in terms of safety, efficacy,
contraindications, perioperative complications, operating time, and estimated
learning curve. We reported data regarding a total of 1185 patients. Concerning
polypectomy and myomectomy procedures, IUM systems demonstrated a better outcome
in terms of operative time and fluid deficit compared to standard surgical
procedures. Complication rates in the inpatient setting were as follows: 0.02%
for IUM using Truclear 8.0 (Smith & Nephew Endoscopy, Andover, Massachusetts) and
0.4% for resectoscopic hysteroscopy. No complications were described using
Versapoint devices. Office polipectomy reported a total complication rate of
10.1% using Versapoint device (Ethicon Women's Health and Urology, Somerville,
New Jersey) and 1.6% using Truclear 5.0 (Smith & Nephew Endoscopy). The reported
recurrence rate after polypectomy was 9.8% using Versapoint device and 2.6% using
Truclear 8.0. Finally, the reported intraoperative and postoperative complication
rate of IUM related to removal of placental remnants using Truclear 8.0 and
MyoSure (Hologic, Marlborough, Massachusetts) was 12.3%. The available evidence
allows us to consider IUM devices as a safe, effective, and cost-effective tool
for the removal of intrauterine lesions such as polyps, myomas (type 0 and type
1), and placental remnants. Evidence regarding Truclear 5.0 suggests that it may
represent the best choice for office hysteroscopy. Further studies are needed to
confirm the available evidence and to validate the long-term safety of IUM in
procedures for which current data are not exhaustive (placental remnants
removal).
4. Biomed Res Int. 2014;2014:783598. Epub 2014 Aug 4.
Intrapartum ultrasound assessment of fetal spine position.
We investigated the role of foetal spine position in the first and second labour
stages to determine the probability of OPP detection at birth and the related
obstetrical implications. We conducted an observational-longitudinal cohort study
on uncomplicated cephalic single foetus pregnant women at term. We evaluated the
accuracy of ultrasound in predicting occiput position at birth, influence of
fetal spine in occiput position during labour, labour trend, analgesia request,
type of delivery, and indication to CS. The accuracy of the foetal spinal
position to predict the occiput position at birth was high at the first labour
stage. At the second labour stage, CS (40.3%) and operative vaginal deliveries
(23.9%) occurred more frequently in OPP than in occiput anterior position (7% and
15.2%, resp.), especially in cases of the posterior spine. In concordant
posterior positions labour length was greater than other ones, and analgesia
request rate was 64.1% versus 14.7% for all the others. The assessment of spinal
position could be useful in obstetrical management and counselling, both before
and during labour. The detection of spinal position, more than OPP, is predictive
of successful delivery. In concordant posterior positions, the labour length,
analgesia request, operative delivery, and caesarean section rate are higher than
in the other combination.
5. Clin Exp Metastasis. 2014 Oct;31(7):853-67. Epub 2014 Jul 20.
Usefulness, methods and rationale of lymph nodes HPV-DNA investigation in
estimating risk of early stage cervical cancer recurrence: a systematic
literature review.
Metastatic involvement of pelvic lymph-nodes (LNs), generally found in 0-29.3 %
of early stages, is the most important prognostic factor in cervical cancer (CC).
However, even in non-metastatic LNs, recurrence rate reaches 10-15 %. The role of
HPV-DNA presence in pelvic LNs has been a point of debate in the last two
decades. The aim of this systematic review is to collect all available data about
LNs HPV-DNA detection in patients affected by early-stage CC in order to
elucidate its clinical and surgical usefulness to choose the best surgical
treatment, the necessity of adjuvant therapy and to estimate the overall
oncological prognosis. The available data in this field results very patchy and
often conflicting in the results. The high correlation between HPV-DNA genome
detected in primary lesion and the one detected in LNs, as well as the high
correlation between LNs metastatic involvement and HPV-DNA presence, lead to
hypothesize that LNs HPV presence represents a potential risk-factor for
recurrence and poor oncological prognosis. The large disparities in
recurrence-rate of cases with LNs positive for HPV-DNA test and negative for
metastases could be explained by the relative "inappropriateness" of PCR test to
discriminate the presence of HPV-genome alone (condition necessary but not
sufficient) or in association with squamous cells (condition necessary and
sufficient). The use of ISH test for HPV-DNA detection in LNs, particularly if
associated to CK19-assay, improve the accuracy of micro-metastasis detection, and
the identification of patients with negative histology but potentially at
high-risk of recurrence and poor oncological prognosis.
6. Arch Gynecol Obstet. 2014 Nov;290(5):951-6. Epub 2014 Jun 4.
Limits and complications of laparoscopic myomectomy: which are the best
predictors? A large cohort single-center experience.
PURPOSE: To determine whether a correlation exists between size, location, type
of myomas and perioperative outcomes.
METHODS: This is a observational study in women undergone to laparoscopic
myomectomy (LM) because of single symptomatic myoma >4 cm in diameter. We
collected data about general features, surgical outcomes,
intraoperative/postoperative complications and time to return to normal activity.
RESULTS: A total of 444 patients (mean age 36.7 ± 6.4 years) resulted eligible
for the study. Myomas sized between 8 and 12 cm were linked to an increased
amount of blood loss (significantly higher in intramural than subserosal myoma).
The removal of intramural myomas >8 cm and the subserosal ones >12 cm required a
significant longer surgical time. Patients returned 17.9 ± 9.5 days after surgery
to their personal activities. Six cases (1.35 %) required conversion to
laparotomy, and only in two cases blood transfusion was necessary.
CONCLUSION: Myomas size and type represent the best predictors of surgical
difficulties and possible intrapostoperative complications. Intramural myomas >8
cm and subserosal ones >12 cm should be considered as a challenging procedure. LM
remains the gold standard approach because of very low perioperative complication
rate and faster return to normal activity.
7. Arch Gynecol Obstet. 2014 Jul;290(1):21-34.
Update on best available options in obstetrics anaesthesia: perinatal outcomes,
side effects and maternal satisfaction. Fifteen years systematic literature
review.
PURPOSE: In modern obstetrics, different pharmacological and non-pharmacological
options allow to obtain pain relief during labour, one of the most important
goals in women satisfaction about medical care. The aim of this review is to
compare all the analgesia administration schemes in terms of effectiveness in
pain relief, length of labour, mode of delivery, side effects and neonatal
outcomes.
METHODS: A systematic literature search was conducted in electronic databases in
the interval time between January 1999 and March 2013. Key search terms included:
“labour analgesia”, “epidural anaesthesia during labour” (excluding anaesthesia
for Caesarean section), “epidural analgesia and labour outcome” and “intra-thecal
analgesia”.
RESULTS: 10,331 patients were analysed: 5,578 patients underwent
Epidural-Analgesia, 259 patients spinal analgesia, 2,724 combined spinal epidural
analgesia, 322 continuous epidural infusion (CEI), 168 intermittent epidural
bolus, 684 patient-controlled infusion epidural analgesia and 152 intra-venous
patient-controlled epidural analgesia. We also considered 341 women who underwent
patient-controlled infusion epidural analgesia in association with CEI and 103
patients who underwent patient-controlled infusion epidural analgesia in
association with automatic mandatory bolus.
CONCLUSION: No significant differences occurred among all the available
administration schemes of neuraxial analgesia. In absence of obstetrical
contraindication, neuraxial analgesia has to be considered as the gold standard
in obtaining maternal pain relief during labour. The options available in the
administration of analgesia should be known and evaluated together by both
gynaecologists and anaesthesiologists to choose the best personalized scheme and
obtain the best women satisfaction. Since it is difficult to identify comparable
circumstances during labour, it is complicate to standardize drugs schemes and
their combinations.
8. Cancer Invest. 2014 Jun;32(5):206-7. Epub 2014 Mar 7.
Could HPV-DNA test solve the dilemma about sentinel node frozen section accuracy
in early stage cervical cancer? Hypothesis and rationale.
In order to reduce the surgical invasiveness in early-stage cervical-cancer
treatment, the sentinel lymph-node (SLN) technique could be considered as a
possible intraoperative-guidance to lymphadenectomy decision making.
Unfortunately its accuracy ranges between 33.3% and 100% in different studies.
Recent manuscripts suggest that HPV-DNA presence in pelvic-lymph-nodes may
represent a molecular marker of micrometastases. According to this hypothesis,
the rationale in proposing the HPV-DNA-test when negative frozen-section occurs
is due to the expected improvement of its diagnostic-accuracy. HPV-DNA test may
represent a marker able to discriminate at frozen section the false-negative from
the truth-negative tests filling the gap between optimal and real frozen-section
accuracy.
9. Cancer Epidemiol Biomarkers Prev. 2014 Jan;23(1):218. Epub 2013 Nov 13.
Long-term statin use and risk of breast cancer--letter.
10. Clin Chem Lab Med. 2014 Mar;52(3):e45-6.
Could kidney glomerular filtration impairment represent the "Achilles heel" of
HE4 serum marker? A possible further implication.
11. Oncol Rep. 2013 Dec;30(6):2545-54. Epub 2013 Sep 19.
Radical trachelectomy: the first step of fertility preservation in young women
with cervical cancer (Review).
Radical trachelectomy (RT) can be performed vaginally or abdominally
(laparotomic, laparoscopic or robotic). The aim of this systematic review was to
compare all techniques in terms of surgical complications, disease recurrence and
subsequent fertility/pregnancy outcomes. A total of 1293 RTs were analyzed
(FIGO-stage: IA1-IIA). The most frequent surgical complications do not differ
from the ones of radical hysterectomy. The recurrence risk is approximately 3%
(range 0-16.8%). The majority of women conceive spontaneously: 284 pregnancies
with 173 live births. The most frequent pregnancy complication was miscarriage
and chorioamnionitis. RT appears to be a safe option for eligible women who
intend to maintain their future pregnancy desire.
12. Reprod Sci. 2014 Apr;21(4):423-31. Epub 2013 Sep 23.
Levonorgestrel intrauterine system in adjuvant tamoxifen treatment: balance of
breast risks and endometrial benefits--systematic review of literature.
Levonorgestrel intrauterine system (LNG-IUS) is used in patients with breast
patients taking tamoxifen (TAM) to prevent endometrial proliferation. The
benefits (on endometrium), the side effects (on breast), and the patients
suitable for this treatment are not still clear. Aim of this systematic review is
to define the breast risks and endometrial benefits in TAM-treated women using
Mirena and to define which patients could benefit from LNG-IUS use. In all, 3
studies on LNG-IUS effects on endometrium in TAM-treated women and 4 studies on
breast cancer recurrence were selected for the study. All studies described a
reduction in benign endometrial pathologies among Mirena users, but controversial
data showed malignant disease and breast cancer recurrence. So it is mandatory to
define hormonal status before TAM treatment. In selected patients Mirena was
proven to protect endometrium. Perspective clinical trials on Mirena
pharmacological features are necessary to establish whether systemic levels of
progesterone could increase breast cancer recurrence in such patients.
13. Obstet Gynecol Surv. 2013 Jun;68(6):467-81.
Update on raloxifene: mechanism of action, clinical efficacy, adverse effects,
and contraindications.
Raloxifene is the only selective estrogen receptor modulator approved for
long-term treatment in the prevention of osteoporotic fractures and for the
reduction of invasive breast cancer risk in post-menopausal women. The
demonstrated beneficial effects on bone and mammalian tissue led clinical and
molecular research to focus mainly on these organs, giving less attention to all
other systemic effects. The aim of this review was to evaluate all described
systemic effects of raloxifene, investigating its molecular and tissutal
mechanism of action. A literature research was carried out in electronic
databases MEDLINE, EMBASE, ScienceDirect, and the Cochrane Library in interval
time between 2000 and 2012. Outcomes were considered in relation to
positive/adverse effects concerning bone metabolism, lipid metabolism,
coagulation pattern, menopausal symptoms, breast cancer onset, and endometrial
cancer onset. Raloxifene acts as an estrogen agonist or antagonist depending on
the tissue. This feature is related to specific actions on at least 2 distinct
estrogen receptors, whose proportions vary according to tissue type. Raloxifene
is a drug for the treatment of osteoporosis and for the prevention of estrogen
receptor-positive breast cancer because it guarantees a safety profile on the
endometrium. Raloxifene is furthermore an effective therapy in women with
increased levels of plasma cholesterol. Raloxifene treatment shifts the
coagulation pattern toward prothrombosis, and the patients should be exhaustively
informed about the risks associated with therapy. Raloxifene does not show to
affect memory and cognition. Finally, it is noteworthy that quality-of-life
studies demonstrated some favorable effects of raloxifene.
14. Reprod Sci. 2014 Apr;21(4):465-76. Epub 2013 Jul 18.
Magnetic resonance-guided focused ultrasound myomectomy: safety, efficacy,
subsequent fertility and quality-of-life improvements, a systematic review.
We performed a systematic review about studies reporting data of myomectomy
performed by magnetic resonance-guided focused ultrasound (MRgFUS) technique in
order to define its safety, feasibility, indications, complications, and impact
on uterine fibroid symptom and health-related quality of life (UFS-QOL) and
fertility. Outcomes were considered according to fibroids shrinkage, nonperfused
volume (NPV), NPV ratio, and uterine fibroid symptoms assessed with UFS-QOL
questionnaire (baseline 3, 4, 6, and 12 months). We analyzed 38 eligible studies
reporting outcomes about 2500 patients (mean age 43.67 years). The MRgFUS results
a safe, efficient, and cost-effective minimal invasive technique for treatment of
uterine fibroids. Increasing experience, device improvements, and availability
for a larger number of patients are enhancing the outcomes, while the obstetrical
ones should be more extensively explored. The MRgFUS could be considered as a
minimal invasive alternative to traditional surgical or radiological procedures
for the treatment of symptomatic uterine myomas improving both QOL and subsequent
fertility.
15. Surg Innov. 2014 Feb;21(1):118-9. Epub 2013 Jul 9.
Could vessel ablation by magnetic resonance-guided focused ultrasound represent a
next future gynecological fertility-sparing approach to fibroids?
16. Endocr Relat Cancer. 2013 Jun 24;20(4):455-62. Print 2013 Aug.
Endometrial surveillance in tamoxifen users: role, timing and accuracy of
hysteroscopic investigation: observational longitudinal cohort study.
To determine the role, timing and indications for endometrial hysteroscopic
investigation in relation to the clinical, ultrasound and histological features
of the endometrium during tamoxifen (TAM) use. We performed an observational
longitudinal cohort study (years 2007-2012) that investigated the endometria of
151 TAM users with hysteroscopy and histology. For all patients, gynaecological
history, years of adjuvant treatment, ultrasound endometrial thickness
measurement and indications for hysteroscopy were recorded. Hysteroscopic
findings showed that 100% of patients referred for simple follow-up had no
evidence of endometrial disease. We found a strong correlation between previous
history of abnormal uterine bleeding (with or without endometrial thickening) and
hysteroscopic suspicion of endometrial atypia that was confirmed by histology.
Hysteroscopy had 83.3% sensitivity, 99% specificity, 83.3% positive predictive
value (PPV) and 99% negative predictive value (NPV) in detecting endometrial
atypia. No significant correlation was found between endometrial thickening to
>5 mm without bleeding and histological atypia. Similarly, the duration of
treatment was not related to endometrial thickening and histological atypia.
Endometrial stromal hyperplasia was detected by histology in 70.5% of patients
with endometrial thickness measurements ranging from 5 to 10 mm. In contrast, no
atypia was detected when endometrial thickness was <5 mm. Ultrasound performed
using a 5-mm cut-off threshold for endometrial thickness resulted in 100%
sensitivity, 15% specificity, 4% PPV and 100% NPV in detecting endometrial
atypia, while a 10-mm cut-off threshold resulted in 84% sensitivity, 69%
specificity, 10% PPV and 99% NPV. Low-risk TAM users do not require different
endometrial surveillance than the general population. Hysteroscopy could play a
fundamental role in determining the endometrial status of patients before the
initiation of TAM treatment and in assessing the endometrial status of patients
when bleeding occurs.
17. Cancer Invest. 2013 Mar;31(3):189. Epub 2013 Feb 14.
Fertility preservation in young women with cervical cancer: an oncologic dilemma
or a new conception of fertility sparing surgery?
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18. BMC Pregnancy Childbirth. 2020 Jul 1;20(1):384.
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Retrospective study 2005-2015 of all cases of fetal death occurred at ≥23 gestational weeks, in Friusli Venezia Giulia, Italy.
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Monasta L, Giangreco M, Ancona E, Barbone F, Bet E, Boschian-Bailo P, Cacciaguerra G, Cagnacci A, Canton M, Casarotto M, Comar M, Contardo S, De Agostini M, De Seta F, Del Ben G, Di Loreto C, Driul L, Facchin S, Giornelli R, Ianni A, La Valle S, Londero AP, Manfè M, Maso G, Mugittu R, Olivuzzi M, Orsaria M, Pecile V, Pinzano R, Pirrone F, Quadrifoglio M, Ricci G, Ronfani L, Salviato T, Sandrigo E, Smiroldo S, Sorz A, Stampalija T, Urriza M, Vanin M, Verardi G, Alberico S.