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Introduction: We present the rare case of an 18-year-old patient with a Dicer-1 mutation-associated sarcoma of the cervix uteri. Case: The patient presented with irregular vaginal bleeding in July 2022. The clinical examination showed an exophytic tumor of the cervix, uterus and ovaries were normal in sonogram. The tumor of the cervix was resected, followed by a diagnostic hysteroscopy and abrasion of the uterine cervix and cavity. Hysteroscopy showed normal findings of the cervix and uterus. After diagnosis of a highly malignant Dicer-1 mutation-associated sarcoma of the cervix, cryopreservation of oocytes was realized. Based on the principle of obtaining maximum oncological safety while preserving fertility in this 18-year-old patient, we recommended chemotherapy rather than radiation with its far severe implications on the patient´s reproductive organs. 4 cycles of chemotherapy consisting of doxorubicin and ifosfamide were applied until December 2022. After re-staging in December 2022 via CT scan and MRI, the abdomen and pelvis as well as control hysteroscopy and abrasion were unremarkable. Until now, the patient is tumor free. Discussion: Primary sarcomas of the cervix are very rare. Recent literature hints towards a distinct DICER-1 sarcoma entity characterized by specific mutational clusters. Limited follow-up data suggested that DICER1-mutant tumors might exhibit a less aggressive clinical course than DICER1-wild-type tumors. Conclusion: Decision-making in case of rare histological entities with sparse recommendations in the literature poses a challenge to the treating physician. Treatment strategies should consider oncological safety as well as options of preserving fertility. Gonadotoxic potential of different strategies should be taken into consideration and discussed in detail with the affected patient. [ABSTRACT FROM AUTHOR]

Simple Summary: The aim of this study was to evaluate the incidence of high-grade glandular pathology in the histological cones of LEEP for CIN3 and to verify the different biological nature of the single CIN3 lesion from CIN3 coexisting with AIS. A sample of 414 women underwent LEEP for CIN3. From the histological examination of the cone, we selected 370 women with a single CIN3, 39 women with CIN3 coexisting with AIS, and 5 women with CIN3 coexisting with AC. Specific HR HPV genotypes and treatment outcome in the study groups were investigated. Women with CIN3 coexisting with AIS showed only four specific HR HPV genotypes (16, 18, 45, 33), the prevalence of genotype 18, the presence of skip lesions (9%), and occult adenocarcinoma (one case of 1A1 adenocarcinoma). Furthermore, CIN3 lesions coexisting with AIS have a higher rate of viral persistence and recurrence than single CIN3 lesions. These characteristics make CIN3 coexisting with AIS closer to the glandular pathology than to the squamous one, making hysterectomy necessary and cervical conization insufficient, which is instead considered the optimal treatment method for a single CIN3. The purpose of this study was to evaluate the incidence of AIS and AC in the histological cone of women treated for CIN3. Furthermore, through the study of the specific HR HPV genotypes, we obtained more information on the possible different nature between the single CIN3 lesion and the CIN3 coexisting with the glandular lesion. Methods. A sample of 414 women underwent LEEP for CIN3. The study sample consisted of 370 women with a CIN3 lesion alone and 44 women with a CIN3 lesion coexisting with AIS or adenocarcinoma. We studied the individual HR HPV genotypes and their frequency in the two groups under study. Furthermore, the therapeutic results and follow-ups for the population were studied on the entire study sample. Results. In patients with a single CIN3 lesion, 11 high-risk genotypes were detected; in patients with CIN3 associated with AIS or AC, only 4 different genotypes were detected (16, 18, 45, 33). Overall, the frequency of HPV 18 was significantly higher in CIN3 coexisting with AIS compared to solitary CIN3 lesions, χ2 = 27.73 (p < 0.001), while the frequency of other high-risk genotypes was significantly higher in patients with a single CIN3 than in patients with CIN3 coexisting with AIS. In our study population, mixed lesions (CIN3 coexisting with AIS), unlike their squamous counterparts (single CIN3 lesions), were characterized by skip lesions, which demonstrate more aggressive behavior and a higher rate of viral persistence and recurrence. Conclusion. A relatively high rate (10.7%) of AIS-AC was found in women treated for CIN3. Our study confirms the multifocal biological nature of the CIN3 lesion coexisting with AIS compared to the single CIN3 lesion. All this justifies the different treatments to which CIN3 lesions coexisting with AIS are addressed; in fact, the latter are treated with hysterectomy, while CIN3 is treated with conization alone. [ABSTRACT FROM AUTHOR]

To investigate the association of molecular subtype with progesterone response in patients with endometrial cancer (EC) or atypical endometrial hyperplasia (AEH). Premenopausal patients aged ≤48 years with tumor-normal sequencing data who received progesterone for EC/AEH from 1/1/2010–6/30/2021 were identified. Tumors were classified as POLE -ultramutated, microsatellite instability-high (MSI-H), copy number-high (CN-H), or copy number-low (CN-L) molecular subtype. Best response to progesterone was compared by subtype. Appropriate statistical tests were performed. Of 20 patients, 7 (35%) had AEH and 13 (65%) had EC. Sixteen tumors (80%) were CN-L, 3 (15%) were MSI-H, and 1 (5%) was POLE -ultramutated. Median time on progesterone was 22 months (range, 3–115). Ten patients (50%) had complete response (CR); median time to CR was 9 months (range, 3–32). Four patients (20%) had stable disease (SD) and 6 (30%) had progressive disease (PD). For CN-L tumors, 10 patients (62%) had CR, 3 (19%) had SD, and 3 (19%) had PD. For MSI-H tumors, 1 patient (33%) had SD and 2 (66%) had PD. For POLE -ultramutated tumors, 1 patient had PD. Median follow-up was 48 months (range, 12–123). Four of 10 patients (40%) with CR recurred; median time from CR to recurrence was 16 months (range, 5–102). Molecular subtype may be associated with progesterone response in patients with EC/AEH. CN-L tumors had the best response, and MSI-H tumors had the poorest. Recurrence after CR is common, and close surveillance is warranted. Larger studies investigating the role of molecular classification in medical management of EC/AEH are needed. • In endometrial cancer/atypical endometrial hyperplasia (AEH), molecular subtype may be associated with progesterone response. • Molecular classification may help guide selection for progestin-based treatments in patients with endometrial cancer/AEH. • Response to progestin varied among molecular subtypes of endometrial cancer. • Copy number-low tumors showed the highest response rate to progestin-based treatments. • Close follow-up is warranted for patients with complete response due to high risk of recurrence. [ABSTRACT FROM AUTHOR]

Introduction. Cervical pregnancies occur when the fertilized egg implants in the wall of the cervix below the internal cervical os. The incidence is between 1 in 8600 and 1 in 12,400 pregnancies. The risk factors include previous instrumentation, cervical or uterine surgery, in vitro fertilization with embryo transfer, uterine anomalies, leiomyomas, synechiae, previous caesarean section, and pelvic inflammatory disease. Sonographic findings in cervical pregnancy may include an hourglass uterine shape, ballooned cervical canal, gestational tissue at the cervix, absence of intrauterine gestational tissue, and a portion of the endocervical canal between the gestation and the endometrial canal. The medical management includes the systemic administration of methotrexate, but failure is common in pregnancies over nine weeks with a crown-rump length (CRL) greater than 10 mm, presence of embryonic cardiac activity, and beta-human chorionic gonadotropin (β-HCG) levels higher than 10,000 mIU/ml. Materials and method. This paper represents a case report of a 34-year-old woman with a history of previous caesarean section and elective abortion, presenting with 8 weeks of amenorrhea. She was diagnosed one week prior with cervical ectopic pregnancy. Results. The ultrasound examination revealed the presence of a gestational sac with an embryo showing cardiac activity, located in the upper part of the cervix, below the uterine scar. The CRL measured 10 mm, corresponding to a gestational age of 7 weeks and 1 day. The uterine cavity displayed an endometrial thickness of 11 mm, and both ovaries appeared normal. With the patient’s informed consent, surgical evacuation was performed, using suction curettage, resulting in minimal bleeding. The cervical lacerations were sutured with transfixion sutures. The subsequent progress was favorable. Conclusions. While it is an extremely rare variety of ectopic pregnancy, cervical pregnancy represents a potential surgical emergency if not diagnosed in a timely manner. The possible complications include uterine rupture with subsequent hemorrhage, requiring hemostatic hysterectomy in such cases [ABSTRACT FROM AUTHOR]

To compare all-cause and cancer-specific mortality between women who underwent fertility-sparing surgery (FSS) versus standard surgery for stage IA and IC epithelial ovarian cancer. Reproductive aged patients (18–45) with stage IA or IC epithelial ovarian cancer diagnosed between 2000 and 2015 were identified in the California Cancer Registry. FSS was defined as retention of the contralateral ovary and the uterus, and standard surgery included at least removal of both ovaries and the uterus. The primary outcome was all-cause mortality and the secondary outcome was cancer-specific mortality. Inverse probability of treatment weighting (IPTW) was used to create two groups balanced on covariates of interest. The Kaplan-Meier method and Cox proportional hazards analysis were used to model survival outcomes. Among 1119 women who met inclusion criteria, 390 (34.9%) underwent FSS. IPTW yielded a balanced cohort of 394 women who underwent FSS and 723 women who underwent standard surgery. Among patients who underwent FSS, there were 45 deaths corresponding to an 85.4% (95% confidence interval [CI] 0.79–0.92) 10-year all-cause survival probability, compared to 81 deaths and 86.4% 10-year all-cause survival probability (95% CI 0.83–0.90) among patients who underwent standard surgery. FSS was not associated with increased all-cause mortality (HR 1.04, 95% CI 0.72–1.49) or cancer-specific mortality (HR 1.50, 95%CI 0.97–2.31). Among reproductive-aged patients with early-stage epithelial ovarian cancer fertility-sparing surgery was not associated with an increased risk of death compared to standard surgery. • Fertility-sparing surgery was not associated with an increased risk of all-cause or cancer-specific mortality. • Among those with a higher risk for recurrence cancer specific survival remained high after fertility sparing surgery. • Fertility-sparing surgery is a safe and reasonable option to consider for patients with early-stage epithelial. [ABSTRACT FROM AUTHOR]

Background: Ovarian serous borderline tumors (SBT) are typically unilateral and are primarily treated using hysterectomy and bilateral salpingooophorectomy (SO). However, most young patients prefer fertility-sparing surgeries (FSS) with tumorectomy or unilateral SO. Micropapillary morphology and invasive implants have been designated as histopathological risk indicators for recurrence or metastasis, but their clinical impact remains controversial because of limitations like diagnostic inconsistency and incomplete surgical staging. Methods: A nationwide multi-institutional population-based retrospective surveillance was conducted with a thorough central pathology review to reveal the clinical features of SBT. Of 313 SBT patients enrolled in the Japanese Society of Clinical Oncology's Surveillance of Gynecologic Rare Tumors, 289 patient records were reviewed for clinical outcomes. The glass slides of patients at stage II–IV or with recurrence or death were re-evaluated by three gynecological pathologists. Result: The 10-year overall and progression-free survival (PFS) rates were 98.6% and 92.3%. The median recurrence period was 40 months and 77.0% was observed in the contralateral ovary within 60 months. Patients aged ≤ 35 years underwent FSS more frequently and relapsed more (p <.001). A clinic-pathological analysis revealed diagnosis during pregnancy, FSS, and treatment at non-university institutes as well as advanced stage and large diameter were independent risk factors of recurrence. Among patients having pathologically confirmed SBTs, PFS was not influenced by the presence of micropapillary pattern or invasive implants. Conclusion: The recurrence rate was lower in this cohort than previous reports, but the clinical impacts of incomplete resection and misclassification of the tumor were still significant on the treatment of SBT. [ABSTRACT FROM AUTHOR]

Abstract Introduction Obesity is a major risk factor in the development of endometrial cancer (EC) in young patients of reproductive age. Fertility sparing treatment is a viable option for a select group of patients with early EC, and involves systemic and intra‐uterine hormonal therapy. Weight loss has been associated with improved outcomes in this group. Bariatric surgery (BS) has been shown to be the most efficient and durable method of weight loss in obese patients. However, there is a paucity of data studying the benefit of BS as part of fertility sparing treatment. Methods We present a retrospective case series of five patients who are undergoing fertility sparing treatment for early EC, who also underwent BS for treatment of obesity and related comorbidities. We aim to show early regression of EC for all the patients and also report on the other health benefits of BS. Results All five patients in the series achieved regression of EC within 6 months of undergoing BS. They also achieved significant weight loss consistent with previous studies, and three patients who had comorbidities related to obesity had remission of these conditions. One of the patients with EC regression also managed to conceive with IVF (In‐vitro Fertilisation). Conclusion Patients on fertility sparing treatment for early EC who underwent BS was associated with early regression within 6 months, significant weight loss and resolution of comorbidities. BS could be a promising component of fertility sparing treatment. Long term, prospective studies are required to confirm the benefits reported in this case series.

Simple Summary: No guidelines regarding optimal treatment exist for primary cervical lymphomas. We have performed a systematic review of the literature about the management of this rare pathology. Conservative treatment with the combination of surgery and chemotherapy or surgery and radiotherapy has been reported in a few cases with apparent success. Furthermore, we have reported pregnancy outcome in patients treated with a fertility sparing approach. The female genital tract can be involved as a secondary manifestation of disseminated lymphomas or leukaemia but can rarely be the primary site of so-called extranodal lymphomas. Primary lymphomas of the female genital tract can affect the uterine corpus, uterine cervix, vulva, vagina, or adnexa. Only about 0.008% of all cervical tumours are primary malignant lymphomas. The most common clinical presentation of primary cervical lymphomas is a history of prolonged minor abnormal uterine bleeding, while unstoppable bleeding at presentation is rarely reported in the literature. "B" symptoms related to nodal lymphomas are usually absent. Since vaginal bleeding is a nonspecific symptom, the first diagnostic hypothesis is usually of one of the more common female genital conditions such as cervical or endometrial carcinoma or sarcoma, fibroids, adenomyosis, or endometriosis. Cervical cytology is usually negative. Preoperative diagnosis requires deep cervical biopsy. No guidelines regarding optimal treatment exists; radiotherapy, chemotherapy, and surgery are used in different combinations. Conservative treatment with the combination of surgery and chemotherapy or surgery and radiotherapy has been reported in a few cases with apparent success. With this review, we aim to understand what the best therapeutic approaches for this rare pathology in young and elderly women are. Moreover, we find favorable pregnancy outcome in patients treated with a fertility sparing approach. [ABSTRACT FROM AUTHOR]

Background: The conservative management of atypical endometrial hyperplasia (AEH) using different management strategies will be important in females who want to conceive. However, complete data were lacking regarding selection criteria of the patients, optimal therapeutic strategies, and follow-up periods. The aim of this study was to evaluate feasibility, safety, effectiveness, fertility, and long-term outcomes of hysteroscopic endometrial resection in combination with Levonorgestrel Intrauterine Device (LNG-IUD) as fertility-sparing strategies of management of premenopausal young females with AEH. Methods: We prospectively evaluated clinical files of 35 patients with AEH who underwent hysteroscopic resection of the lesion with insertion of LNG-IUD. LNG-IUD maintenance in its site was made for 12 months then removal of it was made for women with complete response (CR) then they were allowed to conceive naturally. Patients with recurrent, progressive, or resistant disease will undergo definitive surgical management by total hysterectomy and bilateral salpingoophorectomy. Results: We found that about 31 (88.5%) patients achieved and maintained a CR and LNG-IUD removed. 20 out of the 31 patients (64.5%) who had removed LNG-IUD became pregnant after natural conception in the following twelve months. 13 (65%) babies were born by Caesarean section at 39 weeks of gestation, and seven (35%) were born at term spontaneously. We found no recurrence in the 24 months of followup. Conclusions: We showed that combination of hysteroscopic superficial endometrial resection followed by insertion of LNG-IUD was considered safe and effective management procedure for young females with AEH who desired to preserve their fertility due to negligible progression and recurrence rates with accepted pregnancy and life births rates. [ABSTRACT FROM AUTHOR]

To examine uptake, characteristics, and survival outcome of less-radical fertility-sparing surgery with cervical conization and lymph node evaluation (Cone-LN) in reproductive age patients with early cervical cancer. This retrospective cohort study examined the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The study population included 407 patients aged <50 years with stage IA-IB2 (≤4 cm) cervical cancer who received fertility-sparing surgery from 2004 to 2019. The exposure was fertility-sparing surgery type: Cone-LN (n = 196) or trachelectomy with lymph node evaluation (Trach-LN, n = 211). The main co-outcomes were (i) temporal trends of surgery type, assessed with Cochran-Armitage test, and (ii) clinical and tumor characteristics, assessed with multivariable binary logistic regression model. The secondary outcome was overall survival, assessed with inverse probability of treatment weighting propensity score. The number of patients receiving Cone-LN increased from 43.5% in 2004–2007 to 58.4% in 2016–2019 (P-trend = 0.005). Patients receiving conization and sentinel lymph node (SLN) biopsy alone increased from 0% to 14.4% (P-trend < 0.001). In a multivariable analysis, patients in the Cone-LN group were more likely to undergo SLN biopsy (aOR 6.04) compared to those in the Trach-LN group whereas those with adenocarcinoma (aOR 0.49) and T1b tumors (aOR for ≤2 cm 0.21, and aOR for 2.1–4.0 cm 0.10) were less likely to receive Cone-LN. In a propensity score-weighted model, the Cone-LN and Trach-LN groups had comparable overall survival (7-year rates, 98.9% vs 97.8%). Similar associations were observed for patients with squamous, adenocarcinoma / adenosquamous, T1a classification, and T1b(≤2 cm) classification. The current population-based analysis suggests that the performance of cervical conization with lymph node evaluation, particularly with SLN biopsy, is gradually increasing for early cervical cancer patients desiring future fertility. • Fertility-sparing surgery for cervical cancer was assessed to compare cervical conization and trachelectomy. • Performance of cervical conization and nodal evaluation increased from 43.5% to 58.4%. • Performance of cervical conization and sentinel lymph node biopsy alone increased from 0% to 14.2%. • 7-year overall survival rates were similar between the two surgical approaches (98.9% vs 97.8%). [ABSTRACT FROM AUTHOR]

Sclerosing stromal tumor (SST) is a rare ovarian tumor arising from the sex cord-stromal cells that occurs mainly in young adults during the second and third decades of life and rarely in pediatric and adolescent populations. The objective of this study is to report three illustrative cases of SST in young girls who had undergone surgery at our clinic in or after 2009, and to perform a literature review of this rare ovarian tumor. A retrospective chart review of female patients aged

Extraskeletal Ewing sarcoma is a rare soft tissue tumor primarily affecting pediatric patients. The treatment is currently based on a multidisciplinary approach which allows, in cases of localized disease, good survival rates. We report the case of a 15-year-old female patient with a rapidly growing suspected pelvic mass misdiagnosed following the preliminary radiological exams, which assessed the findings as a mass of ovarian origin. The girl underwent surgery and, thanks to histopathological, immunohistochemical and real-time polymerase chain reaction (RT-PCR) examinations, it was possible to make the right diagnosis and to administer the best treatment in terms of surgery, chemotherapy and radiotherapy, obtaining a long disease-free interval and no recurrence to date. [ABSTRACT FROM AUTHOR]

Most patients diagnosed with endometrial hyperplasia or cancer are obese. Obesity, along with polycystic ovarian syndrome (PCOS) and type-2 diabetes mellitus (T2DM), may act synergistically to increase risk of malignant endometrial pathology. Incidence of malignant endometrial pathology is increasing, particularly in reproductive aged women. In patients who desire future fertility, the levonorgestrel intrauterine device (LNG-IUD) is often utilized. If the first-line progestin therapy fails, there is not an effective second-line adjunct option. Moreover, pregnancy rates following fertility-sparing treatment are lower-than-expected in these patients. This clinical opinion provides a summary of recent studies exploring risk factors for the development of malignant endometrial pathology including obesity, PCOS, and T2DM. Studies assessing efficacy of fertility-sparing treatment of malignant endometrial pathology are reviewed, and a potential new adjunct treatment approach to LNG-IUD is explored. There is an unmet-need for a personalized treatment approach in cases of first-line progestin treatment failure. Glucagon-like peptide 1 receptor agonists are a class of anti-diabetic agents, but may have a role in fertility-sparing treatment of obese patients with malignant endometrial pathology by reducing weight, decreasing inflammation, and decreasing insulin resistance; these changes may also improve chances of subsequent pregnancy. This hypothesis warrants further exploration. [ABSTRACT FROM AUTHOR]

Sclerosing stromal tumor (SST) is a rare ovarian tumor arising from the sex cord-stromal cells that occurs mainly in young adults during the second and third decades of life and rarely in pediatric and adolescent populations. The objective of this study is to report three illustrative cases of SST in young girls who had undergone surgery at our clinic in or after 2009, and to perform a literature review of this rare ovarian tumor. A retrospective chart review of female patients aged <18 years with a diagnosis of SST treated in a tertiary pediatric hospital was performed. Furthermore, a 10-year review of the SST literature was completed. Three cases of SST at our institution were outlined. After reviewing the literature, 18 SST cases were identified. The mean age at diagnosis was 13.4 years, and the reported clinical presentations were abdominal or pelvic pain and menstrual irregularity. Seven patients had abnormal hormone tests or CA-125 levels. In approximately 30% of cases, conservative surgery was performed, preserving residual ovarian tissue. In conclusion, some preoperative findings may help in suggesting the presence of SST. However, definitive diagnosis can only be made by histopathological examination. It is important to consider this tumor because, given its benign behavior, a conservative approach is preferred, particularly in this age group. [ABSTRACT FROM AUTHOR]

Ovarian germ cell tumors of the ovary represent a histologically heterogenous group of tumors with a high incidence at reproductive age. Patients with this pathology are very often young women with amenorrhea. The aim of this article is to present a pictorial essay of this rare pathology and to promote a national tumor registry and protocol. The treatment is individualized according to age, and fertility-sparing surgery is the actual standard of surgical treatment for young patients in early stage of the disease. [ABSTRACT FROM AUTHOR]

This study aimed to assess the accuracy of predicting pelvic lymph node status using sentinel lymph node (SLN) biopsy with indocyanine green (ICG) and to examine the outcomes of SLN biopsy-guided abdominal radical trachelectomy (ART). Patients with stage IA2–IB2 cervical cancer from January 2009 to January 2021 were included. ICG was injected before ART and SLNs were identified, excised, and assessed intraoperatively using fast-frozen sections. Systemic pelvic lymphadenectomy was subsequently performed. The SLN detection rate, sensitivity, and false-negative rate were determined. Thirty patients desiring fertility preservation were enrolled, of whom 26 successfully completed ART and four underwent radical hysterectomies because of metastatic primary SLNs. Bilateral SLNs were identified in all patients. The sensitivity, false-negative rate, and negative predictive value were 100%, 7.7%, and 92.3%, respectively. Three (12%) patients were lost to follow-up: two relapsed and one died of tumor progression. Of the nine patients who tried to conceive after surgery, four achieved pregnancy and three delivered healthy live infants. In women with early-stage cervical cancer who desired to conserve fertility, SLN mapping with ICG had a very high detection rate, sensitivity, and low false-negative rate. SLN biopsy-guided ART is a feasible and accurate method for assessing pelvic node status.

Objective: Improving knowledge to manage an invasive epithelial ovarian cancer at a young age who expect to preserve their reproductive function Method: a Case report Result : A 26 years old, nulliparity, Indonesian woman with chief complaint abdominal enlargement simultaneous with dyspnoea condition. Physical examination revealed an enlarged abdomen until processus xhypoideus with positive shifting dullness. Gynecology examination found normal uterine size, palpable cystic mass originated from adnexa until navel, mobile. CT whole abdomen showed a cystic solid mass in the pelvic area up to mid abdominal size 17,8 x 10,7 x 18,8 cm accompanied by lymphadenopathy in paraaortic and bilateral inguinal. Ascites and pleural fluid cytology examination results were both positive for malignant cells (metastatic adenocarcinoma). The patient was assessed as advanced staged ovarian cancer and procced for Interval Debulking Surgery (IDS) after 3 cycles of Neoadjuvant Chemotherapy (NACT). Postoperative histopathology examination result was high-grade clear cell ovarian carcinoma Conclusion: Fertility-sparing surgery for invasive epithelial ovarian carcinoma could be chosen for selective young age patients who fulfilled the criteria. Education and informed consent is a must regarding the risk of recurrence and prognosis. Keywords: Invasive EOC, fertility sparing, selection criteria, recurrence, prognosis

Uterine sarcomas occur very rarely in young women. Hysterectomy, which is a standard treatment, may not be acceptable for those patients, especially nulliparous women. Fertility-sparing management may be an alternative. The aim of the study was to assess fertility-sparing management in patients with uterine sarcoma. Eleven patients were eligible for the study. Histopathologic types of the tumor included: adenosarcoma (n = 3), low-grade endometrial stromal sarcoma (n = 3), low-grade myofibroblastic sarcoma (n = 1), leiomyosarcoma (n = 1), leiomyosarcoma myxoides (n = 1), rhabdomyosarcoma (n = 1), high grade endometrial stromal sarcoma (n = 1). The mean age of the patients at the time of diagnosis was 27.4 years (range: 17–35) and the average follow-up 61 months (range: 12–158). Six patients received adjuvant treatment: megestrol (n = 5) and chemotherapy (n = 1). Recurrence was diagnosed in five cases. Median time to recurrence was 35 months (range: 8–90). Three patients conceived spontaneously following treatment and gave at least one live birth. In total, five full-term pregnancies were recorded and five healthy children were born. Fertility-sparing management may be considered in some patients with uterine sarcoma; however, it may not be appropriate in high-grade endometrial stromal sarcoma. Patients with adenosarcoma may have a low chance of childbearing. [ABSTRACT FROM AUTHOR]

Sclerosing stromal tumors (SSTs) are rare benign ovarian tumors that occur in adolescents and young adults. They are often treated with unilateral salpingo-oopherectomy due to concern for malignancy. A 13-year-old postpubertal female presented with sharp, constant abdominal pain with physical exam concerning for a lower abdominal mass. An ultrasound revealed a 9.7-cm solid, heterogenous left ovarian mass. The abdomen and pelvis CT confirmed the findings and showed a predominantly cystic mass arising from the left adnexa. During surgery, a smooth and distinct mass arising from the left ovary was encountered without abnormal findings in surrounding structures. A cystectomy was performed, and intraoperative findings showed no evidence of malignancy. Based on the lab, imaging, and surgical findings, staging and salpingo-oopherectomy were not pursued. Given the benign nature of SSTs, it is important to entertain the diagnosis in adolescents presenting with clinically congruent ovarian masses. The minimally invasive approach allows for sparing of the ovary in the adolescent population. [ABSTRACT FROM AUTHOR]

Endometrial cancer is the most common malignancy of the female genital tract. Approximately 25% of cases occur in premenopausal women, and up to 5% of cases occur in women who are younger than 40 years old. The survival rate in these cases is 99%; therefore, uterine-sparing management could be considered under strict criteria selection and the strong desire of the woman to preserve uterus and fertility. Diagnosis should be performed after a hysteroscopic biopsy instead of dilatation and curettage. The highest remission rate was achieved after combining a hysteroscopic resection with hormonal therapy compared to single hormonal treatment. The most common regiments are the following progestins: megestrol acetate (MA) and medroxyprogesterone acetate (MPA) taken orally with a daily dosage of 160 mg–320 mg for MA and 250 mg–600 mg for MP. Evaluations at three and six months could be performed by office endometrial biopsy and/or hysteroscopic directed biopsy especially in the presence of levonorgestrel intrauterine system, and in cases of remission, either a pregnancy attempt or maintenance therapy should be considered. After childbearing, hysterectomy with bilateral salpingo–oophorectomy is recommended, whereas ovarian preservation could be considered depending on the patient's age and whether they fulfil the strict criteria selection. [ABSTRACT FROM AUTHOR]

Extraskeletal Ewing sarcoma is a rare soft tissue tumor primarily affecting pediatric patients. The treatment is currently based on a multidisciplinary approach which allows, in cases of localized disease, good survival rates. We report the case of a 15-year-old female patient with a rapidly growing suspected pelvic mass misdiagnosed following the preliminary radiological exams, which assessed the findings as a mass of ovarian origin. The girl underwent surgery and, thanks to histopathological, immunohistochemical and real-time polymerase chain reaction (RT-PCR) examinations, it was possible to make the right diagnosis and to administer the best treatment in terms of surgery, chemotherapy and radiotherapy, obtaining a long disease-free interval and no recurrence to date.

Benign gynecologic surgery is vital to health care for women in different age groups. Surgical interventions tend to fall into 1 of 2 categories. The first category comprises surgeries specifically aimed at reestablishing or maintaining female reproductive function; this is more succinctly termed fertility-sparing or reproductive surgery. The second category addresses gynecologic conditions in a definitive fashion without focusing on future fertility. Among gynecologic surgeons, the physicians who are reproductive endocrinology and infertility specialists (REIs) are highly trained to be attentive to women's future fertility needs, specifically focusing on minimizing the negative impact of surgery on female reproductive structures/organs. Optimal results during reproductive surgery can be achieved when these procedures are performed through minimally invasive gynecologic surgery (MIGS) approaches. While REIs were the pioneers of microsurgery and MIGS, significant improvement in assisted reproductive technology (ART) outcomes, inadequate surgery compensation, and cultivation of more gynecologists with special training in MIGS have led most REIs to focus primarily on ART as opposed to reproductive surgeries over the last few decades. Given this change in practice pattern, this article reviews the roles that REI subspecialists played in developing microsurgery/MIGS and where the REI specialty currently fits in the spectrum of gynecologic surgeries. (J GYNECOL SURG 38:387) [ABSTRACT FROM AUTHOR]

Objective: Fertility-sparing progestin therapy is highly effective in selected young women with endometrial cancer. In present study, we attempted to evaluate the role of prolonged medication and identify factors predicting successful treatment, and also assess fertility outcomes among young women with early stage endometrial endometrioid carcinoma (EC).Study Design: We retrospectively reviewed clinical data from patients aged <45 years with well-differentiated EC at presumed stage IA (without myometrial invasion) who wished to preserve fertility. They were managed with oral progestin at Kaohsiung Chang Gung Memorial Hospital between June 2005 and June 2019.Results: Forty-five patients were included with a median follow-up of 53.5 months (range 12-170 months). Forty-one patients (91.1%) had complete remission, the cumulative complete response (CR) rates at 3, 6, 9, 12, and >12 months were 17.7%, 48.9%, 60.0%, 68.9% and 91.1%, respectively. Among the 41 responders, 23 attempted to conceive and nine (39.1%) achieved pregnancy with 12 live newborn infants. Eleven (27.5%) responders experienced recurrence at a median of 22 months from CR (range 3-54 months). Multivariate Cox regression analysis revealed that non-diabetes (HR: 4.59; 95% CI: 1.62-12.98) and endometrial thickness <2 cm (HR: 0.39; 95% CI: 1.41-17.67) were significantly factors associated with treatment response.Conclusions: We concluded that prolonged oral progestin treatment was possible with a certain proportion of responders (24.4%) being responded after one year. Diabetes controlled on metformin and endometrial thickness <2 cm could be used as surrogate markers to predict better treatment response. [ABSTRACT FROM AUTHOR]

The prevalence of uterine fibroids is estimated to be approximately 80%. Fibroids can be associated with abnormal uterine bleeding, pressure symptoms, and infertility. Given this high prevalence, approximately 30,000 myomectomies are performed in the United States per year. Minimally invasive approaches are preferred, if feasible. The minimally invasive techniques include laparoscopic, robot-assisted, hysteroscopic, and mini-laparotomy. To discuss the multiple techniques for optimizing the use of mini-laparotomy in minimally invasive myomectomy. We use intraoperative surgical video to demonstrate techniques that optimize the use of the mini-laparotomy for myomectomy. Cleveland Clinic. Patient's undergoing fertility preserving, minimally invasive myomectomy at the Cleveland Clinic. The patient(s) included in this video gave consent for publication of the video and posting of the video online, including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus), and other applicable sites. After the surgeon has selected to proceed with mini-laparotomy myomectomy, different techniques can be employed to optimize management. We demonstrate and discuss these techniques to ensure that surgeons have a set of tools to tackle a fibroid uterus. These techniques include direct palpation of the fibroids, use of a uterine manipulator to visualize the endometrial cavity, use of the uterine manipulator to aid in repair of the cavity if entered, suturing technique that avoids the endometrial cavity and therefore limits foreign body exposure and decreases intrauterine adhesion formation, utilization of barbed suture in a layered fashion, in-situ debulking to avoid injury to fallopian tubes and other critical uterine structures, easy identification of the optimal enucleation plane, use of single hysterotomy for multiple fibroids, visualization of the "Tortuga" sign, and evaluation of the abdominal cavity using the mini-laparotomy site as a port site. To limit postoperative adhesion formation, the investigators place cellulose-based adhesion barriers with peritoneum closure. Although the need for prolonged postoperative observation can be made on a case-by-case basis, we consider this as an outpatient surgery and anticipate same-day discharge for our patients. In this video, we perform a mini-laparotomy myomectomy optimally and describe the techniques employed. Specific techniques employed in mini-laparotomy myomectomy make the case safe, effective, and can lead to same-day discharge. Mini-laparotomy myomectomy is a technique used to perform minimally invasive myomectomy. Following the discussed steps, surgeons can be more confident in performing this method of myomectomy. [ABSTRACT FROM AUTHOR]

To present a case of concurrent uterine arteriovenous malformation (AVM) and isthmocele, treated with ethylene vinyl alcohol copolymer (EVAC) embolization of the AVM followed by robotic isthmocele repair. A stepwise video demonstration with narration. A tertiary care academic hospital. Patient is a 37-year-old with one previous cesarean section who presented with persistent heavy vaginal bleeding after a dilation and evacuation procedure. Imaging showed evidence of an isthmocele and an iatrogenic uterine AVM secondary to the dilation and evacuation procedure. Both entities are morbid conditions associated with significant operative blood loss. Embolization of the acquired AVM was first performed to stabilize bleeding. In addition, owing to the extensive uterine defect and history of infertility, surgical repair of the isthmocele was recommended. A multidisciplinary approach combining interventional radiology and gynecologic surgery expertise, implementing several strategies to minimize blood loss: 1. Image-guided uterine AVM embolization with EVAC [1] 2. Hysteroscopic identification of isthmocele and residual EVAC in the cavity, with fluorescence transillumination to clearly delineate isthmocele borders 3. Robot-assisted laparoscopic approach for bladder flap creation, as well as retroperitoneal space dissection to skeletonize uterine arteries 4. Transient occlusion of uterine arteries using vascular clamps to minimize operative blood loss given the isthmocele size and its proximity to the left uterine artery 5. Resection of the isthmocele and removal of residual intracavitary EVAC 6. Multilayer, bidirectional hysterotomy closure and vascular clamp removal to restore uterine blood supply Successful multidisciplinary treatment of concurrent uterine AVM and isthmocele. Cesarean delivery at 36 to 37 weeks' gestational age was recommended for future deliveries. [ABSTRACT FROM AUTHOR]

Aims. Curative sphincter sparing radiotherapy is a treatment option for early rectal cancer. There are many methods developed for fertility preservation in young patients treated with pelvic radiotherapy. Pregnancy rates after radiotherapy are dependent on the radiation dose to ovaries and uterus. Data on outcomes of total body irradiation suggest a pregnancy is possible following 12-14 Gy TBI, despite elevated rates of preterm deliveries and other complications. Methods. We report a case of full-term delivery of twins after curative chemoradiotherapy for anorectal adenocarcinoma T2 N0 M0 with the total dose 58.6 Gy. The patient underwent laparoscopic laterocranial ovarian transposition before radiotherapy. Results. Long term complete remission was achieved after treatment. Although a spontaneous conception was not successful, the patient underwent an in vitro fertilisation procedure with donor eggs and conceived twins 10 years after the radiotherapy treatment. The mean dose to the uterus was 16 Gy and to the uterine cervix 35 Gy. She reached a full-term pregnancy and delivered two healthy babies by caesarean section at a gestational age of 38 weeks, weighing 2420 g and 2220 g. Conclusion. This is the first case report of the successful pregnancy following sphincter sparing curative pelvic radiotherapy for rectal cancer. Furthermore it allows us to propose an increased limit dose to the uterus enabling fertility sparing beyond the limits achieved from total body irradiation series with 12-14 Gy and accept 16 Gy as uterine body (35 Gy for uterine cervix) limit for IMRT treatment planning in young patients asking for maintaining fertility potential.

Endometrioid endometrial cancer (EEC) is the most common gynecologic malignancy worldwide. One in four cases will be diagnosed before menopause. Endometrial atypical hyperplasia (EAH) is a precursor of endometrial cancer and tends to occur at a young age. Those who have early stage, grade 1 EEC or EAH and wish to preserve their fertility can be managed with hormonal therapy. Hysteroscopic treatment in addition to progestin therapy has been used more commonly in the last decade. Herein, a review of available data on hysteroscopic treatment in EEC and EAH is presented. [ABSTRACT FROM AUTHOR]

Clear cell carcinoma of the ovary (CCOC), accounts for 5–25% of epithelial ovarian cancer (EOC) cases. A significant proportion of patients with CCOC are of reproductive age, wishing to preserve their fertility. The application of fertility sparing surgery (FSS) in those patients has been extensively criticized, due to the high reported recurrence rates and chemotherapy resistance. The aim of the present study was to accumulate the current knowledge on obstetric and fertility outcomes of patients with early stage CCOC who underwent fertility sparing surgery. A meticulous search of 3 electronic databases was conducted for articles published up to June 2020 relevant in the field using the terms "ovarian cancer", "clear cell", "fertility sparing", "conservative treatment". Studies that reported pregnancy and maternal outcomes after fertility sparing surgery for the management of early stage CCOC were considered eligible. A total of 5 studies which comprised of 60 patients with early stage CCOC, who underwent fertility-sparing surgery, were reviewed. Ten patients (16.6%) had disease recurrence. The total clinical pregnancy rate of 32% with a proportion of 24% of live birth rates in 12 of the included patients. The median interval from surgery to pregnancy was 41.5 months, while no evidence of disease was recorded among the patients who achieved pregnancy. No difference in survival and recurrence rates among patients who underwent fertility-sparing surgery and those who had radical surgical procedures. Fertility-sparing treatment for International Federation of Gynaecology and Obstetrics (FIGO) Stage IA/IC CCOC seems to be an acceptable treatment option for selected premenopausal women who strongly wish to preserve their childbearing potential. However, larger studies are needed to validate the safety of the procedure. [ABSTRACT FROM AUTHOR]

Ovarian germ cell tumors of the ovary represent a histologically heterogenous group of tumors with a high incidence at reproductive age. Patients with this pathology are very often young women with amenorrhea. The aim of this article is to present a pictorial essay of this rare pathology and to promote a national tumor registry and protocol. The treatment is individualized according to age, and fertility-sparing surgery is the actual standard of surgical treatment for young patients in early stage of the disease.

Objective: To evaluate timing and a prediction model for pregnancy in early-stage cervical cancer patients who underwent fertility-sparing trachelectomy.Design: Retrospective cohort.Setting: Academic multicenter.Patient(s): Women ages <45 years with clinical stage I-II cervical cancer were enrolled between 2009 and 2013 (n = 393).Intervention(s): Planned fertility-sparing trachelectomy.Main Outcome Measure(s): Cumulative incidences and clinicopathological characteristics of those who developed subsequent pregnancy were examined.Result(s): There were 77 (21.6%) women who had subsequent pregnancies after fertility-sparing trachelectomy with 1-, 2-, and 5-year cumulative pregnancy rates of 2.8%, 6.2%, and 17.4%, respectively. The median time to develop subsequent pregnancy was 3.2 years. In a competing risk analysis, women had a higher risk of recurrent cancer than conception during the first 11 months postsurgery. On multivariable analysis, younger age, being married, and postoperative reproductive treatment were independently associated with an increased chance of developing a subsequent pregnancy. The subsequent pregnancy index (SPI) score to predict the likelihood of having pregnancy was proposed, and it was calculated based on age, marital status, and reproductive treatment (2, 2, and 4 points, respectively). Women with a higher SPI score had significantly higher subsequent pregnancy rates (5-year pregnancy rate; the score was 3 in 4.7% of cases; 4 to 5 in 11.3%; 6 to 7 in 27.4%; and 8 in 50.8%), but they had similar recurrence rates (5.0%).Conclusion(s): The SPI score proposed in our study is useful in predicting subsequent pregnancy in women with early-stage cervical cancer undergoing fertility-sparing trachelectomy. [ABSTRACT FROM AUTHOR]

Introduction: Ectopic pregnancy is the most common cause of mortality during the first trimester of pregnancy, and intrauterine ectopic pregnancies show significantly higher morbidity and mortality than extrauterine ones. Despite being less invasive, safety and effectiveness of the hysteroscopic treatment are still unclear. Moreover, such approach is not standardized. We aimed to evaluate safety and effectiveness of hysteroscopic intact removal of angular or cesarean section scar pregnancies, defining a novel and markedly less invasive hysteroscopic technique with a 5-mm Bettocchi hysteroscope or a 3.5-mm Versascope hysteroscope.Materials and Methods: Medical records and video archives were reviewed for all the patients with angular or caesarean scar pregnancies treated with hysteroscopic intact removal technique from January 2000 to December 2018 at our Department. Success and complication rates were assessed.Results: Four patients with angular (n = 1) or cesarean scar pregnancy (n = 3) met inclusion criteria. Case #1 was treated with bipolar resectoscope, cases #2 and #3 with 5-mm Bettocchi hysteroscope, and case #4 with 3.5-mm Versascope hysteroscope. Cases #2-4 did not require cervical dilatation. Before hysteroscopic treatment, cases #2-4 underwent unsuccessful medical therapy with multiple-dose methotrexate. Hysteroscopic treatment success rate was 100%, while complication rate was 0%. All patients were treated with a novel technique: hysteroscopic intact removal of angular or cesarean scar pregnancies. Such technique was described step-by-step.Conclusions: Hysteroscopic treatment of angular and cesarean scar pregnancies may be a safe and effective minimally invasive option. The novel technique of hysteroscopic intact removal technique may allow a markedly less invasive approach. [ABSTRACT FROM AUTHOR]

Uterine tumor resembling ovarian sex-cord tumor (UTROSCT) is a rare distinct cancer included in the current World Health Organization classification of endometrial stromal tumors. A battery of immunohistochemical markers are necessary for accurate diagnosis. Although few case reports and case series have been documented and therefore providing robust prognostic information several authors agree to consider UTROSCT as a low malignant potential tumour. In literature only five cases of conservative management were reported. We reported our experience and a review of conservative cases of literature. In this article we describe a series of 10 cases of UTROSCT and their clinical and pathologic feature. We report two cases of conservative surgical approach obtaining a successfully pregnancies. All of the patients are still alive. In conclusion, fertility sparing surgery should be offered to patients who wish preserve their fertility however radical surgery must be considerate after childbirth. Close follow-up is required for all patients due to the lack of prognostic biomarkers and long follow up is needed to evaluate safety of conservative surgery. [ABSTRACT FROM AUTHOR]

Background: Given that borderline ovarian tumors (BOTs) are usually found in young, fertile women without a history of childbirth, fertility preservation should be considered in the treatment plan. This retrospective study aimed to evaluate the safety of ovarian cystectomy in patients with BOTs. Methods: Patients with BOTs treated between August 2007 and August 2016 at our institution were divided into two groups according to the type of surgery: the cystectomy group and the oophorectomy group with or without salpingectomy, and differences in surgical outcomes were compared. The cumulative disease recurrence was also compared using Kaplan–Meier curves. Results: Of the 162 patients enrolled, 128 (79.0%) underwent an oophorectomy with or without salpingectomy and 34 (21.0%) underwent an ovarian cystectomy. The patients in the cystectomy group were younger than those in the oophorectomy group (29.2 years vs. 46.5 years, p < 0.001), and the proportion of patients who underwent minimally invasive surgery was higher in the cystectomy group than in the oophorectomy group (88.2% vs. 46.9%, p < 0.001). During the mean follow-up period of 44 months, six patients (3.70%) developed disease recurrence (five [3.9%] and one [2.9%] in the oophorectomy and cystectomy groups, respectively). The two-year disease-free survival rate was 97.1% and 97.6% in the cystectomy and oophorectomy groups, respectively, and did not differ between the groups (p = 0.818). Discussion: Ovarian cystectomy can be considered a safe and effective option for young women with BOTs who wish to preserve their fertility.

Objective: To evaluate long-term outcomes after surgery for apparent early-stage ovarian cancer (OC).Methods: Retrospective analysis of women who underwent staging surgery for apparent early-stage OC at a single center in Milan, Italy, from 1990 to 2008, and had a follow-up longer than 10 years (living women with no recurrence). Univariate and multivariate analyses and propensity score matching were carried out.Results: Overall, 182 women underwent radical (n=148, 81.3%) or conservative (n=34, 18.7%) procedures for early-stage OC. Ten-year disease-free and overall survival were 82.9% (n=151) and 87.9% (n=160), respectively. Conservative or radical surgery had similar disease-free (log-rank test, P=0.783) and overall (log-rank test, P=0.783) survival. These data were confirmed after the application of propensity score matching. High-risk features correlated with non-significant worse disease-free survival (P=0.080). In the high-risk group (≥Grade 3 or ≥ Stage IC), type of surgical approach (conservative vs radical) did not affect survival (hazard ratio, 0.81; 95% confidence interval, 0.18-3.56; P=0.781).Conclusion: Women with early-stage OC had encouraging long-term survival. The presence of high-risk disease had detrimental effects on survival, regardless of surgical approach. High-risk disease should not be considered a contraindication to conservative surgery. [ABSTRACT FROM AUTHOR]

The appendix and ovaries are rarely involved simultaneously in malignancies. The decision to perform an ovarian biopsy or a surgical resection in young patients can be challenging without sufficient clinical information. We describe an 11-year-old girl with bilateral ovarian masses, an enlarged appendix, associated pleural effusion, and ascites. Appendectomy and biopsy of the bilateral ovarian masses led to a diagnosis of aggressive B-cell non-Hodgkin lymphoma. The patient was treated with chemotherapy, which achieved complete remission and bilateral ovarian preservation. If ovarian involvement in malignant lymphoma is suspected, diagnostic methods should spare the ovary and prevent a loss of fertility. To evaluate for possible chemotherapy-induced ovarian damage, including infertility and premature menopause, an interdisciplinary approach is needed for the long-term follow-up of adolescent girls. [ABSTRACT FROM AUTHOR]

Fertility-sparing surgery (FSS) is an established concept within operative gynaecology. Intraoperative ultrasound (IOUS) has the potential of assessing lesion margins, allowing complete resection with minimal damage to the surrounding healthy tissue and could potentially play a major role in FSS for benign or malignant gynaecological pathologies. In this paper, we review the current literature on the use of IOUS in gynaecological FSS. We also propose technical guidance on the IOUS during FSS. The findings of this review demonstrate that IOUS can assist in the safe resection of disease with high rates of completion, low rates of recurrence and without damage to the nearby healthy reproductive organs. Improved training in transvaginal ultrasonography and minimal access surgery are likely to facilitate the application of IOUS in FSS. [ABSTRACT FROM AUTHOR]

(Chemo)radiation may be a required treatment in young women with pelvic malignancies. Irradiation may result in ovarian and uterine failure, compromising the fertility of those patients. While ovarian transposition is an established method to move the ovaries away from the irradiation field, similar surgical procedures regarding the uterus remain investigational. The aim of this study was to carry out a systematic review of the literature on uterine displacement techniques (ventrofixation/transposition) and to simulate the radiation dose received by the uterus in different heights place after the procedures. The systematic review was performed according PRISMA guidelines. PubMed, Scopus, Web of Science and EMBASE were queried to identify included study until March 2023. Retrospectively, a dosimetric study was also performed and Volumetric Modulated Arc Therapy (VMAT) radiotherapy treatment plans were calculated, to assess the dose received by the uterus according to hypothetical different displacement positions taking the case of irradiation for rectal or anal cancer as model. A total of 187 studies were included, after the screening 9 studies were selected for synthesis. Data from the dose simulation revealed that the transposition approach was the most protective with a maximum dose of about 3 and 8 Gy for anal and rectal cancer respectively. None of the simulated ventrofixation positions received a Dmean surpassing 14 Gy. According to the literature review and the simulation results of the present study we may conclude are feasible and safe as fertility sparing approach in young rectal/anal cancer patients. [ABSTRACT FROM AUTHOR]

Endometrial cancer is the most frequent gynecological malignancy, and, although epidemiologically it mainly affects advanced age women, it can also affect young patients who want children and who have not yet completed their procreative project. Fertility sparing treatments are the subject of many studies and research in continuous evolution, and represent a light of hope for young cancer patients who find themselves having to face an oncological path before fulfilling their desire for motherhood. The advances in molecular biology and the more precise clinical and prognostic classification of endometrial cancer based on the 2013 The Cancer Genome Atlas classification allow for the selection of patients who can be submitted to fertility sparing treatments with increasing oncological safety. It would also be possible to predict the response to hormonal treatment by investigating the state of the genes of the mismatch repair.

Endometrial cancer (EC) is a deleterious condition which strongly affects a woman’s quality of life. Although aggressive interventions should be considered to treat high-grade EC, a conservative approach should be taken into consideration for women wishing to conceive. In this scenario, we present an overview about the EC fertility-sparing approach state of art. Type I EC at low stage is the only histological type which can be addressed with a fertility-sparing approach. Moreover, no myometrium and/or adnexal invasion should be seen, and lymph-vascular space should not be involved. Regarding the pharmaceutical target, progestins, in particular medroxyprogesterone acetate (MPA) or megestrol acetate (MA), are the most employed agent in conservative treatment of early-stage EC. The metformin usage and hysteroscopic assessment is still under debate, despite promising results. Particularly strict and imperious attention should be given to the follow-up and psychological wellbeing of women, especially because of the double detrimental impairment: both EC and EC-related infertility consequences.

Background: Adenocarcinoma in situ (AIS) of the cervix, is increasing in incidence, particularly in women of reproductive age. Fertility preservation is often desired. In a predominantly Hispanic population, we sought to determine the incidence of occult cervical cancer co-existing with AIS, and evaluate how conization margin status correlates with residual disease upon hysterectomy. Methods: A retrospective study utilizing a comprehensive cancer center database was conducted. Data from patients with histologically proven AIS of the cervix were abstracted. Results: Of 47 patients that met the criteria, 23 (49%) were Hispanic, 21 (45%) were White, two (4%) were Asian, and one (2%) was Black. The median age was 37. Forty-two patients underwent cervical conizations; 13/42 (48%) had positive margins upon conization; 28/42 (67%) underwent hysterectomies. Furthermore, 6/13 (46%) patients with positive conization margins had residual disease in hysterectomy specimens, with 2/13 (15%) found to have invasive cancer. In contrast, 0/14 (0%) of patients with negative margins had residual disease (p = 0.036, Chi-squared 4.41, df = 1). In total, 2/27 (7%) patients who underwent hysterectomies had invasive cancer (7%). Conclusions: Positive margins upon cervical conization for AIS of the cervix were correlated with a relatively high rate of residual AIS and occult invasive cancer. Negative conization margins were correlated with no residual disease. Those patients may be candidates for fertility-sparing treatment.

Radical trachelectomy is considered in patients with early-stage cervical cancer who desire future fertility. This article is accompanied by a video that provides step-by-step demonstration of a uterine artery-sparing robotic-assisted radical trachelectomy in a patient with stage IB1 squamous cell carcinoma of the cervix, a 2-cm mass, and a desire for future fertility. We also conducted a review of the literature examining the use of uterine artery-sparing techniques among minimally invasive radical trachelectomies. Using PubMed, Google Scholar, and Ovid search tools, 28 total publications were reviewed, of which 16 were eligible for use in our comparison. With the addition of our case report, a total of 154 cases sparing the uterine artery and 40 cases sacrificing the uterine artery were examined, including both conventional laparoscopic and robotic-assisted approaches. Data describing patient demographics as well as surgical, oncologic, and fertility outcomes were collected. The mean age was 30 years for the spared group and 32 years for the sacrificed group. At least 42% of the women in the spared and 53% of the uterine artery-sacrificed group were nulliparous. The majority of cases in both the spared and sacrificed groups represented squamous cell histology (71% for spared and 51% for sacrificed) followed by adenocarcinoma (24% vs 43%). The majority of the patients in both groups had stage IB1 disease (79% for spared vs 65% for sacrificed). The operative times among the 2 groups were similar, with a mean time of 314 minutes (range, 170-420 minutes) in the spared group and 283 minutes (range, 172-345 minutes) in the sacrificed group. The mean estimated blood loss was 173 mL (range, 23-300 mL) in the spared group and 77 mL (range, 50-250 mL) in the sacrificed group. The recurrence rates for the uterine artery-sparing and -sacrificing groups were equal at 2.6% after a mean follow-up of 42 months and 26 months, respectively. The methods of reporting fertility outcomes were varied among the different publications, with 41 patients achieving pregnancy in the spared group and 2 patients achieving pregnancy in the sacrificed group. Among patients who were not trying to conceive or had not conceived, 15 patients in the spared group and 6 patients in the sacrificed group were reported to have normal menses. The successful preservation of uterine arteries supports the maintenance of uterine arterial blood flow and is used by many gynecologic surgeons performing minimally invasive radical trachelectomy, with promising oncologic and obstetric outcomes. [ABSTRACT FROM AUTHOR]

Background: Endometrial cancer and atypical hyperplasia are rare in young women but create a dilemma between desire for pregnancy and oncologic outcomes.Objective: To identify remission rates and associated prognostic factors in patients undergoing fertility-sparing management for endometrial cancer and atypical hyperplasia.Search Strategy: MEDLINE was searched for studies published between January 1, 1950 and July 31, 2017 using various search terms.Selection Criteria: Studies evaluating fertility-sparing management in patients aged between 19 and 44 years with atypical hyperplasia or stage I endometrial cancer.Data Collection and Analysis: Use of PRISMA guidelines to conduct a meta-analysis of the proportion of patients in remission and meta-regression analysis to test the effect of possible prognostic factors for remission.Main Results: A total of 3673 studies were screened; 65 studies including 1604 patients met the inclusion criteria. The remission rate was 0.75 (95% CI, 0.73-0.77). Operative hysteroscopy for endometrial sampling was associated with higher remission rates (OR 2.31; 95% CI, 1.10-4.84; P=0.03). Studies with higher ratios of infertile women were associated with higher remission rates (OR 4.21; 95% CI, 1.44-12.33; P<0.01).Conclusion: Operative hysteroscopy is the preferred endometrial sampling method for patients with atypical hyperplasia or endometrial cancer undergoing fertility-sparing management. [ABSTRACT FROM AUTHOR]

Purpose: Cervical cancer (CC) ranks 2nd for mortality among women of reproductive age in the United States. Abdominal radical trachelectomy (ART) is a fertility sparing approach that has been proposed in women with early stage CC who wish to preserve their fertility. The aim of the present meta-analysis was to evaluate the short- and long-term outcomes of RH vs ART for early stage CC.Methods: A total of 5 electronic databases were searched for articles published up to December 2018. Prospective and retrospective trials reporting outcomes for women who underwent ART or RH for the management of early stages CC, were considered eligible for inclusion. Statistical meta-analysis was performed using the RevMan 5.3 software.Results: A total of 5 studies which included 840 women who underwent ART or radical trachelectomy (RH) were included in the present meta-analysis. Among them, 324 underwent ART whereas the remaining 516 had RH. Despite the fact that ART was associated with significantly prolonged operative time compared to RH (840 patients MD 36.82 min, 95% CI 20.15-53.49, p < 0.001), neither 5-year OS nor 5-year DFS were different among the two groups (714 patients OR 1.39, 95% CI 0.53-3.62, p = 0.51 and 682 patients OR 1.08, 95% CI 0.52-2.25, p = 0.84, respectively).Conclusions: ART is a more complex and time consuming technique, but equally safe compared to RH in terms of oncological outcomes for selected women with early stage CC and allows for more CC survivors of childbearing age to preserve their fertility. [ABSTRACT FROM AUTHOR]

Aims. Curative sphincter sparing radiotherapy is a treatment option for early rectal cancer. There are many methods developed for fertility preservation in young patients treated with pelvic radiotherapy. Pregnancy rates after radiotherapy are dependent on the radiation dose to ovaries and uterus. Data on outcomes of total body irradiation suggest a pregnancy is possible following 12-14 Gy TBI, despite elevated rates of preterm deliveries and other complications. Methods. We report a case of full-term delivery of twins after curative chemoradiotherapy for anorectal adenocarcinoma T2 N0 M0 with the total dose 58.6 Gy. The patient underwent laparoscopic laterocranial ovarian transposition before radiotherapy. Results. Long term complete remission was achieved after treatment. Although a spontaneous conception was not successful, the patient underwent an in vitro fertilisation procedure with donor eggs and conceived twins 10 years after the radiotherapy treatment. The mean dose to the uterus was 16 Gy and to the uterine cervix 35 Gy. She reached a full-term pregnancy and delivered two healthy babies by caesarean section at a gestational age of 38 weeks, weighing 2420 g and 2220 g. Conclusion. This is the first case report of the successful pregnancy following sphincter sparing curative pelvic radiotherapy for rectal cancer. Furthermore it allows us to propose an increased limit dose to the uterus enabling fertility sparing beyond the limits achieved from total body irradiation series with 12-14 Gy and accept 16 Gy as uterine body (35 Gy for uterine cervix) limit for IMRT treatment planning in young patients asking for maintaining fertility potential. [ABSTRACT FROM AUTHOR]

Non-tubal ectopic pregnancies (NT-EPs) are rare but potentially life-threatening conditions. The incidence ranges are between 5–8.3% of all ectopic pregnancies. For this retrospective observational study, 16 patients with NT-EP and treated from January 2014 to May 2020 were recruited. Demographic details, symptoms, Beta human chorionic gonadotrophin (β-hCG) levels, ultrasound findings, management and treatment outcomes were presented. In hemodynamically stable patients, diagnosis was made using ultrasounds and β-hCG levels. Laparoscopy was essential to identify and remove the ectopic pregnancy in clinical unstable patients. A radical laparoscopic approach was chosen in one case of cervical pregnancy diagnosed late in the first trimester. Medical treatment and minimally invasive procedure, alone or combined, resulted in effective strategies in asymptomatic women with an early diagnosis of NT-EP. We report cases of cervical pregnancies successfully treated by hysteroscopy alone or combined with medical treatment, the first case of scar pregnancy treated by mini-reseptoscope and curettage and the fifth case of interstitial pregnancy treated with Methotrexate and Mifepristone. In this manuscript we report a single center experience in the management of NT-EPs with the aim of outlining the importance of the early diagnosis for a minimally invasive treatment in order to reduce maternal morbidity and mortality and preserve future fertility.

Endometrial carcinoma (EC) is the most common gynaecological cancer, with 2-14% of cases occurring in women

Background/aim: The vanishing cancer phenomenon was first reported in radical prostatectomy specimens in the absence of neoadjuvant treatment. Reported cases are mostly well-differentiated and low-volume tumors. A similar entity was described for hysterectomy specimens of patients with biopsy proven endometrial cancer (EC). In this study, we discuss the probable reasons for vanishing EC and long-term follow-up results of EC patients without residual tumors in hysterectomy specimens. Materials and methods: This study was carried at two institutions in Ankara, Turkey, in a retrospective design. The computerized databases of both institutions were searched for endometrioid type EC patients whose final pathological specimens failed to show any residual tumor. Results: We evaluated 38 endometrial biopsy confirmed EC patients with no residual tumor detected in the hysterectomy specimens among a total of 224 women (17%) with the disease confined to the endometrium. During the follow-up period, no recurrences were noted among the patients. Conclusion: It can be suggested that premenopausal women with FIGO grade 1 endometrioid type EC with MRI proven "absent myometrial invasion" would have a significant probability of having no residual tumor after endometrial biopsy without any further medical treatment. [ABSTRACT FROM AUTHOR]

Objective To evaluate the prevalence and safety of uterine preservation among premenopausal women diagnosed with a malignant ovarian germ-cell tumor (MOGCT) of advanced stage (stage II-IV). Materials and methods The National Cancer Database was accessed and a cohort of women aged < 40 years, diagnosed with a MOGCT were identified. Those with stage II-IV disease who underwent cancer-directed surgery and received chemotherapy were selected for further analysis. Performance of hysterectomy was assessed from site-specific surgery codes. Overall survival (OS) was determined following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox multivariate model was constructed to control for possible confounders. Results A total of 526 eligible patients were identified; rate of hysterectomy was 20.2%. Women who had a hysterectomy were older (median age 30.5 vs 20 years, p < 0.001) and more likely to present with bilateral tumors (12.6% vs 3.8%, p < 0.001). No differences were noted based on tumor histology (p = 0.67). Rate of uterine preservation was 82.8%, 79.5% and 75% for those with stage II, III and IV disease respectively (p = 0.46). There was no difference in OS between women who had hysterectomy and those who did not (p = 0.051); five-year OS rates were 87.1% and 94.4% respectively. After controlling for disease stage, tumor histology and patient race, uterine preservation was not associated with a decreased survival (HR: 0.59, 95% CI: 0.28, 1.24, p = 0.19). Conclusions Uterine preservation was not associated with decreased survival and should be considered in women with advanced stage GCTs interested in future fertility. [ABSTRACT FROM AUTHOR]

Endometrial cancer is the fifth most common female cancer worldwide and the third leading female cancer in the Western world. The marked surge in endometrial cancer incidence is alarming. The aim of the present review is to focus on endometrial cancer affecting young women of reproductive age. Surgery, namely abdominal or laparoscopic hysterectomy, with or without salpingo-oophorectomy, and sentinel lymph node detection has become the standard surgical strategy for early stage endometrioid endometrial cancer. However, premenopausal women might want to preserve their fertility, especially if they are nulliparous or have not reached their desired number of children at the time of diagnosis. Conservative, uterus-sparing treatment, based on progestin products, may be an advantageous option for patients meeting the necessary criteria. Potential candidates have to be committed to following a rigorous protocol of treatment, investigations and follow-up. The evidence in favor of this approach, although limited, is encouraging and patients who have achieved a histologically documented disease complete remission could attempt to conceive spontaneously or with the immediate use of assisted reproductive technology techniques. The risk of partial or negative response to progestin treatment or cancer recurrence is well documented, thus patients have to be aware of the possible need for interruption of conservative treatment and hysterectomy. [ABSTRACT FROM AUTHOR]

Purpose: To validate the oncological safety of fertility preservation in malignant ovarian germ cell tumors (MOGCTs) and to define the significance of maximal cytoreduction in early stage MOGCTs. Materials and Methods: Sixty-nine patients with stage I and II MOGCTs who underwent surgical treatment were included in the study. Fertility-sparing surgery is defined as conservative surgery and hysterectomy and contralateral salpingo-oophorectomy were defined as definitive surgery. Both surgical approaches involved lymphadenectomy and omentectomy. Most patients received platinum-based combinations for adjuvant therapy. Survival outcomes of the conservative surgery group were compared with the definitive surgery group. Results: Median age of the study group was 21 years (range: 12-40 years). Median tumor size measured 150 mm (range, 20-300 mm). Surgery type (conservative surgery vs. definitive surgery) and lymphadenectomy (performed vs. not performed) were insignificant for the recurrence ( p = 0.758, p = 0.271). However, surgical outcome (maximal vs. optimal and suboptimal) and type of tumor (dysgerminoma vs. nondysgerminoma) determined the recurrence ( p = 0.001, p = 0.021). Conclusion: Fertility-conserving approach is safe in early stage MOGCTs. However, maximal cytoreduction should be achieved in this group of patients, without conceding fertility-conserving approach. On the other hand, development of chemotherapy options with less gonadotoxic effects, but equal or stronger efficiency in comparison with platinum-based chemotherapy, will certainly facilitate management of this patient group. [ABSTRACT FROM AUTHOR]