Uterine fibroids

Different proliferative and apoptotic activity in peripheral versus central parts of human uterine leiomyomas

OBJECTIVE

To determine whether there are differences in proliferative and apoptotic activity and in expression of sex steroid receptors between central and peripheral parts of human uterine leiomyomas in different menstrual cycle phases.

METHODS

Biopsy specimens of the myometrium and peripheral and central parts of uterine leiomyomas were obtained from 15 women in the proliferative phase and 8 women in the secretory phase. Mitotic cells were detected by immunohistochemical staining for Ki67. Apoptotic cells were detected by the TUNEL method. Mitotic and apoptotic indexes were calculated. Tissue levels of oestrogen and progesterone receptors were measured using a commercial monoclonal receptor enzyme immunoassay kit.

RESULTS

During the secretory phase the mitotic index was significantly higher in the peripheral than in the central parts of the leiomyomas. During the proliferative phase the apoptotic index was significantly higher in the peripheral compared with the central parts. These differences were not reflected by differences in receptor expression.

CONCLUSIONS

The results of this study suggest that the growth of a human uterine leiomyoma mainly occurs in the peripheral parts of the tumour, during the secretory phase of the menstrual cycle. The findings emphasise the importance of being consistent when taking samples for research work.

Saline infusion sonohysterography: technique, indications, and imaging findings

OBJECTIVE

To review the technique, indications, and common imaging findings regarding saline infusion sonohysterography.

METHODS

The literature on saline infusion sonohysterography was reviewed. Pertinent images from our institution are presented to illustrate common imaging findings.

RESULTS

From the literature review, we summarize the various clinical scenarios in which saline infusion sonohysterography is useful and give examples from our clinical practice.

CONCLUSIONS

Saline infusion sonohysterography is a useful procedure for evaluation of endometrial and subendometrial abnormalities.

Germline fumarate hydratase mutations in families with multiple cutaneous and uterine leiomyomata

Germline mutations in the fumarate hydratase gene (FH) predispose to multiple cutaneous and uterine leiomyoma syndrome (MCL) and MCL associated with renal cell cancer. MCL is inherited in an autosomal dominant pattern, manifesting as skin leiomyoma and uterine fibroids in affected individuals. Fumarate hydratase, a component of the tricarboxylic acid cycle, acts as a tumor suppressor gene in the development of cutaneous and uterine leiomyoma and renal cell cancer in this syndrome. Here we report the clinical and mutational analysis of five families with MCL, with the identification of five new mutations affecting highly conserved residues of the FH protein. These results provide further evidence for the role of the FH gene in the pathogenesis of MCL.

Uterine fibroids and gynecologic pain symptoms in a population-based study

OBJECTIVE

To determine the association between dyspareunia, dysmenorrhea, and noncyclic pelvic pain and the presence and characteristics of uterine fibroids.

DESIGN

Population-based cross-sectional study.

SETTING

Desio, Italy.

PATIENT(S)

Six hundred thirty-five non-care-seeking participants of the Seveso Women's Health Study with an intact uterus who underwent transvaginal ultrasound.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ultrasound-detected presence of uterine fibroids and fibroid characteristics including volume, number, location, and position. Current dyspareunia, dysmenorrhea, and noncyclic pelvic pain was measured by self-report on a visual analog scale.

RESULT(S)

Uterine fibroids were detected in 96 women (15%). Women with fibroids were more likely to report moderate or severe dyspareunia (adjusted odds ratio [OR] = 2.8, 95% confidence interval [CI] = 0.9-8.3, statistically significant trend) and moderate or severe noncyclic pelvic pain (adjusted OR = 2.6, 95% CI = 0.9-7.6, statistically significant trend) than women without fibroids. Moderate or severe dysmenorrhea was not associated with the presence of fibroids (adjusted OR = 1.1, 95% CI = 0.5-2.6). Number and total volume of fibroids were not related to pain.

CONCLUSION(S)

This is the first population-based study of gynecologic pain symptoms and fibroids. Dyspareunia and noncyclic pelvic pain, but not dysmenorrhea, increased in severity with the presence of uterine fibroids. Fibroid-associated pain symptomatology in a non-care-seeking population may be different from that of a clinic population.

Distinctive proliferative phase differences in gene expression in human myometrium and leiomyomata

OBJECTIVE

To gain a comprehensive view of the gene expression and regulation involved in uterine leiomyomata and matched normal myometrium using oligonucleotide microarray-based hybridization analysis.

DESIGN

Retrospective analyses of tissue obtained in a prospective randomized clinical study.

SETTING

Academic institution.

PATIENT(S)

Seven patients with leiomyomata scheduled for surgery during the proliferative phase.

INTERVENTIONS(S)

Seven paired samples of leiomyomata and adjacent myometrium were obtained from patients undergoing hysterectomy.

MAIN OUTCOME MEASURE(S)

The total RNA extracted from leiomyomata and myometrium was used for gene expression profiling of 6800 human genes using high-density oligonucleotide microarrays. In addition, reverse transcriptase-semiquantitative polymerase chain reaction and immunohistochemistry were used to validate tumor-specific gene expression.

RESULT(S)

A comparison of expression patterns in each paired sample revealed 68 genes significantly up- or down-regulated in each paired tissue sample, of which 23 genes showed increased expression and 45 showed decreased expression in leiomyomata compared with normal myometrium. Cluster analysis supported the relevance of these candidate genes for distinguishing between normal myometrium and leiomyomata biologic activity.

CONCLUSION(S)

Expression profiling of uterine leiomyomata using high-density oligonucleotide microarrays yields signature patterns that reflect the distinctive differences between normal human myometrium and leiomyomata during the proliferative phase. These observations suggest that a number of genes are involved in the tumorigenesis of leiomyomata.

Focused ultrasound treatment of uterine fibroid tumors: safety and feasibility of a noninvasive thermoablative technique

OBJECTIVE

The purpose of this study was to determine the safety and efficacy of focused ultrasound surgery with magnetic resonance imaging guidance for the noninvasive treatment of uterine leiomyomas.

STUDY DESIGN

Fifty-five women with clinically significant uterine leiomyomas were treated. Pain and complications were assessed prospectively, and posttreatment magnetic resonance imaging was used to measure the treatment effects. Patients in three of the five centers underwent planned hysterectomy after treatment, which provided pathologic correlation of treatment.

RESULTS

Seventy-six percent of the enrolled patients completed the full treatment session. All treatments were conducted in an outpatient setting with minimal discomfort for subjects and no major complications. Pathologic examination of the uterus confirmed that magnetic resonance imaging guidance provides the safe and accurate delivery of effective levels of thermal energy with a 3-fold increase in volume of histologically documented necrosis, compared with treatment volume (6.6 +/- 0.8 vs 18.4 +/- 3.9 mL, P <.005).

CONCLUSION

Magnetic resonance imaging-guided focused ultrasound surgery appears to be a well-tolerated treatment for uterine leiomyomas.

Mutations in the fumarate hydratase gene cause hereditary leiomyomatosis and renal cell cancer in families in North America

Hereditary leiomyomatosis and renal cell cancer (HLRCC) is an autosomal dominant disorder characterized by smooth-muscle tumors of the skin and uterus and/or renal cancer. Although the identification of germline mutations in the fumarate hydratase (FH) gene in European families supports it as the susceptibility gene for HLRCC, its role in families in North America has not been studied. We screened for germline mutations in FH in 35 families with cutaneous leiomyomas. Sequence analysis revealed mutations in FH in 31 families (89%). Twenty different mutations in FH were identified, of which 18 were novel. Of these 20 mutations, 2 were insertions, 5 were small deletions that caused frameshifts leading to premature truncation of the protein, and 13 were missense mutations. Eleven unrelated families shared a common mutation: R190H. Eighty-one individuals (47 women and 34 men) had cutaneous leiomyomas. Ninety-eight percent (46/47) of women with cutaneous leiomyomas also had uterine leiomyomas. Eighty-nine percent (41/46) of women with cutaneous and uterine leiomyomas had a total hysterectomy, 44% at age < or =30 years. We identified 13 individuals in 5 families with unilateral and solitary renal tumors. Seven individuals from four families had papillary type II renal cell carcinoma, and another individual from one of these families had collecting duct carcinoma of the kidney. The present study shows that mutations in FH are associated with HLRCC in North America. HLRCC is associated with clinically significant uterine fibroids and aggressive renal tumors. The present study also expands the histologic spectrum of renal tumors and FH mutations associated with HLRCC.

DNA hypomethylation and imbalanced expression of DNA methyltransferases (DNMT1, 3A, and 3B) in human uterine leiomyoma

OBJECTIVE

Despite the high prevalence of uterine leiomyoma in women, little is known about the pathophysiology of this tumor. This study intends to define the epigenetic modulation of this tumor.

METHODS

Twenty-three pairs of leiomyomas and their adjacent myometria were collected. Status of DNA global methylation was determined by using DNA methyl acceptance assay and immunohistochemistry staining with 5-methylcytidine antibody. MRNA level of DNA methyltransferases (DNMT1, 3A, and 3B) was assessed by quantitative real time PCR.

RESULTS

DNA global hypomethylation was detected in the leiomyoma tissues as compared with the adjacent myometria. DNMT1 expression was increased in 47.5% and was equal in 47.5% in leiomyomas compared to the adjacent myometria. On the other hand, over 74% of cases showed decreased expression of DNMT3A and 3B in leiomyomas compared to the adjacent myometria.

CONCLUSION

Global hypomethylation and imbalanced expression of DNMTs in uterine leiomyoma suggested a potential mechanism of epigenetic modulation in the development of this tumor.

Heparin inhibits the motility and proliferation of human myometrial and leiomyoma smooth muscle cells

Uterine fibroids (leiomyomas) are a major women's health problem. Currently, the standard for treatment remains hysterectomy, because no other treatment modalities can reduce both symptoms and recurrence. As leiomyomas are a hyperproliferation of smooth muscle cells, we sought to understand the regulation of uterine smooth muscle cell mitogenesis by the glycosaminoglycan heparin, which has been extensively studied as an anti-proliferative molecule in vascular smooth muscle cells. Using matched pairs of human myometrial and leiomyoma smooth muscle cells from the same uterus, we demonstrate that the proliferation and motility of both cell types are inhibited by heparin. We report that the decrease in cell number seen in the presence of heparin is not because of cell death. Interestingly, there is significant patient-to-patient variability in the proliferation response but not in the motility response to heparin. Furthermore, nonanticoagulant and anticoagulant heparin were equally effective at inhibiting leiomyoma and myometrial smooth muscle cell proliferation. These results warrant further investigation into the possibility that heparin might be useful in the treatment of uterine fibroids.

A randomized, placebo-controlled, dose-ranging trial comparing fulvestrant with goserelin in premenopausal patients with uterine fibroids awaiting hysterectomy

OBJECTIVE

To compare the use of a new antiestrogen fulvestrant with goserelin in reducing uterine fibroid growth before hysterectomy.

DESIGN

An international, multicenter, randomized, placebo-controlled study.

SETTING

Departments of obstetrics and gynecology.

PATIENT(S)

Premenopausal women (n = 307) diagnosed with uterine fibroids requiring hysterectomy.

INTERVENTION(S)

Over a 12-week period, patients received fulvestrant (50 mg, 125 mg, or 250 mg) as an i.m. injection, goserelin (3.6 mg) as a s.c. injection, or an injection-matched placebo once every 4 weeks. Patients underwent a hysterectomy at week 13.

MAIN OUTCOME MEASURES

Efficacy endpoints included changes in fibroid growth, endometrial thickness, and uterine volume. The excretion of urinary markers of bone resorption was also examined.

RESULT(S)

Goserelin significantly reduced fibroid growth and endometrial thickness compared with placebos. Fulvestrant did not significantly alter fibroid volume or endometrial thickness or change endpoints such as endometrial histology or vaginal bleeding. Fulvestrant was associated with fewer postmenopause-related adverse events than goserelin. Goserelin, but not fulvestrant, significantly increased markers of bone resorption.

CONCLUSION(S)

At doses equivalent to those used for the treatment of breast cancer in postmenopausal women, fulvestrant did not significantly inhibit fibroid growth and, of particular note, did not lead to bone resorption.

Use of a single preoperative dose of misoprostol is efficacious for patients who undergo abdominal myomectomy

OBJECTIVE

To investigate the effectiveness of a single preoperative dose of misoprostol in abdominal myomectomies.

DESIGN

Placebo-controlled randomized prospective study.

SETTING

Department of obstetrics and gynecology in a university hospital.

PATIENT(S)

Twenty-five women with symptomatic uterine leiomyomas.

INTERVENTION(S)

Among patients undergoing abdominal myomectomies, an hour before the operation women in the study group (n = 13) were given a single dose of vaginal misoprostol (400 microg); those in the control group (n = 12) were given placebo.

MAIN OUTCOME MEASURE(S)

Intraoperative blood loss, duration of operation, duration of postoperative hospitalization, and the need for blood transfusion were compared between the control and study groups.

RESULT(S)

Blood loss, operation time, and need for postoperative blood transfusion were significantly reduced in the group given vaginal misoprostol. No difference was observed among patients in terms of the time of hospitalization.

CONCLUSION(S)

A single preoperative dose of vaginal misoprostol is a simple, reliable method for reducing intraoperative blood loss and need for postoperative blood transfusion after abdominal myomectomies.

The effect of a levonorgestrel-releasing intrauterine device in the treatment of myoma-related menorrhagia

In this open observational study we evaluated the effectiveness of a levonorgestrel-releasing intrauterine device (LNG-IUD) in the treatment of myoma-related menorrhagia. Nineteen patients with recurrent menorrhagia lasting more than 3 months and with fibromyomatosus uterus were treated for 12 months with a LNG-IUD releasing 20 micro g/day of levonorgestrel. Menstrual blood loss, measured objectively by the pictorial blood loss assessment chart score (PBAC), level of serum hemoglobin and pattern of uterine bleeding were recorded at 3, 6, 9 and 12-month follow-up visits. Median monthly PBAC score during the two menstrual cycles before treatment was 310. After LNG-IUD, the PBAC score gradually decreased from a median value of 186 at 3 months to a median value of 155, 108 and 96 at 6, 9 and 12 months of treatment, respectively. Despite the statistically significant reduction of PBAC score, persistent menorrhagia, defined as a monthly PBAC score of 100 or higher, was observed at 12 months in 14 patients, whereas only one woman was amenorrheic and 4 were hypomenorrheic. In conclusion our study demonstrates the clinical reduced effectiveness of LNG-IUD in the treatment of myoma-related menorrhagia.

Successful treatment of a symptomatic uterine leiomyoma in a perimenopausal woman with a nonsteroidal aromatase inhibitor

OBJECTIVE

To assess the management of symptomatic leiomyomas using a nonsteroidal aromatase inhibitor in perimenopausal women.

DESIGN

Case report.

SETTING

Academic clinical practice.

PATIENT(S)

A 53-year-old woman suffering from recurrent urinary retention secondary to a uterine leiomyoma.

INTERVENTION(S)

Fadrozole, orally, 2 mg daily for 8 weeks and then 1 mg daily for 4 weeks.

MAIN OUTCOME MEASURE(S)

Measurements of leiomyoma volume, and levels of serum E(2), LH, and FSH.

RESULT(S)

Urinary retention resolved after 2 weeks of treatment and did not recur. Leiomyoma volume estimated by ultrasonography revealed a 71% reduction after 8 weeks of treatment.

CONCLUSION(S)

Fadrozole was useful for the management of a symptomatic leiomyoma without transient deterioration of symptoms. Clinical trials are warranted.

MR imaging-guided focused ultrasound surgery of uterine leiomyomas: a feasibility study

The feasibility and safety of magnetic resonance (MR) imaging-guided focused ultrasound surgery for uterine leiomyomas is reported. Sequential sonications were delivered to nine targets. Temperature-sensitive phase-difference MR imaging monitored the location of the focus and measured tissue temperature elevations, ensuring therapeutic dose. MR images and hysterectomy specimens were evaluated. Six leiomyomas received full therapeutic doses, and 98.5% of the sonications were visualized. MR thermometry was successful in all sonications and cases. Focal necrotic lesions were seen in all cases at MR, and five were pathologically confirmed. MR imaging-guided focused ultrasound causes thermocoagulation and necrosis in uterine leiomyomas and is feasible and safe, without serious consequences.

Gonadotropin-releasing hormone and reproductive medicine

The hypothalamic gonadotropin-releasing hormone (GnRH) is a key regulator of the reproductive system, mainly through its effects on pituitary luteinizing hormone (LH) and follicle-stimulating hormone (FSH) release. Gonadotropin-releasing hormone analogues are modifications of the natural decapeptide, being either agonists (GnRHa) or antagonists. GnRHa may imitate the native hormone and induce an endogenous LH surge; however, sustained treatment with GnRHa results in complete refractoriness of LH and FSH production. This aspect of GnRHa action is the main application of the GnRHa in reproduction today. The hypogonadotropic hypogonadal state that results from the sustained treatment is the basis for additional applications of the GnRHa. The agonists appear to be effective, to some extent, for the treatment of endometriosis and were proved to be beneficial prior to surgery for fibroma uteri. GnRHa is used in assisted reproduction for both induction of an endogenous LH surge and for induction of ovulation, and its capacity to cause refractoriness of the pituitary may be used to avoid a premature LH surge. It is suggested that the GnRHa have a direct effect on ovarian steroidogenesis, which is independent of its action on the pituitary. This unwanted effect and other possible drawbacks of the agonists are thought to be eliminated with the use of the antagonists. The mechanism of action of these antagonists is through competitive blocking of the GnRH receptor, which results in a rapid but reversible suppression of gonadotropin secretion. As for GnRHa, GnRH antagonists have been proven effective to prevent the LH surge and to reduce the incidence of severe ovarian hyperstimulation syndrome in controlled ovarian stimulation cycles.

Selective uterine artery embolization in the management of uterine myomas

OBJECTIVE

To evaluate the effectiveness of uterine artery embolization in women with uterine myomas in terms of the clinical results for the relief of related symptoms.

DESIGN

A pilot study on 26 women affected by uterine single myoma.

SETTING

Tertiary level care in an university hospital.

PATIENT(S)

Twenty-six patients, aged 32 to 54 years, suffering of menorrhagia, pelvic pain, and abdominal mass for single myoma, intramural localization.

INTERVENTION(S)

Selective uterine artery embolization performed under peridural anesthesia.

MAIN OUTCOME MEASURE(S)

We measured the x-ray dose to which patients were exposed. Color power Doppler ultrasound examinations were performed during the follow-up evaluations at 1 to 6 months and 1 year after the procedure.

RESULT(S)

Uterine artery embolization was successfully performed in 100% of cases. The mean fluoroscopy time was of 20 minutes during the procedure. The mean dose of x-ray absorbed by the ovary was estimated at 18.7 cGy and the mean dose of x-ray absorbed by the skin was 126.7 cGy. A reduction of myoma volume of 55% was found at 6 months' ultrasound examination and 75% at the 1-year examination.

CONCLUSION(S)

Patients are well satisfied and have short recovery times with this procedure. Uterine artery embolization may be a valid alternative to traditional surgery.

Cost effectiveness of pre-operative gonadotrophin releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy

OBJECTIVE

To conduct a cost effectiveness analysis of pre-operative gonadotrophin releasing hormone agonists (GnRHa) in women with uterine fibroids undergoing hysterectomy or myomectomy.

DESIGN

A cost effectiveness analysis using the effectiveness data from a systematic review of GnRHa.

SETTING

Secondary care.

SAMPLE

Women with uterine fibroids undergoing hysterectomy or myomectomy and women volunteers.

METHODS

Effectiveness data were used from a systematic review to construct a model and to calculate the cost per surgical outcome avoided. In order to evaluate the value women place on the outcome, a willingness to pay analysis of women volunteers was undertaken.

MAIN OUTCOME MEASURES

(a) The cost of avoiding abdominal hysterectomy and the cost of avoiding a vertical incision at either hysterectomy or myomectomy; (b) The value that women place on avoiding abdominal hysterectomy and on avoiding a vertical incision at either hysterectomy or myomectomy. All costs are in NZ dollars.

RESULTS

For hysterectomy, the additional cost of treatment with GnRHa was NZ$1190 per case. The cost of avoiding one abdominal procedure was NZ$4577 per case and the cost of avoiding one vertical incision was NZ$6263. For a myomectomy, the additional cost of treatment with GnRHa was NZ$1535 per case. The cost of avoiding one vertical incision was NZ$4651 per case. These costs exceeded the benefit women placed on the outcomes.

CONCLUSION

Although the pre-operative use of GnRHa results in benefits which include less frequent abdominal incisions in the case of hysterectomy and less frequent vertical incisions in the case of myomectomy, the benefits do not justify the costs. This study highlights the importance of considering both the benefits and costs in health care decisions.

An image-guided high intensity focused ultrasound device for uterine fibroids treatment

A high intensity focused ultrasound (HIFU) device was developed for treating uterine fibroid tumors. This prototype device enables image-guided therapy by aligning a commercially available abdominal ultrasound image probe to a vaginal HIFU transducer so the HIFU focus is in the image plane. The device was designed based on anatomical constraints of the female pelvic structures. HIFU was generated using a 3.5 MHz PZT-8 crystal, 25.4 mm in diameter, bonded to an aluminum lens. Computer simulations were performed to ensure that effective focusing was achievable at a fixed focal depth of 40 mm. Transducer efficiency was empirically determined to be 58%, and the half pressure maximum focal dimensions were 11 mm in length and 1.2 mm in width. A water-filled latex condom surrounding the transducer provided acoustic coupling, a stand-off, and allowed water circulation for transducer cooling. In vitro experiments in a tissue-mimicking gel phantom and in turkey breast demonstrated ultrasound image-guided lesion formation, or tissue necrosis, at the focus due to HIFU induced thermal and cavitation effects. The HIFU treatment site appeared as a hyperechoic spot on the ultrasound image at intensities above 1250 W/cm2. The results of in vitro experiments and in vivo ergonomic testing in six human volunteers indicated that the device has the potential of providing a nonsurgical approach for uterine fibroid treatment. Future in vivo studies in large animal models and fibroids patients are planned.

Low frequency of somatic mutations in the FH/multiple cutaneous leiomyomatosis gene in sporadic leiomyosarcomas and uterine leiomyomas

Germline mutations in the fumarate hydratase gene at 1q43 predispose to dominantly inherited skin and uterine leiomyomata and leiomyosarcomas. The enzyme, which is a component of the tricarboxylic acid cycle, acts as a tumour suppressor. To evaluate fumarate hydratase in respective sporadic tumours, we analysed a series of 26 leiomyosarcomas and 129 uterine leiomyomas (from 21 patients) for somatic mutations in fumarate hydratase and allelic imbalance around 1q43. None of the 26 leiomyosarcomas harboured somatic mutations in fumarate hydratase. Fifty per cent of leiomysarcomas tested showed evidence of allelic imbalance at 1q, but this was not confined to the vicinity of fumarate hydratase. Only 5% (seven out of 129) of the leiomyomas showed allele imbalance at 1q42-q43 and no somatic mutations in fumarate hydratase were observed. Our findings indicate that mutations in fumarate hydratase do not play a major role in the development of sporadic leiomyosarcomas or uterine leiomyomas.

British Journal of Cancer (2002) 87, 446–448. doi:10.1038/sj.bjc.6600502www.bjcancer.com

© 2002 Cancer Research UK

Low frequency of somatic mutations in the FH/multiple cutaneous leiomyomatosis gene in sporadic leiomyosarcomas and uterine leiomyomas

Germline mutations in the fumarate hydratase gene at 1q43 predispose to dominantly inherited skin and uterine leiomyomata and leiomyosarcomas. The enzyme, which is a component of the tricarboxylic acid cycle, acts as a tumour suppressor. To evaluate fumarate hydratase in respective sporadic tumours, we analysed a series of 26 leiomyosarcomas and 129 uterine leiomyomas (from 21 patients) for somatic mutations in fumarate hydratase and allelic imbalance around 1q43. None of the 26 leiomyosarcomas harboured somatic mutations in fumarate hydratase. Fifty per cent of leiomysarcomas tested showed evidence of allelic imbalance at 1q, but this was not confined to the vicinity of fumarate hydratase. Only 5% (seven out of 129) of the leiomyomas showed allele imbalance at 1q42-q43 and no somatic mutations in fumarate hydratase were observed. Our findings indicate that mutations in fumarate hydratase do not play a major role in the development of sporadic leiomyosarcomas or uterine leiomyomas

Differential effect of gonadotropin-releasing hormone analogue treatment on estrogen levels and sulfatase activity in uterine leiomyoma and myometrium

OBJECTIVE

To investigate the effect of GnRH treatment on estrogen levels and sulfatase activity in leiomyoma and myometrium tissue.

DESIGN

Retrospective analyses of tissue obtained in a prospective randomized clinical study.

SETTING

Gynecology departments of eight hospitals in the Netherlands.

PATIENT(S)

Thirty-two patients scheduled for leiomyoma surgery.

INTERVENTION(S)

Patients were randomized to receive either GnRHa (3.75 mg/4 weeks of triptorelin or 3.6 mg/4 weeks of goserelin) or no GnRHa for 4 months. At subsequent surgery, leiomyoma and myometrium samples were collected.

MAIN OUTCOME MEASURE(S)

Estrone, estradiol, and sulfatase activity levels in leiomyoma and myometrium.

RESULT(S)

In myometrium, levels of estrone, estradiol, and sulfatase activity were significantly lower in the treated group (to median values of 46%, 21%, and 61%, respectively). In leiomyomas of treated patients, the reduction in median estrone level (to 65% of untreated value) was comparable to that in myometrium. The reduction in estradiol level in leiomyoma, however, was significantly less than in myometrium (median to 58% vs. 21%), and no significantly lower sulfatase activity was found.

CONCLUSION(S)

Estradiol and sulfatase results show that the effect of GnRHa treatment on leiomyoma differs from the effect on myometrium, suggesting a continuing estrogenic stimulus in leiomyoma tissue despite treatment.

Multiple cutaneous and uterine leiomyomas: refinement of the genetic locus for multiple cutaneous and uterine leiomyomas on chromosome 1q42.3-43

Cutaneous leiomyomas, rare benign tumors originating from the arrector pili muscle of the hair follicle, can be associated with the common uterine fibroids in a syndrome called multiple cutaneous and uterine leiomyomas. Multiple cutaneous and uterine leiomyomas are inherited as an autosomal dominant trait, providing an excellent opportunity for the study of the common non-Mendelian manifestation of isolated uterine fibroids. This study reports the clinical and molecular characterization of an extended family with multiple cutaneous and uterine leiomyomas. Linkage analysis has shown that the disease in this family is linked to the recently reported genetic locus for multiple cutaneous and uterine leiomyomas, with a maximum two-point LOD score of 4.453 for markers D1S2670, D1S2785, D1S547, and D1S1609. The identification of key recombination events has allowed us to refine substantially the location of the genetic locus for multiple cutaneous and uterine leiomyomas, from 14 cM to an interval of 4.55 or 7.19 cM, depending on the final phenotype of a young family member in which one of the key recombination events has occurred. In addition, we provide a description of the interesting pattern and progression of the skin phenotype in this four-generation kindred. The refinement of the genetic locus for multiple cutaneous and uterine leiomyomas and the availability of an extended multigeneration pedigree will facilitate the identification of the mutated gene responsible for multiple cutaneous and uterine leiomyomas, which, in turn, may provide key information for the understanding of the molecular basis of the common uterine fibroids.

The added value of transvaginal sonohysterography over transvaginal sonography alone in women with known or suspected leiomyoma

OBJECTIVE

To assess whether sonohysterography provides added diagnostic value over transvaginal sonography in patients with suspected or known myomas by comparing diagnostic confidence, interobserver agreement, accuracy, and change in diagnoses when 2 independent observers interpreted transvaginal sonography alone and later interpreted transvaginal sonography and sonohysterography together.

METHODS

Hard copy images from 72 women were interpreted independently by 2 sonologists on separate occasions, rating parameters (abnormal uterus, myoma in any location, submucous myoma, classification of location of a submucous myoma with respect to the uterine cavity, myoma remote from the cavity, adenomyosis, and focal and diffuse endometrial lesions) on a scale of 1 to 5 (1 indicated definitely no; 2, probably no; 3, uncertain; 4, probably yes; and 5, definitely yes). Correlation was made with clinical and imaging follow-up, surgery, and pathologic examination.

RESULTS

The added information provided by sonohysterography resulted in improved diagnostic confidence for most parameters. Interobserver agreement was markedly improved for the diagnosis and location of submucous myomas and focal endometrial lesions. Sensitivity values for submucous myomas and focal endometrial lesions were 100% and 90% for transvaginal sonography and sonohysterography together and 100% and 70% for transvaginal sonography alone.

CONCLUSIONS

We found that sonohysterography does provide additional information over transvaginal sonography alone and is an important adjunct to transvaginal sonography in symptomatic women with known or suspected myomas, particularly before surgical or medical therapy.

Familial cutaneous leiomyomatosis is a two-hit condition associated with renal cell cancer of characteristic histopathology

Little has been known about the molecular background of familial multiple cutaneous leiomyomatosis (MCL). We report here a clinical, histopathological, and molecular study of a multiple cutaneous leiomyomatosis kindred with seven affected members. This detailed study revealed strong features of a recently described cancer predisposition syndrome, hereditary leiomyomatosis and renal cell cancer (HLRCC). The family was compatible with linkage to the HLRCC locus in 1q. Also, all seven cutaneous leiomyomas derived from the proband and analyzed for loss of heterozygosity displayed loss of the wild-type allele, confirming the association with a susceptibility gene in chromosome 1q. One individual had had renal cell cancer at the age of 35 years. This tumor displayed a rare papillary histopathology, which appears to be characteristic for HLRCC. The derived linkage, loss of heterozygosity, and clinical data suggest that MCL and HLRCC are a single disease with a variable phenotype. The possibility that members of leiomyomatosis families are predisposed to renal cell cancer should be taken into account.