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Zhao YQ, Ren YF, Li BB, Wei C, Yu B. The mysterious association between adiponectin and endometriosis. Front Pharmacol 2024; 15:1396616. [PMID: 38813109 PMCID: PMC11133721 DOI: 10.3389/fphar.2024.1396616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/29/2024] [Indexed: 05/31/2024] Open
Abstract
Adiponectin is a pleiotropic cytokine predominantly derived from adipose tissue. In addition to its role in regulating energy metabolism, adiponectin may also be related to estrogen-dependent diseases, and many studies have confirmed its involvement in mediating diverse biological processes, including apoptosis, autophagy, inflammation, angiogenesis, and fibrosis, all of which are related to the pathogenesis of endometriosis. Although many researchers have reported low levels of adiponectin in patients with endometriosis and suggested that it may serve as a protective factor against the development of the disease. Therefore, the purpose of this review was to provide an up-to-date summary of the roles of adiponectin and its downstream cytokines and signaling pathways in the aforementioned biological processes. Further systematic studies on the molecular and cellular mechanisms of action of adiponectin may provide novel insights into the pathophysiology of endometriosis as well as potential therapeutic targets.
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Affiliation(s)
| | | | - Bing-Bing Li
- College of Integrated Chinese and Western Medicine, Jining Medical University, Jining, Shandong Province, China
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2
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Zhu S, Wang A, Xu W, Hu L, Sun J, Wang X. The heterogeneity of fibrosis and angiogenesis in endometriosis revealed by single-cell RNA-sequencing. Biochim Biophys Acta Mol Basis Dis 2023; 1869:166602. [PMID: 36400338 DOI: 10.1016/j.bbadis.2022.166602] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
Fibrosis, angiogenesis and chronic inflammation are the inherent characteristics of endometriosis (EMS). The cellular heterogeneity of ectopic and non-ectopic endometrium by single-cell RNA-sequencing (scRNA-seq)at secretory phase without the disturbance of hormone drugs hasn't been explored so far. In this study, scRNA-seq was adopted to explore the properties of ectopic endometrium (ECE), eutopic endometrium (EUE) and normal endometrium (NOE) at secretory phase. We found that (i) The proportion of myofibroblasts, pericytes, endothelial cells and macrophages in ECE overwhelms that of non-ectopic tissues (EUE and NOE), and Myofibro.C2 was the predominant myofibroblast sub-cluster in ECE. (ii) Myofibroblasts were mainly fibroblast-to-myofibroblast transdifferentiation (FMT) and pericytes were endothelial cell-dependent differentiation in ECE. (iii) Both myofibroblasts and pericytes had a low differentiation potential. (iv) The increased inflammation score, deceased NK cells, T cell exhaustion score and antigen-presenting capacity in ECE confirmed the inflammatory properties and immunodeficiency of ECE. These findings suggested that myofibroblasts, pericytes and macrophages may be the potential targets for anti-fibrotic, anti-angiogenic and anti-inflammatory therapy of EMS.
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Affiliation(s)
- Shu Zhu
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, The First Clinical Medical College of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu Province, China
| | - Anqi Wang
- Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Wei Xu
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, The First Clinical Medical College of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu Province, China
| | - Longfei Hu
- Singleron Biotechnologies, Yaogu Avenue 11, Nanjing, Jiangsu, China
| | - Jiafan Sun
- Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiuli Wang
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, The First Clinical Medical College of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu Province, China.
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3
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Quan Q, Wu J, Yu M, Tang J. Immune micro-environment and drug analysis of peritoneal endometriosis based on epithelial-mesenchymal transition classification. Front Endocrinol (Lausanne) 2022; 13:1035158. [PMID: 36523599 PMCID: PMC9745086 DOI: 10.3389/fendo.2022.1035158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Epithelial-mesenchymal transition (EMT) is a complex event that drives polar epithelial cells transform from adherent cells to motile mesenchymal cells, in which are involved immune cells and stroma cells. EMT plays crucial roles in migration and invasion of endometriosis. The interaction of endometrial implants with the surrounding peritoneal micro-environment probably affects the development of peritoneal endometriosis. To date, very few studies have been carried out on peritoneal endometriosis sub-type classification and micro-environment analysis based on EMT. The purpose of this study is to investigate the potential application of EMT-based classification in precise diagnosis and treatment of peritoneal endometriosis. METHOD Based on EMT hallmark genes, 76 peritoneal endometriosis samples were classified into two clusters by consistent cluster classification. EMT scores, which calculated by Z score of 8 epithelial cell marker genes and 8 mesenchymal cell marker genes, were compared in two clusters. Then, immune scores and the abundances of corresponding immune cells, stroma scores and the abundances of corresponding stroma cells were analyzed by the "xCell" package. Futhermore, a diagnostic model was constructed based on 9 diagnostic markers which related to immune score and stroma score by Lasso-Logistic regression analysis. Finally, based on EMT classification, a total of 8 targeted drugs against two clusters were screened out by drug susceptibility analysis via "pRRophetic" package. RESULTS Hallmark epithelial-mesenchymal transition was the mainly enriched pathway of differentially expressed genes between peritoneal endometriosis tissues and endometrium tissues. Compared with cluster 2, EMT score and the abundances of most infiltrating stroma cell were significantly higher, while the abundances of most infiltrating immune cells were dramatically less. The diagnostic model could accurately distinguish cluster 1 from cluster 2. Pathway analysis showed drug candidates targeting cluster 1 mainly act on the IGF-1 signaling pathway, and drug candidates targeting cluster 2 mainly block the EGFR signaling pathway. CONCLUSION In peritoneal endometriosis, EMT was probably promoted by stroma cell infiltration and inhibited by immune cell infiltration. Besides, our study highlighted the potential uses of the EMT classification in the precise diagnosis and treatment of peritoneal endometriosis.
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Affiliation(s)
- Qingli Quan
- NHC Key Laboratory of Male Reproduction and Genetics, Guangdong Provincial Reproductive Science Institute (Guangdong Provincial Fertility Hospital), Guangzhou, China
- *Correspondence: Qingli Quan, ; Jia Tang,
| | - Jiabao Wu
- NHC Key Laboratory of Male Reproduction and Genetics, Guangdong Provincial Reproductive Science Institute (Guangdong Provincial Fertility Hospital), Guangzhou, China
| | - Meixing Yu
- Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jia Tang
- NHC Key Laboratory of Male Reproduction and Genetics, Guangdong Provincial Reproductive Science Institute (Guangdong Provincial Fertility Hospital), Guangzhou, China
- *Correspondence: Qingli Quan, ; Jia Tang,
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4
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Velho RV, Taube E, Sehouli J, Mechsner S. Neurogenic Inflammation in the Context of Endometriosis-What Do We Know? Int J Mol Sci 2021; 22:ijms222313102. [PMID: 34884907 PMCID: PMC8658724 DOI: 10.3390/ijms222313102] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 12/25/2022] Open
Abstract
Endometriosis (EM) is an estrogen-dependent disease characterized by the presence of epithelial, stromal, and smooth muscle cells outside the uterine cavity. It is a chronic and debilitating condition affecting ~10% of women. EM is characterized by infertility and pain, such as dysmenorrhea, chronic pelvic pain, dyspareunia, dysuria, and dyschezia. Although EM was first described in 1860, its aetiology and pathogenesis remain uncertain. Recent evidence demonstrates that the peripheral nervous system plays an important role in the pathophysiology of this disease. Sensory nerves, which surround and innervate endometriotic lesions, not only drive the chronic and debilitating pain associated with EM but also contribute to a growth phenotype by secreting neurotrophic factors and interacting with surrounding immune cells. Here we review the role that peripheral nerves play in driving and maintaining endometriotic lesions. A better understanding of the role of this system, as well as its interactions with immune cells, will unearth novel disease-relevant pathways and targets, providing new therapeutics and better-tailored treatment options.
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Affiliation(s)
- Renata Voltolini Velho
- Department of Gynecology Charité with Center of Oncological Surgery, Endometriosis Research Center Charité, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany; (R.V.V.); (J.S.)
| | - Eliane Taube
- Institute of Pathology, Charité Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany;
| | - Jalid Sehouli
- Department of Gynecology Charité with Center of Oncological Surgery, Endometriosis Research Center Charité, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany; (R.V.V.); (J.S.)
| | - Sylvia Mechsner
- Department of Gynecology Charité with Center of Oncological Surgery, Endometriosis Research Center Charité, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany; (R.V.V.); (J.S.)
- Correspondence: ; Tel.: +49-030-450664866
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Gruber TM, Mechsner S. Pathogenesis of Endometriosis: The Origin of Pain and Subfertility. Cells 2021; 10:cells10061381. [PMID: 34205040 PMCID: PMC8226491 DOI: 10.3390/cells10061381] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 01/04/2023] Open
Abstract
Endometriosis (EM) and adenomyosis (AM) are common conditions with pain and infertility as the principal symptoms. The pathophysiology of pain in EM and AM comprises sensory and somatoform pain mechanisms. Over time, these may aggravate and lead to individual complex disease patterns if not diagnosed and treated. Despite the known facts, several years often pass between the onset of symptoms and diagnosis. Chronic pain disorders with changes on a neuronal level frequently arise and are linked to depressive disorders, with the process becoming a vicious cycle. Additionally, women with EM and AM suffer from sub- and infertility. Low fecundity rates are caused by anatomical changes in combination with behavioral changes in the sexual activity of women with chronic pain as well as local proinflammatory factors that not only decrease implantation rates but also promote early abortions.
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Affiliation(s)
- Teresa Mira Gruber
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Obstetrics, Augustenburger Platz 1, 13353 Berlin, Germany;
| | - Sylvia Mechsner
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Endometriosis Centre Charité, Department of Gynaecology, Augustenburger Platz 1, 13353 Berlin, Germany
- Correspondence:
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La Greca G, Colarossi C, Di Mattia P, Gozzo C, De Zuanni M, Piombino E, Memeo L. Endomyometriosis of the Rectum With Disseminated Peritoneal Leiomyomatosis 8 Years After Laparoscopic Myomectomy: A Case Report. Front Surg 2021; 8:666147. [PMID: 33937318 PMCID: PMC8085435 DOI: 10.3389/fsurg.2021.666147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/22/2021] [Indexed: 11/15/2022] Open
Abstract
Endomyometriosis is a rare finding and it can be challenging to diagnose and to treat. It can arise in the uterus, in the ovary, in the broad ligament, in the peritoneal surface and in other pelvic structures. Usually patients with endomyometriosis are asymptomatic, but symptoms could occur due to large dimensions or site of the mass. We present a case of a 49-year-old woman with a symptomatic pelvic mass in the rectal wall, with no history of endometriosis, who underwent laparoscopic myomectomy 8 years earlier.
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Affiliation(s)
- Giorgio La Greca
- Surgical Oncology Unit, Department of Experimental Oncology, Mediterranean Institute of Oncology, Catania, Italy
| | - Cristina Colarossi
- Pathology Unit, Department of Experimental Oncology, Mediterranean Institute of Oncology, Catania, Italy
| | - Paolo Di Mattia
- Surgical Oncology Unit, Department of Experimental Oncology, Mediterranean Institute of Oncology, Catania, Italy
| | - Cecilia Gozzo
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, Italy
| | - Marco De Zuanni
- Surgical Oncology Unit, Department of Experimental Oncology, Mediterranean Institute of Oncology, Catania, Italy
| | - Eliana Piombino
- Pathology Unit, Department of Experimental Oncology, Mediterranean Institute of Oncology, Catania, Italy
| | - Lorenzo Memeo
- Pathology Unit, Department of Experimental Oncology, Mediterranean Institute of Oncology, Catania, Italy
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Xu Z, Zhang L, Yu Q, Zhang Y, Yan L, Chen ZJ. The estrogen-regulated lncRNA H19/miR-216a-5p axis alters stromal cell invasion and migration via ACTA2 in endometriosis. Mol Hum Reprod 2020; 25:550-561. [PMID: 31323679 DOI: 10.1093/molehr/gaz040] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/27/2019] [Accepted: 07/10/2019] [Indexed: 12/11/2022] Open
Abstract
Fibrotic tissue may contribute to the origin of some endometriosis-related symptoms, such as chronic pelvic pain and infertility. Alterations in the H19/miR-216a-5p/ACTA2 pathway may mediate the regulation of eutopic endometrial stromal cell (euESC) invasion and migration and may represent a potential mechanism underlying fibrous tissue formation or fibrosis in women with endometriosis. In this study, we aimed to determine the expression of H19 and ACTA2 in endometrial tissues of women with endometriosis. Two groups of 23 infertile women with endometriosis and 23 matched infertile women without endometriosis were investigated. Primary cultured cells of endometrial tissues were analyzed using RT-PCR and western blotting (WB) to determine expression of H19 and ACTA2. 5-Ethyl-2'-deoxyuridine, CCK8 and Transwell assays were used to study the functions of H19 and ACTA2. Human embryonic kidney 293 cells were used for luciferase assays to study miR-216a-5p binding sites with H19 and ACTA2. We found that H19 and ACTA2 levels were significantly higher in endometriosis euESCs than in control euESCs (P < 0.05) and were positively correlated in endometriosis euESCs. Luciferase assays indicated that H19 regulates ACTA2 expression via competition for inhibitory miR-216a-5p binding sites. Our results indicate that alterations in the estrogen/H19/miR-216a-5p/ACTA2 pathway regulated endometriosis euESC invasion and migration. Downregulation of H19 or ACTA2 inhibited endometriosis euESC invasion and migration; however, estrogen promoted endometriosis euESC invasion and migration via H19. The main limitation of our study was that experiments were conducted in vitro and further in vivo studies are required in the future. However, our study showed that primary cultured cells represented endometriosis cells more clearly than cell lines.
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Affiliation(s)
- Zhen Xu
- School of Medicine, Shandong University, 44 Wenhua West Road, Jinan, China.,Reproductive Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan, China.,National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, 157 Jingliu Road, Jinan, China.,Shandong Provincial Key Laboratory of Reproductive Medicine, 157 Jingliu Road, Jinan, China
| | - Liping Zhang
- School of Medicine, Shandong University, 44 Wenhua West Road, Jinan, China.,Reproductive Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan, China.,National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, 157 Jingliu Road, Jinan, China.,Shandong Provincial Key Laboratory of Reproductive Medicine, 157 Jingliu Road, Jinan, China
| | - Qian Yu
- School of Medicine, Shandong University, 44 Wenhua West Road, Jinan, China.,Reproductive Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan, China.,National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, 157 Jingliu Road, Jinan, China.,Shandong Provincial Key Laboratory of Reproductive Medicine, 157 Jingliu Road, Jinan, China
| | - Yanan Zhang
- School of Medicine, Shandong University, 44 Wenhua West Road, Jinan, China.,Reproductive Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan, China.,National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, 157 Jingliu Road, Jinan, China.,Shandong Provincial Key Laboratory of Reproductive Medicine, 157 Jingliu Road, Jinan, China
| | - Lei Yan
- School of Medicine, Shandong University, 44 Wenhua West Road, Jinan, China.,Reproductive Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan, China.,National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, 157 Jingliu Road, Jinan, China.,Shandong Provincial Key Laboratory of Reproductive Medicine, 157 Jingliu Road, Jinan, China
| | - Zi-Jiang Chen
- School of Medicine, Shandong University, 44 Wenhua West Road, Jinan, China.,Reproductive Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan, China.,National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, 157 Jingliu Road, Jinan, China.,Shandong Provincial Key Laboratory of Reproductive Medicine, 157 Jingliu Road, Jinan, China.,Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, 845 Lingshan Road, Shanghai, China
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Han X, Hu F, Chen F, Wang W. The inhibition of bone morphogenetic protein 1 attenuates endometriosis lesions in vivo and in vitro. Arch Gynecol Obstet 2020; 302:415-422. [PMID: 32524385 DOI: 10.1007/s00404-020-05612-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate the potential role of Bone morphogenetic protein 1 (BMP1) in endometriosis lesions. METHODS Endometriosis model in mice was established. The expression of BMP1-3 expression in mice of endometriosis lesions was evaluated. The effect of the treatment with anti-BMP1 antibodies on the expression of MMP2, MMP9, TGF-β, IL-17, IL-1β, Col1a1 and Col1a2 levels in mice was evaluated. In endometriosis cell model, the expression of IL-17, IL-1β, MMP2 and MMP9 levels and MIF, YWHAZ, β-catenin and CAP39 mRNA levels was also detected. RESULTS The expression of BMP1-3 expression was upregulated in mice of endometriosis lesions (p < 0.01). Treatment with anti-BMP1 antibodies dose-dependently reduced MMP2, MMP9, TGF-β, IL-17, IL-1β, Col1a1 and Col1a2 levels in mice (p < 0.01). Treatment with anti-BMP1 antibodies suppressed TGF-β/PI3K/Akt signaling pathway. In vitro cell, si-BMP1 suppressed TGF-β/PI3K/Akt signaling pathway. CONCLUSION The data support the hypothesis that the inhibition of BMP1 is involved in the pathogenesis of endometriosis lesions.
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Affiliation(s)
- Xinyue Han
- Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, China
| | - Feifei Hu
- Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, China
| | - Fang Chen
- Department of Obstetrics and Gynecology, Baotou City Central Hospital, Baotou, China
| | - Wei Wang
- Department of Neurology, The University of Hong Kong-Shenzhen Hospital, 1 Haiyuan 1st Road, Futian District, Shenzhen City, 518000, China.
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Bioinformatic analysis reveals the importance of epithelial-mesenchymal transition in the development of endometriosis. Sci Rep 2020; 10:8442. [PMID: 32439908 PMCID: PMC7242372 DOI: 10.1038/s41598-020-65606-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/07/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Endometriosis is a frequently occurring disease in women, which seriously affects their quality of life. However, its etiology and pathogenesis are still unclear. Methods: To identify key genes/pathways involved in the pathogenesis of endometriosis, we recruited 3 raw microarray datasets (GSE11691, GSE7305, and GSE12768) from Gene Expression Omnibus database (GEO), which contain endometriosis tissues and normal endometrial tissues. We then performed in-depth bioinformatic analysis to determine differentially expressed genes (DEGs), followed by gene ontology (GO), Hallmark pathway enrichment and protein-protein interaction (PPI) network analysis. The findings were further validated by immunohistochemistry (IHC) staining in endometrial tissues from endometriosis or control patients. Results: We identified 186 DEGs, of which 118 were up-regulated and 68 were down-regulated. The most enriched DEGs in GO functional analysis were mainly associated with cell adhesion, inflammatory response, and extracellular exosome. We found that epithelial-mesenchymal transition (EMT) ranked first in the Hallmark pathway enrichment. EMT may potentially be induced by inflammatory cytokines such as CXCL12. IHC confirmed the down-regulation of E-cadherin (CDH1) and up-regulation of CXCL12 in endometriosis tissues. Conclusions: Utilizing bioinformatics and patient samples, we provide evidence of EMT in endometriosis. Elucidating the role of EMT will improve the understanding of the molecular mechanisms involved in the development of endometriosis.
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