Benedetta Guani

Assisted reproductive technology (ART) is increasingly utilized worldwide, yet concerns remain regarding its potential association with breast and gynecological malignancies and the safety of fertility-preservation strategies in cancer survivors. Ovarian stimulation exposes women to supraphysiologic hormone levels, raising questions about cancer risk, particularly for hormone-sensitive tumors. Current evidence, however, is largely reassuring. Registry-based studies and meta-analyses demonstrate no consistent increase in breast or endometrial cancer following ART, although endometrial cancer risk remains inconclusive despite large new cohorts. Cervical cancer has not been linked to ART exposure. For ovarian cancer, risk appears primarily driven by underlying infertility, parity, and endometriosis rather than ART itself, and no excess risk is observed among BRCA mutation carriers. In parallel, fertility preservation (FP) has become an integral component of gynecologic oncology care for reproductive-aged women. Strategies including cryopreservation of oocytes, embryos, or ovarian tissue, as well as fertility-sparing surgery or hormonal therapy, can be safely pursued in carefully selected early-stage cancers. Pregnancy and livebirth rates vary by diagnosis: outcomes are favorable after breast and cervical cancers, more limited in endometrial cancer due to endometrial receptivity challenges, and possible but less predictable in ovarian cancer, where stage and histology guide feasibility. Available observational evidence does not suggest a clear increase in recurrence risk among carefully selected patients, although evidence remains limited and long-term follow-up is needed. Overall, current data suggest ART is safe when individualized to patient and tumor characteristics, highlighting the importance of proactive fertility counseling, modified stimulation protocols, and multidisciplinary care to optimize oncologic and reproductive outcomes.

Background: Breast cancer is the most common malignancy in women, and sentinel lymph node (SLN) biopsy is essential for accurate nodal staging while avoiding unnecessary axillary dissection. Aim: This study aimed to compare SLN detection rates between two dual-tracer techniques: indocyanine green plus patent blue (ICG + PB) and technetium-99m plus patent blue (99mTc + PB), and to identify factors associated with detection failure for each tracer. Methods: All clinically node-negative breast cancer patients undergoing SLN biopsy between January 2014 and December 2024 were retrospectively evaluated. SLN detection was considered successful when at least one node was identified intraoperatively and confirmed histologically. Multivariate analysis assessed clinical and tumor-related predictors of failure. Results: A total of 269 procedures (258 patients) were analyzed, including 152 ICG + PB and 117 99mTc + PB procedures. Detection rates were comparable between groups (95.4% vs. 94.9%, p = 0.96), with no significant differences in the number of SLNs retrieved or nodal positivity. Multivariate analysis identified increasing patient age as the only independent predictor of PB failure, while no variables were associated with ICG failure. Tumor location in the upper-inner quadrant was the sole predictor of 99mTc failure. Conclusions: ICG + PB and 99mTc + PB provide equivalent and high SLN detection rates. ICG appears to be a robust, radiation-free alternative with no identifiable predictors of failure, supporting its role as an effective mapping strategy, particularly in centers aiming to optimize workflow and patient safety, despite the limited available data on its efficacy.

STUDY AIMS: Robson’s Ten-Group Classification System (TGCS) was proposed to describe caesarean section rates by ten patient-centred risk-specific groups. The aim of the study was to describe Swiss caesarean section rates according to this classification, further stratifying it according to region and type of structure where delivery took place. We also aimed to compare our results to the standard caesarean section rates, recommended by the World Health Organization (WHO). METHODS: An observational study including all women delivering in health facilities in Switzerland in the period 2014–2021. A total of 695,733 deliveries were included. Core variables used for classification were semi-automatically generated using routine data provided by the Swiss Federal Statistics Office. Caesarean section rates were reported according to the TGCS. Data were also stratified according to each of the 26 Swiss cantons, as well as to the typology of hospital where delivery took place. RESULTS: The major relative contributors to the overall caesarean section rate were Group 2 (nulliparous, above 37 weeks, with induction) and Group 5 (women with previous caesarean section, above 37 weeks with a singleton pregnancy), respectively accounting for 20.7% and 30.1% of all caesarean sections. We also showed that the Swiss population was similar to the population considered in the WHO recommendation. Nonetheless, the caesarean section rate among our population exceeded that suggested by the WHO recommendations, being respectively of 44.4% vs 39.9% and 86.0% vs 74.4% for Groups 2 and 5. Large variations were detected in the caesarean section rate when looking at the different cantons, ranging from 29.8% to 59.6% for Group 2 and between 58.0% and 100.0% for Group 5. CONCLUSION: Routine data collection allowed us to describe caesarean section rates throughout Switzerland according to the TGCS. The Swiss caesarean section rate was higher than the caesarean section rate recommended by the WHO, even though the population characteristics were comparable. Substantial differences were found when stratifying caesarean section rates according to the canton, as well as to the type of structure where delivery took place.

Enhancing clinical practice: the Endoscore app for automated surgical data capture and endometriosis scoring - Facts, Views and Vision in ObGyn

Background: Breast-conserving surgery (BCS) is recommended for early-stage breast cancer, with the aim of removing tumors while preserving breast tissue. Achieving clear margins is crucial to minimizing re-excision and recurrence risks. The Histolog^® Scanner (HS), a confocal laser microscopy device, enables real-time intraoperative margin assessments. This study describes surgeon training, HS integration into clinical practice, and its impact on surgical outcomes. Methods: One surgeon participated in an online training program related to Histolog image of breast tissue. We assessed the time and workload required for the surgeon’s training, as well as the implementation of the HS into the surgical workflow. We retrospectively analyzed patients who underwent BCS with an intraoperative margin assessment performed by the trained surgeon using HS between December 2022 and January 2025. The re-excision rate was collected, and sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated using the final pathology assessment as the gold standard. Results: The surgeon completed the online training in 6 h 22 min over six days. HS integration into the routine workflow occurred smoothly. Retrospective analysis included 68 consecutive patients representing two years of clinical practice. The surgeon using the HS exhibited a sensitivity of 100%, specificity of 96.3%, accuracy of 96.9%, PPV of 85.7%, and NPV of 100%. Intraoperative HS usage eliminated re-excision in all cases. Integrating the HS into routine BCS procedures provides a highly accurate intraoperative margin assessment and significant reduction of re-excision rates.

Endometriosis is a debilitating disease that affects millions worldwide

Background/Objectives: Adenomyosis is a debilitating gynecologic condition that affects both multiparous older women and nulliparous younger women, inducing a variety of symptoms such as dysmenorrhea, menorrhagia, and infertility. Thermal ablation techniques are new procedures that have been proposed for the treatment of adenomyosis. They include high-intensity focused ultrasound (HIFU), percutaneous microwave ablation (PMWA), and radiofrequency ablation (RFA). Because thermal ablation techniques are minimally invasive or noninvasive, fertility is not impaired while symptoms improve. In addition, hospital stays and financial costs are generally reduced, increasing the interest in these alternative management options. Methods: In this narrative review, we conducted a thorough literature search of PubMed/Medline from the database inception to September 2022. In our search, we focused on noninvasive treatment methods such as HIFU ablation, RFA ablation, and PMWA as well as adenomyosis-specific terms and noninvasive techniques (ultrasonography, ultrasound, or magnetic resonance imaging). The queries were a combination of MeSH terms and keywords. The search was limited to the English language. Abstracts were screened according to their content, and relevant articles were selected. Results: Overall, the results showed that the above-mentioned ablation techniques are effective and safe in providing adenomyosis treatment. Lesion size and uterus volume are reduced, leading to considerable symptom alleviation with all three methods. Positive results concerning safety and fertility preservation have been described as well. Conclusions: Nonetheless, more research is required in this field to compare the efficacy and safety of different ablation techniques with traditional therapies. Such research will help improve these procedures and their associated decision-making processes.

Adenomyosis is a benign condition commonly encountered in patients with infertility. While the definitive surgical management is hysterectomy, conservative surgical management is gaining attention in patients desiring future fertility. This review explores whether the surgical treatment of adenomyosis affects fertility outcomes for patients trying to conceive. The PubMed and Medline databases were searched using the keywords: “adenomyosis”, “surgery”, “radiofrequency”, “infertility”, “pregnancy”, “sterility”, “conception”, “miscarriage”, and “endometrial receptivity”. Abstracts were screened, and relevant articles were selected for review. This review reveals that surgery appears to improve fertility outcomes with or without medical therapy; however, the risk of uterine rupture remains high and the best technique to reduce this risk is still not known. More studies are needed to formulate the best surgical approach for preserving fertility in treating adenomyosis and to establish standardized guidelines.

Objective The purpose of this study was to establish a consensus on the surgical technique for sentinel lymph node (SLN) dissection in cervical cancer. Methods A 26 question survey was emailed to international expert gynecological oncology surgeons. A two-step modified Delphi method was used to establish consensus. After a first round of online survey, the questions were amended and a second round, along with semistructured interviews was performed. Consensus was defined using a 70% cut-off for agreement. Results Twenty-five of 38 (65.8%) experts responded to the first and second rounds of the online survey. Agreement ≥70% was reached for 13 (50.0%) questions in the first round and for 15 (57.7%) in the final round. Consensus agreement identified 15 recommended, three optional, and five not recommended steps. Experts agreed on the following recommended procedures: use of indocyanine green as a tracer; superficial (with or without deep) injection at 3 and 9 o’clock; injection at the margins of uninvolved mucosa avoiding vaginal fornices; grasping the cervix with forceps only in part of the cervix is free of tumor; use of a minimally invasive approach for SLN biopsy in the case of simple trachelectomy/conization; identification of the ureter, obliterated umbilical artery, and external iliac vessels before SLN excision; commencing the dissection at the level of the uterine artery and continuing laterally; and completing dissection in one hemi-pelvis before proceeding to the contralateral side. Consensus was also reached in recommending against injection at 6 and 12 o’clock, and injection directly into the tumor in cases of the tumor completely replacing the cervix; against removal of nodes through port without protective maneuvers; absence of an ultrastaging protocol; and against modifying tracer concentration at the time of re-injection after mapping failure. Conclusion Recommended, optional, and not recommended steps of SLN dissection in cervical cancer have been identified based on consensus among international experts. These represent a surgical guide that may be used by surgeons in clinical trials and for quality assurance in routine practice.