Endometriosis and Infertility

Endometrial stromal sarcoma arising from endometriosis: a clinicopathological study and literature review

OBJECTIVES

We aimed to investigate the nature of endometrial stromal sarcoma (ESS) arising from endometriosis.

METHODS

The clinical data of 5 patients with ESS arising from endometriosis were reviewed retrospectively. The expression of CD117, HER2/neu, EGFR, VEGF, and PDGFR was analyzed by immunohistochemical staining.

RESULTS

The median age of the 5 patients was 45 years. The primary tumor sites were the ovary in 2, the pelvis in 2, and the cervical canal in 1 patient. Three patients had disseminated disease at diagnosis. Four patients underwent complete tumor resection. All of the 5 cases received adjuvant chemotherapy and 2 received progesterone therapy, while none were treated with radiotherapy. No recurrence occurred in the 4 cases who had complete tumor resection, and the only patient who progressed was the patient in whom the tumor was unresectable. Tumor cells in all cases exhibited positive staining for PDGFR and were negative for CD117 and HER2/neu. The expression of EGFR and VEGF was observed in 2 and 4 cases, respectively.

CONCLUSION

ESS arising from endometriosis is rare. Complete tumor resection in ESS arising from endometriosis may reduce the recurrence rate.

Macrophage migration inhibitory factor antagonist blocks the development of endometriosis in vivo

Endometriosis, a disease of reproductive age women, is a major cause of infertility, menstrual disorders and pelvic pain. Little is known about its etiopathology, but chronic pelvic inflammation is a common feature in affected women. Beside symptomatic treatment of endometriosis-associated pain, only two main suboptimal therapeutic approaches (hormonal and invasive surgery) are generally recommended to patients and no specific targeted treatment is available. Our studies led to the detection of a marked increase in the expression of macrophage migration inhibitory factor (MIF) in the eutopic endometrium, the peripheral blood and the peritoneal fluid of women with endometriosis, and in early, vascularized and active endometriotic lesions. Herein, we developed a treatment model of endometriosis, where human endometrial tissue was first allowed to implant into the peritoneal cavity of nude mice, to assess in vivo the effect of a specific antagonist of MIF (ISO-1) on the progression of endometriosis and evaluate its efficacy as a potential therapeutic tool. Administration of ISO-1 led to a significant decline of the number, size and in situ dissemination of endometriotic lesions. We further showed that ISO-1 may act by significantly inhibiting cell adhesion, tissue remodeling, angiogenesis and inflammation as well as by altering the balance of pro- and anti-apoptotic factors. Actually, mice treatment with ISO-1 significantly reduced the expression of cell adhesion receptors αv and ß3 integrins (P<0.05), matrix metalloproteinases (MMP) 2 and 9 (P<0.05), vascular endothelial cell growth factor (VEGF) (P<0.01), interleukin 8 (IL8) (P<0.05), cyclooxygenease (COX)2 (P<0.001) and the anti-apoptotic protein Bcl2 (P<0.01), but significantly induced the expression of Bax (P<0.05), a potent pro-apoptotic protein. These data provide evidence that specific inhibition of MIF alters endometriotic tissue growth and progression in vivo and may represent a promising potential therapeutic avenue.

Diameter of dominant leiomyoma is a possible determinant to predict coexistent endometriosis

OBJECTIVE

To identify the frequency and assess risk factors for unexpected discovery of peritoneal endometriotic implants in patients who underwent myomectomy or hysterectomy for symptomatic uterine leiomyomas.

STUDY DESIGN

We retrospectively collected medical records of 829 patients with symptomatic leiomyomas in The University of Tokyo Hospital. All the patients underwent abdominal or laparoscopic surgeries between January 2001 and December 2010 and the presence or absence of endometriosis during surgery was analyzed. Possible determinant to predict coexistent endometriosis was statistically investigated.

RESULTS

In total, 105 leiomyoma cases (12.7% in 829 patients) were diagnosed with endometriosis. Patients with small dominant leiomyomas were significantly complicated by peritoneal endometriotic implants (small leiomyomas were classified as < 8 cm). The patients with both diagnoses were more likely to be infertile and at age 39 years or younger than those with leiomyoma alone.

CONCLUSIONS

Women undergoing myomectomy or hysterectomy with both endometriosis and leiomyomas have several different clinical features compared with women with only leiomyomas. The size of largest leiomyoma may provide an important clue for coexistent endometriosis. Women with substantial infertility despite a smaller leiomyomas burden may be more likely to have a surgical indication for concomitant endometriosis.

Assessment of endometrial receptivity

OBJECTIVE

To provide a focused review of the scientific literature pertaining to endometrial receptivity.

DESIGN

Review of the literature and appraisal of relevant articles.

SETTING

Academic teaching hospital.

PATIENT(S)

Women with infertility.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Critical review of the literature.

RESULT(S)

Although a consensus has been achieved regarding the existence of a temporally defined period during which embryo attachment and invasion can occur (called the "window of implantation"), reliable methods to assess "receptivity" have not been established or adequately validated. In women with certain gynecologic disorders, including endometriosis, tubal disease, and polycystic ovary syndrome, endometrial receptivity seems to be compromised, leading to infertility and pregnancy loss. The establishment of reliable biomarkers for the detection of defects in endometrial receptivity has been a long-sought goal that remains an elusive target. The validation of endometrial biomarkers will require properly designed and implemented studies based on the recognition that endometrial receptivity defects are not equally distributed in women with endometriosis or these other conditions.

CONCLUSION(S)

Rapidly advancing technologies are bringing new biomarkers to the clinical arena that promise to further reveal the complexities of the implantation process.

Co-expression of bone morphogenetic protein 6 with estrogen receptor a in endometriosis

BACKGROUND

Bone morphogenetic protein 6 (BMP-6) has decisive role in controlling multiple organogenetic processes, as well as modulating cell differentiation and proliferation. Considering those pleiotropic effects, we focused on determining expression of that multifunctional growth factor in ectopic endometriotic tissues.

MATERIALS AND METHODS

In this prospective study, 85 consecutive women with endometriosis were included. All patients underwent gynecological operations due to endometriosis associated problems and tissue specimens were collected from ectopic endometriotic lesions. Immunohistochemical staining of paraffin sections for both BMP-6 and estrogen receptors a (ERa) was performed in all 85 cases using an avidin-biotin-peroxidase procedure.

RESULTS

Ectopic endometrium showed intense cytoplastic immunoreactivity to BMP-6 in both epithelium and stroma. In addition, we have demonstrated that BMP-6 expression is highly associated with strong expression of ERa.

DISCUSSION

The availability of BMP-6 in the ectopic endometrium may be at least partly involved in the mechanisms of attachment, survival and expansion of endometriosis. Moreover, the statistically significant correlation in expression of BMP-6 and ERa demonstrated in this study may be associated with the development of rich in estrogen microenvironment, but requires further investigation. In conclusion, this is the first study in our knowledge demonstrating strong expression of BMP-6 in endometriosis.

Dienogest in long-term treatment of endometriosis

Endometriosis is a chronic disease primarily affecting women of childbearing age, in which endometriotic lesions form outside the uterus, typically leading to painful symptoms, fatigue, and infertility. The symptoms of endometriosis may cause significant impairment in quality of life and represent a substantial economic burden to patients, families, and society. There is no cure for endometriosis; management consists of alleviating pain and other symptoms, reducing endometriotic lesions, and improving quality of life. Recurrence after surgical intervention is common, while the clinical evidence to support the efficacy and safety of many medications currently used in endometriosis is limited. Dienogest is an oral progestin that has been investigated extensively in the treatment of endometriosis in two clinical programs performed in Europe and Japan, including dose-ranging, placebo-controlled, active comparator-controlled, and long-term (up to 65 weeks) studies. These studies demonstrated that dienogest 2 mg daily effectively alleviates the painful symptoms of endometriosis, reduces endometriotic lesions, and improves indices of quality of life. Dienogest showed a favorable safety and tolerability profile in these studies, with predictable adverse effects, high rates of patient compliance, and low withdrawal rates. This review article describes the clinical trial evidence that characterizes the efficacy and safety of dienogest in endometriosis, including two studies characterizing dienogest in long-term use. The relevance of these findings to the management of endometriosis in clinical practice is discussed.

Single-nucleotide polymorphisms in the lysyl oxidase-like protein 4 and complement component 3 genes are associated with increased risk for endometriosis and endometriosis-associated infertility

This study was conducted to assess genetic associations with endometriosis in a Puerto Rican population. Statistically significant differences in the allelic frequencies and genotype distribution of genetic variants in lysyl oxidase-like protein 4 (LOXL4) and complement component 3 (C3) were documented in patients with endometriosis-associated infertility versus controls, and in patients with endometriosis versus controls, respectively. In women who have the risk genotype at both single-nucleotide polymorphisms, the estimated risk for endometriosis nearly doubled.

MUC4 gene polymorphisms associate with endometriosis development and endometriosis-related infertility

BACKGROUND

Mucin 4 (MUC4) plays an important role in protecting and lubricating the epithelial surface of reproductive tracts, but its role in the pathogenesis of endometriosis is largely unknown.

METHODS

To correlate MUC4 polymorphism with the risk of endometriosis and endometriosis-related infertility, we performed a case-control study of 140 patients and 150 healthy women. Six unique single-nucleotide polymorphisms (SNPs) (rs882605, rs1104760, rs2688513, rs2246901, rs2258447 and rs2291652) were selected for this study. DNA fragments containing the target SNP sites were amplified by polymerase chain reaction using the TaqMan SNP Genotyping Assay System to evaluate allele frequency and distribution of genotype in MUC4 polymorphisms.

RESULTS

Both the T/G genotype of rs882605 and the frequency of haplotype T-T (rs882605 and rs1104760) were higher in patients than in controls and were statistically significant. The frequency of the C allele at rs1104760, the C allele at rs2688513, the G allele at rs2246901 and the A allele at rs2258447 were associated with advanced stage of endometriosis. Moreover, the G allele at rs882605 was verified as a key genetic factor for infertility in patients. Protein sequence analysis indicated that amino acid substitutions by genetic variations at rs882605, rs2688513 and rs2246901 occur in the putative functional loops and the type D von Willebrand factor (VWFD) domain in the MUC4 sequence.

CONCLUSIONS

MUC4 polymorphisms are associated with endometriosis development and endometriosis-related infertility in the Taiwanese population.