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ΟBJECTIVE: This study aimed at comparing survival outcomes between systematic axillary lymph node dissection (ALND) vs sentinel lymph node and axillary lymph node dissection only if sentinel positive (SLN ± ALND) in early-stage, clinically node-negative breast cancer patients. ΜETHODS: A systematic review and meta-analysis adhered to PRISMA guidelines was performed. Included studies were prospective randomized controlled trials (RCTs) comparing survival outcomes of ALND vs. SLN ± ALND in early-stage, node-negative breast cancer patients. Patients enrolled were only those with tumor size lower than 4 cm, clinically negative nodes and treated with breast-conservative surgery. Primary endpoints were locoregional recurrence, overall death and cancer-related death. RESULTS: There were four studies included in the analysis, enrolling overall 2982 patients, of which 1494 in ALND arm and 1488 in the SLN ± ALND arm. No statistically significant difference was observed in locoregional recurrence, breast cancer-related death and overall death. Locoregional recurrence was observed in 2.8% (ALND) vs. 4.1% (SLND ± ALND), (RR 0.69, 95% CI 0.20-2.30). Overall death rate was 7.0% vs. 6.8% respectively, (RR 1.00, 95% CI 0.73-1.39, I

Background: In Greece the population-level impact of HPV vaccination is unknown due to lacking official registries. This study presents in a pragmatic frame the comparison of cervical pathology data between HPV-vaccinated and unvaccinated women referred for colposcopy. Materials and Methods: This is an observational prospective cohort study performed in 7 academic Obstetrics & Gynaecology departments across Greece between 2009-2019. Cases were women that had completed HPV vaccination before coitarche and were referred for colposcopy due to abnormal cytology. For each vaccinated woman an unvaccinated matched control was selected. Results: A total of 849 women who had been vaccinated before coitarche and 849 unvaccinated controls were recruited. The combination of cytological, colposcopic and molecular findings necessitated treatment in only a single case among vaccinated (0.1%) and in 8.4% among unvaccinated. Conclusion: Despite potential bias, this study’s message is clear: HPV vaccination at a proper age can markedly reduce development of severe cervical precancer and consequently, the need for treatments with their long-term related obstetrical morbidity.

Introduction: Approximately 1% of adolescents have polycystic ovary syndrome (PCOS) and almost 40–70% of these patients are overweight or obese. Obese adolescents with PCOS have more severe...

Inguinal endometriosis is a very rare entity with uncertain pathophysiology, that poses several diagnostic and therapeutic challenges. This study aimed to summarize published literature on the diagnosis and treatment of this condition. Thus, a systematic literature search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library. An effort was made to numerically analyze all parameters included in case reports and retrospective analyses, as well. The typical and atypical features of this condition, investigations used, type of treatment and histopathology were recorded. More specifications about the surgical treatment, such as operations previously performed, type of surgery and treatment after surgery have been acknowledged. Other sites of endometriosis, the presence of pelvic endometriosis and the follow-up and recurrence have been also documented. Overall, the search yielded 61 eligible studies including 133 cases of inguinal endometriosis. The typical clinical presentation includes a unilateral inguinal mass, with or without catamenial pain. Transabdominal or transvaginal ultrasound was typically used as the first line method of diagnosis. Groin incision and exploratory surgery was the treatment indicated by the majority of the authors, while excision of part of the round ligament was reported in about half of the cases. Chemotherapy and radiotherapy were initiated in cases of coexisting endometriosis-related neoplasia. Inguinal recurrence or malignant transformation was rarely reported. The treatment of inguinal endometriosis is surgical and a long-term follow-up is needed. More research is needed on the effectiveness of suppressive hormonal therapy, recurrence rate and its relationship with endometriosis-associated malignancies.

Background Paediatric and adolescent gynaecology is a special field of interest within general gynaecology and obstetrics. The care for children and young people differs from adults. In gynaecology, children should not be treated like little adults. Within Europe, there is great variability in the provision of care, availability of clinical networks and lack of national standards within paediatric and adolescent gynaecology. Therefore, this review aims to summarize the current evidence regarding best clinical practice within Europe. Methods A search was performed in Embase and Medline from 1974 onwards. Inclusion criteria were paediatric and adolescent population, gynaecology or reproductive health, care provision and evidence based clinical guidelines. In most papers recommendations were made, so no outcome measures could be used. It was, therefore, not possible to perform a meta-analysis. The risk of bias of the studies was assessed according to the GRADE and AGREE-2 guidelines. Results 91 papers were identified and a total of 7 papers were included in the final analysis. The main recommendations are: - improvement for accessibility for healthcare facility, - training of healthcare staff in communication and examination according to developmental age, - develop evidence based clinical guidelines and standardize content of care delivered, - add training in general adolescent topics to training curriculum of paediatric and adolescent gynaecology. Conclusion and implications There is limited information about best clinical practice and low quality of evidence of healthcare service available in the field of Paediatric and Adolescent Gynaecology. As a result there is a need to refine standards of training and care. EURAPAG should encourage adaptation of the unified standards of care in each European country. Furthermore, at this moment, there is insufficient inclusion of curriculum related to PAG in the undergraduate and post graduate training for recognition of patterns and symptoms in young women. EURAPAG should not only take a lead to develop common curriculum for undergraduate and post graduate education and training to address this unmet need but should also lead on their implementation within Europe.

Large Loop Excision of the Transformation Zone (LLETZ) is thought to be the treatment of choice for the high-grade precancerous lesions. The cone is also the “gold standard” specimen for the diagnosis of the underlying cervical disease once it includes the entire area of carcinogenesis for the squamous epithelium (transformation zone). In most research studies, therapeutic success after conization is a term generally assigned for disease clearance, that is, absence of residual high grade/CIN2+ histology by the end of a reasonable follow-up period, aiming at risk reduction for future recurrence and development of invasion. Conversely, positive cone margins as a reflection of an incomplete excision may, to some extent, represent a negative prognostic factor. Therefore, margin status may also be regarded as an indicator for the quality of a clinical service. The chapter summarizes all current evidence regarding optimal treatment of positive margins after LEEP.

Ovarian cancer is the second most common malignant disease of the female genital tract, but the first in mortality because it is usually diagnosed at an advanced stage. Options for early detection, diagnosis, and treatment are limited. Prevention of ovarian cancer relates to primary prevention by avoiding factors that are epidemiologically associated with an increased incidence of ovarian cancer and the adoption of protective habits. These include interventions to exclude the fallopian tubes and ovaries. Secondary prevention is related to early diagnosis. The chapter aims to summarize current evidence on prevention of ovarian cancer as well as role of surgery to prevent advanced-stage disease.

Background: Adolescence is accompanied by a variety of changes in young breast development, which greatly affects the adolescent’s psychology and socialization. Summary: PubMed, EMBASE, and the Cochrane Library were searched for studies relative to epidemiology, clinical characteristics, diagnosis, and management of all breast disorders in adolescence and their consequences. Development disorders are breast asymmetry, breast atrophy, breast hypoplasia, hypomastia, juvenile breast hypertrophy, and tuberous breast. Breast congenital abnormalities include athelia, amastia, accessory breast tissue, polymastia, polythelia, and congenital disorders of nipples. Breast infections are commonly caused from Gram-positive coccus rather than Gram-negative bacteria. Breast abscess occurs when breast infections are not promptly treated. Nipple discharge is caused by a variety of conditions and should be managed carefully. Fibrocystic changes, cysts, and fibroadenomas are the most common benign masses in adolescence. Primary, secondary, or metastatic breast cancer is extremely rare in adolescence. However, clinicians should include breast cancer in the differential diagnosis of a breast mass in adolescence. Key Messages: Clinicians should be aware of all breast disorders that may occur in adolescence. Early diagnosis and treatment will result in the reassurance of adolescents and their families without any detrimental effect on their psychology, sexual behavior, and socialization. Adolescents with breast disorders may require a multidisciplinary approach by a pediatrician, a gynecologist specializing in pediatric-adolescent gynecology, a plastic surgeon, and a psychologist for the best management of breast disorders.

Gonadotropin-releasing hormone (GnRH) analogs represent the treatment of choice in patients with central precocious puberty (CPP). Recently, GnRH analogs that can be administered every 3 months have been developed and appear to be as safe and effective as one-monthly formulations. However, there are limited data regarding its long term safety and efficacy profile. We aimed to evaluate the long-term safety and efficacy treatment of CPP with GnRH analogs every 3 months.We prospectively studied all patients who were diagnosed with CPP in our center between January 2015 and December 2019. All patients were treated with intramuscular leuprolide acetate 11.25 mg every 3 months.Twenty-four patients with CPP were included in the study. Mean follow-up was 3.1 years. Height gain ranged between 4 and 6 cm. Bone mineral density (BMD) was not affected. Body mass index (BMI) increased in all subjects but none was obese at the end of follow-up.Treatment of patients with CPP with GnRH analogs every 3 months induces substantial increases in height and does not affect BMI or BMD. Therefore, it represents an attractive option for these young patients.

It is well-established that adults with polycystic ovary syndrome (PCOS) have an increased prevalence of several cardiometabolic risk factors, including obesity, insulin resistance, type 2 diabetes mellitus, and dyslipidemia. Accumulating data suggest that these risk factors are already present in adolescence in patients with PCOS. This has major implications for the management of this population since the timely identification of these risk factors is essential for preventing cardiovascular disease in adulthood. The present review summarizes the existing evidence regarding the prevalence of traditional and non-traditional cardiometabolic risk factors in adolescents with PCOS.

Overweight and obesity in childhood and adolescence has been growing epidemic in the last 30 years, with 5%–25% affected young people in Europe. Body mass index plotted on percentile charts for age and sex is the gold standard diagnostic. According to World Health Organization, cutoff points are 85th–97th percentile for overweight and ≥97th percentile for obesity. Sedentary and poor eating habits are the main etiologic factors. Being overweight and obese at a young age stimulates early puberty, a premature adrenarche, and accelerates linear growth. Increase in leptin, sex steroids, insulin, insulin growth factor-1, insulin resistance and a reduction in sex hormone–binding globulin have been identified. Almost all the systems in the human body are affected by being overweight and obese. These conditions also worsen young people’s quality of life and are linked to various psychological and behavioral problems. The increase in pediatric obesity is alarming because of its association with health and is a critical early risk factor for adult morbidity and mortality.

Acute vulvar ulceration in children and non-sexually active adolescents is rare and presents as single or multiple painful ulcers with necrotic margins that usually resolve without scarring. In add...

Background Paraurethral cyst is a rare cause of interlabial mass in neonates with an incidence of 1 in every 2000-7000 live births and represents less than 0.5% of congenital malformations of the urinary tract. Case We report the case of a paraurethral cyst in a neonate, which regressed spontaneously during follow-up without complications. Summary and Conclusion Paraurethral cyst should be considered in the differential diagnosis of interlabial masses in newborns. Because of the high probability of spontaneous regression, expectant management appears to represent the management of choice.

Objective: Human papilloma virus (HPV) vaccination may result in misconceptions that encourage young women to adopt risky contraceptive practices. The purpose of this article was to investigate whether HPV vaccination status was associated with choice of contraceptive method and adoption of risky sexual behaviour. Methods: Vaccinated and non-vaccinated visitors to a university department paediatric and adolescent gynaecology clinic were asked to anonymously fill in a survey comprising questions on sociodemographic characteristics, sexual history, opinions on contraception and attitudes towards contraception. Results: A total of 191 women were studied, 75 (39.3%) of whom had received the HPV vaccination and 116 (60.7%) of whom had not. The main contraceptive methods used in both groups were male condom (46%), emergency contraception (14%) and coitus interruptus (12%). The vaccinated group was less religious and had better educated mothers compared with the non-vaccinated group (relative risk [RR] 0.64; 95% confidence interval [CI] 0.45, 0.93; p = .016 vs RR 1.91; 95% CI 1.01, 3.63; p = .027, respectively). They also had an earlier sexual debut (RR 1.94; 95% CI 1.06, 3.55; p = .015), agreed that vaccination increased the safety of sex (RR 1.45; 95% CI 1.02, 2.05; p = .039) and considered the HPV vaccine a prerequisite to initiation of a sexual relationship (RR 1.87; 95% CI 1.34, 2.63; p < .001). Conclusion: HPV vaccination did not affect sexual behaviour, attitudes to condom use or choice of contraceptive method.

Modern cytopathology labs offer an outstanding portfolio of important testing services that must be of high quality and credibility. Over the last decade, clinical cytopathology was influenced by the wide implementation of computer sciences. Cytopathology labs wishing to achieve a seamless workflow process have successfully adopted automation and information management systems. Innovative information technologies, including e-health, constitute a valuable tool for interlaboratory collaboration and quality improvement. Cloud computing will enhance the opportunities in cytological data management and sharing. The authors present thorough research of mobile applications related to cytopathology and try to foresee applications that may benefit modern cytopathology. Also, the feasibility of such applications for inter-laboratory comparisons, proficiency testing, and diagnostic accuracy validation is examined. Finally, the role of mobile applications for providing and/or enhancing the laboratory capabilities through educational training and other research activities is investigated.

Lymphangioma circumscriptum is a rare benign disorder of unknown etiology affecting lymph vessels in the deep dermal and subcutaneous layers. The commonest sites of presentation are the axilla, shoulders, groins, tongue and oral cavity. Lymphangioma circumscriptum of the vulva is very rare can be either congenital or secondary to lymphadenectomy or pelvic radiation in patients with genital cancer, genital tuberculosis, Crohn's disease, cellulitis, morbid obesity and immobilization. We report the case of congenital lymphangioma circumscriptum of the vulva in an adolescent with congenital lymphedema of the leg.

Objective: To evaluate sexual behavior of adolescent and young women and the extent to which these were affected by HPV vaccination . Methods: Prospective observational study of 287 females 12 to 26 years attending an outpatient PAG Clinic of a University Hospital. Patients were asked to fill an anonymous questionnaire of 84 questions regarding demographic characteristics, HPV awareness and sexual behavior. Attitudes and alterations in sexual behavior in relation to HPV vaccination were compared between the vaccinated and the non-vaccinated group. Results: Of the population of 287 young women that was studied, 125 (43.6%) were vaccinated and 162 (56.4%) were not. During the study period vaccination increased from 31% to 58% of the cohort. Vaccinated cohort was of younger age, had coital sex in younger age (RR=0.75; 95% CI 0.58-0.98, p=0.040) and their partners were younger too. More of the vaccinated group had higher level of education (p=0.047), were not religiously oriented (p=0.022) and their mothers had higher education (RR=1.57; 95% CI 1.00-2.47, p=0.032) compared to the non-vaccinated. More of the non-vaccinated group had coital sex (RR=0.040; 95% CI 0.58-0.98, p=0.040). No differences were found between the vaccinated and non-vaccinated group on attitude to sex and relationships. More young women on the vaccinated group believed that vaccination should be done early (p=

Study Objective Intrauterine devices (IUDs) still remain underused in adolescents. Pain during insertion might prevent adolescents to opt for a levonorgestrel-releasing IUD. This study aimed to conduct a systematic review, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, and critically appraise published data with respect to the efficacy of various substances (analgesics or not) in preventing pain during levonorgestrel-releasing IUD insertion in nulliparous women as a proxy for adolescents. Design, Setting, Participants, Interventions, and Main Outcome Measures A comprehensive computerized systematic literature search of all English language studies between 2006 and 2016 was performed in PubMed, EMBASE, Scopus, Evidence Based Medicine Reviews (Cochrane Database and Cochrane Central Register of Controlled Trials), and Google Scholar. Relevant article reference lists were manually searched. Results The computerized database search revealed 31 citations of relevance, 9 of which with a total of 355 treated women and 345 controls fulfilled the inclusion/exclusion criteria. In women treated with misoprostol (n = 150) vs placebo (n = 145), the median visual analogue scale (VAS) score ± SD were 5.7 ± 2.1 vs 5.1 ± 2.2, respectively. In the previously mentioned population, there was a nonsignificant change in VAS score (odds ratio, 1.44; 95% confidence interval, 0.86-2.40). In women treated with lidocaine (n = 140) vs placebo (n = 136), the median VAS score ± SD were 4.6 ± 2.1 vs 5.8 ± 2, respectively. In the aforementioned population, there was a significant decrease in VAS score (odds ratio, 0.12; 95% confidence interval, 0.02-0.91). Conclusion In nulliparous women, lidocaine treatment seems to be a reasonable choice. However, further studies are required to examine the different routes and modes of administration as well as optimal quantities.

High prevalence and mortality rates of cervical cancer create an imperative need to clarify the uniqueness of HPV (Human Papillomavirus) infection, which serves as the key causative factor in cervical malignancies. Understanding the immunological details and the microenvironment of the infection can be a useful tool for the development of novel therapeutic interventions. Chronic infection and progression to carcinogenesis are sustained by immortalization potential of HPV, evasion techniques, and alterations in the microenvironment of the lesion. Inside the lesion, Toll-like receptors expression becomes irregular; Langerhans cells fail to present the antigens efficiently, tumor-associated macrophages aggregate resulting in an unsuccessful immune response by the host. HPV products also downregulate the expression of microenvironment components which are necessary for natural-killer cells response and antigen presentation to cytotoxic cells. Additionally HPV promotes T-helper cell 2 (Th2) and T-regulatory cell phenotypes and reduces Th1 phenotype, leading to suppression of cellular immunity and lesion progression to cancer. Humoral response after natural infection is inefficient, and neutralizing antibodies are not adequate in many women. Utilizing this knowledge, new endeavors, such as therapeutic vaccination, aim to stimulate cellular immune response against the virus and alter the milieu of the lesion.