Alessandro Favilli

Reproductive and Oncologic Outcomes in Young Women with Stage IA and Grade 2 Endometrial Carcinoma Undergoing Fertility-Sparing Treatment: A Systematic Review

Background: Endometrial cancer (EC) is the most common gynecological malignancy in both Europe and the USA. Approximately 3–5% of cases occur in women of reproductive age. Fertility-sparing treatment (FST) options are available, but very limited evidence regarding grade 2 (G2) ECs exists in the current literature. This systematic review aimed to comprehensively evaluate reproductive and oncologic outcomes among young women diagnosed with stage IA or G2EC disease who underwent FST. Methods: A comprehensive search of the literature was carried out on the following databases: MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), the Health Technology Assessment Database, and Web of Science. Only original studies that reported the oncologic and reproductive outcomes of patients with stage IA and G2EC tumors who underwent FST were considered eligible for inclusion in this systematic review (CRD42023484892). Studies describing only the FST for endometrial hyperplasia or G1 EC were excluded. Results: Twenty-two papers that met the abovementioned inclusion criteria were included in the present systematic review. Preliminary analysis suggested encouraging oncologic and reproductive outcomes after FST. Conclusions: The FST approach may represent a feasible and safe option for women of childbearing age diagnosed with G2EC. Despite these promising findings, cautious interpretation is warranted due to inherent limitations, including heterogeneity in study designs and potential biases. Further research with standardized methodologies and larger sample sizes is imperative for obtaining more robust conclusions.

Step-by-step hysteroscopic treatment of International Federation of Gynaecology and Obstetrics type 3 myoma with the cold loop technique

To demonstrate the "cold loop technique" for the hysteroscopic treatment of International Federation of Gynaecology and Obstetrics (FIGO) type 3 myomas. Step-by-step demonstration of the technique using educative video. FIGO type 3 myomas exhibit complete myometrial development while encroaching on the endometrium. This hybrid nature, combining features of both submucous and intramural myomas, may have a detrimental "double hit" effect for patients seeking pregnancy. Currently, there is a dearth of robust evidence regarding the ideal surgical approach for FIGO type 3 myomas. Despite the preference for the hysteroscopic approach due to their closer proximity to the uterine cavity compared with the serosa, the primary limitations of the conventional hysteroscopic approach include the risks of damaging healthy myometrium and the significant risk of adhesions. We showcase the hysteroscopic treatment of a 29-mm FIGO type 3 myoma on the anterior uterine wall using the "cold loop technique." The video emphasizes key procedural phases: opening the "endometrial-myometrial window" with minimal sacrifice of myometrium; identifying the correct cleavage plane through blunt dissection of fibroconnective bridges anchoring the myoma to the pseudocapsule using cold loops; and slicing the detached intramural component of the fibroid, displaced into the uterine cavity, with an electrical loop. Integrity of the uterine cavity and the healthy myometrium surrounding the myoma and avoiding postsurgical intrauterine adhesions. The myoma was completely removed in a single surgical step, and at the end of the procedure, the myoma's "notch" and its intact pseudocapsule were clearly visible. The patient was discharged in good health the day after the surgery. At the 3-month follow-up, the diagnostic office hysteroscopy revealed a fully recovered uterine cavity. The "cold loop technique" holds the potential to facilitate the safe removal of FIGO type 3 myomas, minimizing the risk of damage to the adjacent healthy myometrium and resulting in a lower likelihood of postoperative adhesions. This is especially critical for women contemplating conception.

Cold Knife Versus Carbon Dioxide for the Treatment of Preinvasive Cervical Lesion

Background and Objectives: Cervical cancer (CC) represents a significant health concern worldwide, particularly for younger women. Cold knife (CK) conization and carbon dioxide (CO2) laser conization are two techniques commonly used to remove pre-invasive lesions, offering a potential curative intent in cases of incidental diagnosis of CC. This study aimed to assess the clinical implications and pathological outcomes of CK vs. CO2 laser conization for pre-invasive lesions. Materials and Methods: We retrospectively analyzed women who underwent CO2 or CK conization for high-grade preinvasive lesions (CIN2/3, CIS and AIS) between 2010 and 2022. Patient demographics, surgical details and pathological outcomes were collected. Pregnancy outcomes, including composite adverse obstetric rates, and oncological follow-up data, were also obtained. Results: In all, 1270 women were included; of them, 1225 (96.5%) underwent CO2, and 45 (3.5%) underwent CK conization. Overall, the rate of positive endocervical or deep margins was lower with CO2 laser compared to CK (4.3% vs. 13.3%, p = 0.015). Incidental CC was diagnosed in 56 (4.4%) patients, with 35 (62.5%) squamous and 21 (46.6%) adenocarcinomas. In a multivariate regression model, the relative risk for positive endocervical or deep margins is significantly greater in cases of incidental diagnosis of CC (p < 0.01). In cases of incidental diagnosis of CC, we found that the probabilities of having either positive endocervical or deep margins after CO2 laser or CK conization are similar, with a higher risk in case of adenocarcinoma lesion. Among women with CC, 42 (75%) opted for radical treatment, while 14 (25%) underwent a follow-up. Only one woman (7.1%) in the follow-up group, who had undergone CK conization, experienced a composite adverse obstetric outcome. No recurrences were observed after a median follow-up of 53 months. Conclusions: CO2 laser conization achieved a lower positive margin rate overall. CK and CO2 conization appear to be equivalent oncological options for incidental CC.

The challenge of FIGO type 3 leiomyomas and infertility: Exploring therapeutic alternatives amidst limited scientific certainties

AbstractUterine leiomyomas (ULs) are non‐cancerous tumors composed of smooth muscle cells that develop within the myometrium and represent the most prevalent pathological condition affecting the female genital tract. Despite the volume of available research, many aspects of ULs remain unresolved, making it a “paradoxical disease” where the increase in available scientific literature has not been matched by an increase in solid evidence for clinical management. Fertility stands at the top of the list of clinical issues where the role of ULs is still unclear. The leiomyoma subclassification system, released by the International Federaion of Gynecology and Obstetrics (FIGO) in 2008, introduced a new and more effective way of categorizing uterine fibroids. The aim was to go beyond the traditional classification “subserosal, intramural and submucosal”, facilitating a detailed examination of individual ULs impact on the female reproductive system. The “type 3 UL” is a special type of myoma, characterized by its complete myometrial development while encroaching the endometrium. It is a unique “hybrid” between a submucous and an intramural UL, that may exert a detrimental “double hit” mechanism, which is of particular interest in patients wishing pregnancy. To date, no robust evidence is available regarding the management of type 3 ULs. The aim of this narrative review is to provide a comprehensive overview of the physiopathological mechanisms that type 3 UL may exert on fertility, and to present new perspectives that may help us to better understand both the need for and the methods of treating this unique type of fibroid.