Markers of endometrial function in women with unexplained recurrent pregnancy loss: a comparison between morphologically normal and retarded endometrium

BACKGROUND

Endometrial defect, usually described as luteal phase defect (LPD), is associated with recurrent miscarriage. Recurrent miscarriage has also been associated with the abnormal expression of various molecules by endometrial cells. The aim of this study was to determine if any of these molecules or cells could be used to distinguish LPD from in-phase endometrium.

METHODS

Immunocytochemistry was used to compare endometrial expression of CD45+, CD56+, CD3+ and CD4+ cells, leukaemia inhibitory factor, interleukin-6 and estrogen and progesterone receptors in precisely timed endometrial biopsies obtained between days LH+6 and LH+11 from recurrent miscarriage women with in-phase and retarded endometrium.

RESULTS

In all samples there was a positive correlation between the number of CD45+ cells and LH day and a negative correlation between progesterone receptor and LIF expression and LH day. A significantly lower number (P<0.05) of CD56+ cells in peri-implantation endometrium and a decreased mid-cycle estrogen level (P<0.05) was seen in women with LPD compared to in-phase endometrium when single analysis was carried out. However, these differences were not significant after application of the Bonferroni correction for multiple analysis.

CONCLUSIONS

The results are in line with previous associations observed between estrogen levels and LPD and suggest that the number of CD56+ cells is different in LPD and in-phase endometrium, although this could be due to delayed endometrial development in women with LPD. Interpretation must be cautious because these differences could have arisen by chance.

The ATAC adjuvant breast cancer trial in postmenopausal women: baseline endometrial subprotocol data

OBJECTIVE

The ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial is a randomised, double-blind trial comparing 'Arimidex' (anastrozole), alone or in combination with tamoxifen, relative to tamoxifen alone as a five year adjuvant treatment for postmenopausal women with early breast cancer. Because tamoxifen is associated with endometrial pathology, the ATAC endometrial subprotocol was initiated to establish the background prevalence of pathology, and to assess prospectively the incidence and nature of intrauterine changes before and following endocrine therapy.

SETTING

International. POPULATION AND STUDY DESIGN: Two hundred and eighty-five women entered the subprotocol: the mean age was 60 years (range 44-80 years); 113 women (40%) had taken hormone replacement therapy prior to randomisation, and 238 women were parous (84%). The age at onset of the menopause was 32-58 years, with the majority becoming menopausal between 46 and 55 years of age. Two hundred and seventy-two women had a hysteroscopy before they commenced trial medication. Hysteroscopy was performed successfully in 265 women. In six women, failure of hysteroscopy at baseline led to withdrawal from the study. Three of the women who withdrew had a pipelle biopsy taken. Therefore, the total number of endometrial biopsies at baseline was 268.

MAIN OUTCOME MEASURES

To assess the demographic characteristics of women entering the endometrial subprotocol and their hysteroscopic and histological findings before commencing trial medication.

RESULTS

At hysteroscopy, there was a diagnosis of endometrial polyps in 34 women (13%), fibroids in 16 women (6%) and one case of suspicious endometrium, which was confirmed as a polyp on histology. Only 21 of the 34 polyps seen hysteroscopically were proven histologically (62% accuracy of hysteroscopy). Final histology found the prevalence of endometrial diagnostic categories as follows: 123 inactive endometrium (46%), 20 benign polyps (7%), 17 secretory endometrium (6%), 7 proliferative endometrium (3%), 3 atypical hyperplasia (2 in a polyp), 1 simple hyperplasia (in a polyp) and 1 fibroid. The remaining women had pipelle samples with insufficient tissue obtained, indicating a normal endometrial cavity.

CONCLUSION

This is the first study of such size in gynaecologically asymptomatic breast cancer patients. This paper describes the findings in individual patients before any trial treatment was given. In this baseline group, 82% (219/268) of women had a normal endometrial cavity; 18% (49/268) had endometrial activity (proliferative or secretory endometrium in 9%) or an intracavity abnormality (hyperplasia, polyps and a fibroid in 9%). In total, 36% of biopsies had insufficient tissue for diagnosis, which in combination with a normal hysteroscopy was classed as normal. The appearance of a polyp hysteroscopically in this group was not proven histologically in approximately 40% of cases. The development of uterine pathology over time in the ATAC study will subsequently be assessed against the findings of this baseline paper.

A tumour-derived mutant allele of XRCC2 preferentially suppresses homologous recombination at DNA replication forks

Homologous recombination repair (HRR) is required for both the repair of DNA double strand breaks (DSBs) and the maintenance of the integrity of DNA replication forks. To determine the effect of a mutant allele of the RAD51 paralog XRCC2 (342delT) found in an HRR-defective tumour cell line, 342delT was introduced into HRR proficient cells containing a recombination reporter substrate. In one set of transfectants, expression of 342delT conferred sensitivity to thymidine and mitomycin C and suppressed HRR induced at the recombination reporter by thymidine but not by DSBs. In a second set of transfectants, the expression of 342delT was accompanied by a decreased level of the full-length XRCC2. These cells were defective in the induction of HRR by either thymidine or DSBs. Thus 342delT suppresses recombination induced by thymidine in a dominant negative manner while recombination induced by DSBs appears to depend upon the level of XRCC2 as well as the expression of the mutant XRCC2 allele. These results suggest that HRR pathways responding to stalled replication forks or DSBs are genetically distinguishable. They further suggest a critical role for XRCC2 in HRR at replication forks, possibly in the loading of RAD51 onto gapped DNA.

Hypoxia-induced gene expression in human macrophages: implications for ischemic tissues and hypoxia-regulated gene therapy

Macrophages accumulate in ischemic areas of such pathological tissues as solid tumors, atherosclerotic plaques and arthritic joints. Studies have suggested that hypoxia alters the phenotype of macrophages in a way that promotes these lesions. However, the genes up-regulated by macrophages in such hypoxic tissues are poorly characterized. Here, we have used cDNA array hybridization to investigate the effects of hypoxia on the mRNAs of 1185 genes in primary human monocyte-derived macrophages. As shown previously in other cell types, mRNA levels for vascular endothelial growth factor (VEGF) and glucose transporter 1 (GLUT-1) were up-regulated by hypoxia. However, the mRNAs of other genes were also up-regulated including matrix metalloproteinase-7 (MMP-7), neuromedin B receptor, and the DNA-binding protein inhibitor, Id2. The promoters of GLUT-1 and MMP-7 confer hypoxic inducibility on a reporter gene in RAW 264.7 macrophages, indicating that the hypoxic up-regulation of these mRNAs may occur, at least in part, at the transcriptional level. GLUT-1 and MMP-7 mRNA were also shown to be up-regulated in hypoxic macrophages in vitro by real-time RT-PCR, and these proteins were elevated in hypoxic macrophages in vitro and in hypoxic areas of human breast tumors. The hypoxia up-regulated genes identified could be important for the survival and functioning of macrophages in hypoxic diseased tissues, and their promoters could prove useful in macrophage-delivered gene therapy.

Refining the diagnosis of hydatidiform mole: image ploidy analysis and p57KIP2 immunohistochemistry

AIM

To determine whether image analysis of ploidy status and immunohistochemical analysis of p57KIP2 (a paternally imprinted, maternally expressed gene) can be used to refine the diagnosis of molar pregnancy.

METHODS AND RESULTS

The original histological diagnosis in 40 randomly selected cases of hydatidiform mole was reviewed and confirmed in 38 cases (22 complete moles, 16 partial moles). These cases were anonymized and submitted for further analysis. Tissue from each case was submitted for flow cytometric assessment of DNA ploidy using a FACSort flow cytometer and for automated image cytometric assessment using a novel digital imaging system. Tissue sections from each case were immunostained with a monoclonal mouse antibody to p57KIP2. Correlations between the histopathological diagnosis, image cytometry, flow cytometry and p57KIP2 immunohistochemistry were determined using kappa statistics. The concordance between histological diagnosis and p57KIP2 was very good (kappa = 0.89). Twenty of the 22 (90.9%) complete moles showed no immunoreactivity for p57KIP2. The remaining two cases showed nuclear immunoreactivity in villous cytotrophoblast. In one of these, the pattern of staining resembled that of a partial mole. In the other, the staining pattern supported the diagnosis of a twin molar/non-molar pregnancy. All 16 partial moles were p57KIP2 immunoreactive. On flow cytometry, all 22 complete moles were diploid and 12/16 partial moles were triploid (the remaining four cases originally diagnosed as partial moles were found to be diploid). On image cytometry, one case originally diagnosed as complete mole was found to contain a triploid population. Thus, by using a combination of image cytometry and p57KIP2 status we were able to refine the diagnosis of molar pregnancy in five (13%) of the cases studied.

CONCLUSIONS

Automated image cytometry is a readily performed investigation which is comparable to, but more sensitive than, flow cytometry. Complementary use of ploidy analysis and p57KIP2 status can now help to distinguish a diploid hydropic miscarriage (p57KIP2-positive), diploid complete mole (p57KIP2-negative) and triploid partial mole (p57KIP2-positive).

Recent advances in the pathology of the vulva

This review addresses recent and important advances in our knowledge of several uncommon or rare disorders of the vulva including Paget's disease, vulva intraepithelial neoplasia, lichen sclerosus and squamous hyperplasia and their relationship to squamous carcinoma. Emphasis is placed on the two biologically different types of squamous carcinoma related and unrelated to human papillomavirus infection. Finally, the relatively recent concept of the sentinel node as applied to vulva carcinoma is discussed.

Production of activins by the human endosalpinx

Uterine tubes from 11 premenopausal and 6 postmenopausal women were collected and examined for the presence of inhibin, activin, and follistatin in the endosalpinx. Immunocytochemistry of tissue from both the isthmic and ampullary regions demonstrated clear staining for the beta(A)- and beta(B)-subunits that increased in intensity from the isthmus to the ampulla. Staining for follistatin showed a similar pattern, but no staining for the alpha-subunit was observed. Although staining for the beta(A)-subunit was seen in almost every epithelial cell, staining for the beta(B)-subunit was more variable. Western blotting showed a band with an apparent molecular mass of 28 kDa (corresponding to the activin dimer) and a band of approximately 60 kDa (corresponding to the pro-protein of activin). In situ hybridization confirmed the presence of mRNA for the beta(A)- and beta(B)-subunits in the endosalpinx. These results indicate that the endosalpinx is able to synthesize activin, not inhibin, suggesting that in premenopausal women they may have an important role in the biology of the developing embryo. The role in postmenopausal women is less certain, but could lead to the stimulation of FSH secretion by the pituitary gland or other autocrine/paracrine function within the uterine tube.

Symposium part IV: investigative approaches to endocervical pathology

There is continuing interest in the study of adenocarcinoma of the cervix and its precursors because of its increase in incidence, both absolute and relative, to squamous neoplasia and the complexity of benign glandular lesions with which endocervical neoplasia may be confused. Investigative techniques may be applied as aids to diagnosis, as prognostic markers, and to further our understanding of etiopathogenesis. This article focuses on recent developments in the four areas of epithelial glycoproteins, molecular markers, cell proliferation markers, and human papillomaviruses as applied to endocervical pathology. Although immunohistochemistry remains dominant, a wide range of other techniques is discussed.

Effect on endometrium of long term treatment with continuous combined oestrogen-progestogen replacement therapy: follow up study

OBJECTIVE

To determine effects of five years of treatment with an oral continuous combined regimen of 2 mg 17beta-oestradiol and 1 mg norethisterone acetate on endometrial histology in postmenopausal women.

DESIGN

Follow up study in postmenopausal women.

SETTING

31 menopause clinics in the United Kingdom.

PARTICIPANTS

534 postmenopausal women, all with an intact uterus, who had completed nine months of treatment with oral continuous combined 2 mg 17beta-oestradiol and 1 mg norethisterone acetate agreed to take part in a long term follow up study. Women were assigned to different groups on the basis of the treatment status immediately before entering the original study: 360 women had taken sequential oestrogen-progestogen hormone replacement therapy, 164 had taken no hormone replacement therapy, and 10 had taken unopposed oestrogen therapy.

METHODS

Endometrial aspiration specimens were taken before the women started the continuous combined regimen, after 9 and 24-36 months, and at the end of the five year treatment period or on withdrawal from the study.

MAIN OUTCOME MEASURE

Results of endometrial histology.

RESULTS

The duration of treatment with continuous combined hormone replacement therapy was 4.4 (range 1.1-5.9) years. Data on endometrial specimens were available for 526 women after nine months of treatment, 465 women after 24-36 months of treatment, and 398 women who completed the five years treatment (345 women) or were withdrawn between the two latter visits for biopsies (53 women). No cases of endometrial hyperplasia or malignancy were detected at biopsy; 69% of women had an endometrium classified as atrophic or unassessable on completion of the study or withdrawal from it. Before the continuous combined therapy was started, complex hyperplasia was detected in 21 women who had taken sequential hormone replacement therapy before the study and in one who had taken unopposed oestrogen. All of these women had normal results on histological examination of endometrial tissue after nine months of treatment with continuous combined hormone replacement therapy, and hyperplasia did not recur after up to five years of treatment.

CONCLUSIONS

Long term treatment (for up to five years) with continuous combined hormone replacement therapy containing oestradiol 2 mg and norethisterone 1 mg daily was associated with neither endometrial hyperplasia nor malignancy. In women who had complex hyperplasia during previous sequential or unopposed regimens, the endometrium returned to normal during treatment with continuous combined hormone replacement therapy. These findings provide reassurance about the long term safety of this continuous combined regimen in terms of the endometrium.

The effect of phytoestrogens on the female genital tract

Environmental oestrogens have been implicated in the pathogenesis of hormonally treated cancers (such as breast and prostate cancer), male infertility, and abnormalities of the male and female reproductive tracts. They may be derived from plants (phytoestrogens), pharmaceuticals, or other synthetic compounds not originally intended to have oestrogenic activity (including soy based infant formulas). This review will discuss the evidence from both animal studies and humans for an effect of these ubiquitous compounds on the development of the human female genital tract, in addition to prolonging the menstrual cycle, alleviating symptoms of the menopause, and protecting against the development of endometrial carcinoma.

Studies of embryo transfer from cattle clinically affected by bovine spongiform encephalopathy (BSE)

Semen from 13 bulls, eight with clinical bovine spongiform encephalopathy (BSE), was used to artificially inseminate (AI) 167 cows with clinical BSE, and their resultant embryos were collected non-surgically seven days after AI. The viable and non-viable embryos with intact zonae pellucidae were washed 10 times (as recommended by the International Embryo Transfer Society) then frozen. Later, 587 of the viable embryos were transferred singly into 347 recipient heifers imported from New Zealand, and 266 live offspring were born of which 54.1 per cent had a BSE-positive sire and a BSE-positive dam. The recipients were monitored for clinical signs of BSE for seven years after the transfer, and the offspring were monitored for seven years after birth. Twenty-seven of the recipients and 20 offspring died while being monitored but none showed signs of BSE. Their brains, and the brains of the recipients and offspring killed after seven years, were examined for BSE by histopathology, PrP immunohistochemistry, and by electron microscopy for scrapie-associated fibrils. They were all negative. In addition, 1020 non-viable embryos were sonicated and injected intracerebrally into susceptible mice (20 embryos per mouse) which were monitored for up to 700 days, after which their brains were examined for spongiform lesions. They were all negative. It is concluded that embryos are unlikely to carry BSE infectivity even if they have been collected at the end-stage of the disease, when the risk of maternal transmission is believed to be highest.

Primary endometrioid adenocarcinoma of the large intestine arising in colorectal endometriosis

AIMS

Three cases of endometrioid adenocarcinoma arising in colorectal endometriosis are described with discussion of their macroscopic and microscopic pathology and diagnosis, using immunohistochemistry.

METHODS AND RESULTS

Three middle-aged women presented with symptoms and signs of colorectal mass effect. Two had a preceding history of gynaecological endometriosis and all three had either been on hormone replacement therapy or had functioning ovaries prior to presentation with colorectal disease. Each underwent resection of tumours of the distal large intestine. The definitive diagnosis was dependent on histological examination and immunohistochemistry, which was used to demonstrate an origin in endometriotic tissue.

CONCLUSIONS

Endometrioid adenocarcinoma is a rare complication of colorectal endometriosis, this report contributing to a total of 25 cases in the literature. Definitive diagnosis, aided by immunohistochemical studies, is important to enable the identification of the optimal management for this uncommon condition.

Expression of HIF-1alpha by human macrophages: implications for the use of macrophages in hypoxia-regulated cancer gene therapy

Large numbers of monocytes extravasate from the blood into human tumours, where they differentiate into macrophages. In both breast and prostate carcinomas, these cells accumulate in areas of low oxygen tension (hypoxia), where they respond to hypoxia with the up-regulation of one or more hypoxia-inducible factors (HIFs). These then accumulate in the nucleus and bind to short DNA sequences called hypoxia-response elements (HREs) near or in such oxygen-sensitive genes as that encoding the pro-angiogenic factor vascular endothelial growth factor (VEGF). This stimulates gene expression and could explain why, in part, macrophages express abundant VEGF only in avascular, hypoxic areas of breast carcinomas. It also suggests that macrophages could be used to deliver HRE-regulated therapeutic genes specifically to hypoxic tumour areas. A recent study suggested that hypoxic macrophages accumulate HIF-2 rather than HIF-1, prompting the search for HRE constructs that optimally bind HIF-2 for use in macrophage-based gene therapy protocols. However, the present study shows that human macrophages accumulate higher levels of HIF-1 than HIF-2 when exposed to tumour-specific levels of hypoxia in vitro; that macrophages in human tumours express abundant HIF-1; and that expression from HRE-driven reporter constructs in the human macrophage-like cell line MonoMac 6 correlates more closely with HIF-1 than with HIF-2 up-regulation under hypoxia. Taken together, these findings suggest that HIF-1 may be the major hypoxia-inducible transcription factor in macrophages and that HIF-1-regulated constructs are likely to be effective in macrophage delivery of hypoxia-regulated gene therapy to human tumours.

The knowledge and attitudes of surgical staff towards the use of opioids in cancer pain management: can the Hospital Palliative Care Team make a difference?

The principles of cancer pain management are well established, but evidence suggests that these are not incorporated into daily practice and patients are still in pain. Deficiencies in knowledge and inappropriate attitudes towards the use of opioids may partially explain why the management of cancer pain is still such a widespread problem. This study assessed the knowledge and attitudes of 135 nursing and medical staff working in a surgical unit, before and after working with a newly established Hospital Palliative Care Team. The baseline survey highlighted the existence of a number of myths and misconceptions in relation to opioid use. Results of the follow-up survey indicated that the knowledge and attitudes of doctors and nurses had improved after working with the team, but that this probably occurred as a result of good working relationships and case discussions rather than through formal teaching. The study provided a useful method of identifying deficiencies in knowledge and attitude among staff, and helped to raise awareness of the problem of cancer pain management. Our challenge now is to work with staff to ensure that positive changes in knowledge and attitudes are translated into the everyday practice of hospital nurses and doctors caring for patients with cancer.

Hormone replacement therapy and the endometrium

Modern hormone replacement therapy (HRT) regimens contain oestrogen and progestogen, given either in a cyclical or continuous combined manner. Most endometrial biopsies from women on sequential HRT show weak secretory features. Approximately 15% show proliferative activity, although this figure may be less if more than nine days of progestogen is given in each cycle. A small proportion will show an inactive or atrophic endometrium. Up to 50% of biopsies from women on continuous combined HRT contain minimal endometrial tissue for histopathological analysis: this correlates well with an atrophic endometrium with no appreciable pathology. Of the 50% with more substantial material, approximately one half will show endometrial atrophy, and one half will show weak secretory features. Proliferative, menstrual, and pseudodecidual changes are rare. Approximately 20% of women given unopposed oestrogen for one year develop endometrial hyperplasia. The relative risk of endometrial carcinoma is two to three. This is dramatically reduced by the addition of progestogen to the regimen, but cyclical progestogen as part of a sequential HRT regimen does not completely eliminate the risk of carcinoma. The prevalence of endometrial hyperplasia associated with sequential HRT is 5.4%, and that of atypical hyperplasia (endometrial intraepithelial neoplasia) is 0.7%. Continuous combined HRT is not associated with the development of hyperplasia or carcinoma, and may normalise the endometrium of women who have developed complex hyperplasia on sequential HRT. The probability of a histopathologist finding clinically relevant pathology in an endometrial biopsy specimen of a patient on HRT is low and is more likely to be a manifestation of pre-existing disease.