Gianluca Raffaello Damiani

Myoma expulsion after minimally invasive therapeutic strategies: a systematic review

Uterine leiomyomas are very common benign tumors of the myometrium which often occur in women in fertile age. They can cause pain, heavy bleeding, fertility impairment. Historically, the treatment available for this condition was only the surgical one. During the last decades, several new therapeutic possibilities became available to treat fibroids in a minimally invasive way, with the aim to avoid surgery and its possible complications. The aim of this review is to focus on these new techniques and on their complications, with particular regard to myoma expulsion. This study consists of a systematic review of the most recent scientific Literature, focusing on the final outcomes of minimally invasive treatments. We tried to answer the question if these uterus sparing approaches effectively were decisive for patients without any further treatments. In fact, the slice of patients who is mainly affected by myomas is the one of women in their fertile age, in which hysterectomy is obviously not suggested (in order let them complete the family planning) but the treatment of myomas should be pursued to relieve the symptoms and also to improve fertility. Another question we analyzed is the correlation between these minimally invasive techniques and spontaneous myoma expulsion. We conducted bibliographic research on scientific databases, identifying no. 35 papers which suited to our study. The overall expulsion rate in patients minimally - invasive treated was 14.4%, and among the different non - surgical minimally invasive techniques, MrgFUS seems to be related to the highest rate of myoma expulsion. Fibroid expulsion is resolutive in most cases, but in 1.4% of cases additional medical care to remove residual fibroid tissue is required. Severe adverse events of these procedures (utero - enteric fistule, uterine necrosis, sepsis) were observed in 0.9% of women. Fibroids expulsion can be considered not an adverse but a favorable event after fibroids' treatment. The expulsion (that in some cases can be asymptomatic or mild symptomatic) can lead to improvement of symptoms, and in the end turns out to be resolutive in most cases. Further studies are needed, especially to evaluate the efficacy and the fibroid expulsion rate of the newest minimally invasive techniques.

The Role of Hormonal Replacement Therapy in BRCA Mutated Patients: Lights and Shadows

All cancers develop as a result of mutations in genes. DNA damage induces genomic instability and subsequently increases susceptibility to tumorigenesis. Women who carry mutations of BRCA 1 and BRCA2 genes have an augmented risk of breast and ovarian cancer and a markedly augmented probability of dying because of cancer compared to the general population. As a result, international guidelines recommend that all BRCA1\2 mutation carriers be offered risk-reducing bilateral salpingo-oophorectomy at an early age to reduce the risk of cancer and decrease the mortality rate of this high-risk population. NCCN guidelines recommend risk-reducing bilateral salpingo-oophorectomy in pre-menopausal women, between 35–40 years in BRCA1 mutation carriers and between 40–45 years in BRCA2 mutation carriers. Unfortunately, the well-documented reduction of cancer risk is counterbalanced by early sterility and premature ovarian failure with an early onset of secondary menopausal syndromes such as neuromotor, cardiovascular, cognitive and urogenital deficiency. Hormonal replacement therapy significantly compensates for hormonal deprivation and counteracts menopausal syndrome morbidity and mortality; however, some data suggest a possible correlation between hormonal medications and cancer risk, especially in BRCA1\2 carriers who undergo long-term regimens. Conversely, short-term treatment before the age of natural menopause does not appear to increase the cancer risk in BRCA1 mutation carriers without a personal history of breast cancer after prophylactic surgery. Few data are available on BRCA2 mutation carriers and more well-designed studies are needed. In conclusion, clinicians should propose short-term hormone replacement therapy to BRCA 1 carriers to counteract hormonal deprivation; personalized counselling should be offered to BRCA2 mutation carriers for a balance between the risks and benefits of the treatment.