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Chen B, Zhao L, Yang R, Xu T. New insights about endometriosis-associated ovarian cancer: pathogenesis, risk factors, prediction and diagnosis and treatment. Front Oncol 2024; 14:1329133. [PMID: 38384812 PMCID: PMC10879431 DOI: 10.3389/fonc.2024.1329133] [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: 10/28/2023] [Accepted: 01/23/2024] [Indexed: 02/23/2024] Open
Abstract
Previous studies have shown that the risk of malignant transformation of endometriosis in premenopausal women is approximately 1%, significantly impacting the overall well-being and quality of life of affected women. Presently, the diagnostic gold standard for endometriosis-associated ovarian cancer (EAOC) continues to be invasive laparoscopy followed by histological examination. However, the application of this technique is limited due to its high cost, highlighting the importance of identifying a non-invasive diagnostic approach. Therefore, there is a critical need to explore non-invasive diagnostic methods to improve diagnostic precision and optimize clinical outcomes for patients. This review presents a comprehensive survey of the current progress in comprehending the pathogenesis of malignant transformation in endometriosis. Furthermore, it examines the most recent research discoveries concerning the diagnosis of EAOC and emphasizes potential targets for therapeutic intervention. The ultimate objective is to improve prevention, early detection, precise diagnosis, and treatment approaches, thereby optimizing the clinical outcomes for patients.
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Affiliation(s)
| | | | | | - Tianmin Xu
- Department of Obstetrics and Gynecology, The Second Hospital of Jilin University, Changchun, China
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2
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A Systematic Review of Atypical Endometriosis-Associated Biomarkers. Int J Mol Sci 2022; 23:ijms23084425. [PMID: 35457244 PMCID: PMC9029517 DOI: 10.3390/ijms23084425] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 02/06/2023] Open
Abstract
Ovarian endometriosis may increase the risk of malignancy. Several studies have suggested atypical endometriosis as the direct precursor of endometriosis-associated ovarian cancer. We performed an advanced, systematic search of the online medical databases PubMed and Medline. The search revealed n = 40 studies eligible for inclusion in this systematic review. Of these, n = 39 were finally included. The results from included studies are characterized by high heterogeneity, but some consistency has been found for altered expression in phosphoinositide 3-kinase (PI3K)/AKT/mTOR pathway, ARID1a, estrogen and progesterone receptors, transcriptional, nuclear, and growth factors in atypical endometriosis. Although many targets have been proposed as biomarkers for the presence of atypical endometriosis, none of them has such strong evidence to justify their systematic use in clinical practice, and they all need expensive molecular analyses. Further well-designed studies are needed to validate the evidence on available biomarkers and to investigate novel serum markers for atypical endometriosis.
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Liu G, Wang Y, Chen Y, Ren F. Malignant transformation of abdominal wall endometriosis: A systematic review of the epidemiology, diagnosis, treatment, and outcomes. Eur J Obstet Gynecol Reprod Biol 2021; 264:363-367. [PMID: 34391052 DOI: 10.1016/j.ejogrb.2021.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/23/2021] [Accepted: 08/04/2021] [Indexed: 02/07/2023]
Abstract
Malignant transformation of abdominal wall endometriosis (AWE) is rare. The clinical characteristics and treatment of malignant transformation of AWE are not well known. Therefore, in this review, we performed a thorough search for malignant transformation of AWE on MEDLINE and Web of Science from their inception to May 2021. In total, the data of 46 patients with malignant transformation of AWE were retrieved, and all the data on these patients were collected. After reviewing and analyzing the clinical parameters, we found that cesarean scar was the most common site of malignant transformation of AWE, and the most common pathological type of malignant transformation of AWE was clear cell cancer, followed by endometrioid adenocarcinoma. The main symptoms of malignant transformation of AWE included an abdominal nodule or mass, and ultrasonography was the first choice for diagnosis. The most widely accepted treatment was surgical resection of local lesions with adjunctive chemotherapy and/or radiotherapy, and the overall survival of patients with malignant transformation of AWE was poor. In conclusion, malignant transformation of AWE is rare, and the prognosis is poor. Thus, improving abdominal surgical technology and avoiding iatrogenic ectopia and implantation of the endometrium are necessary to prevent malignant transformation of AWE.
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Affiliation(s)
- Gang Liu
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110004, China
| | - Yizi Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110004, China
| | - Yinghan Chen
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110004, China
| | - Fang Ren
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110004, China.
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Chen H, Malentacchi F, Fambrini M, Harrath AH, Huang H, Petraglia F. Epigenetics of Estrogen and Progesterone Receptors in Endometriosis. Reprod Sci 2020; 27:1967-1974. [PMID: 32700282 DOI: 10.1007/s43032-020-00226-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/25/2020] [Indexed: 12/16/2022]
Abstract
Endometriosis is an estrogen-dependent inflammatory gynecological disease. Increased estrogen activity and progesterone resistance are the main hormonal substrate of this disease and are associated with inflammatory response and debilitating symptoms, including pain and infertility. Estrogens and progesterone act via their specific nuclear receptors. The regulation of receptor expression by epigenetics maybe a critical factor for endometriosis. The present review aims to discuss the epigenetic mechanisms related to the expression of estrogen receptors (ERs) and progesterone receptors (PRs) in patients with endometriosis, including two classic epigenetic mechanisms: DNA methylation and histone modification, and, other non-classic mechanisms: miRNAs and lncRNA. Several in vitro and in vivo studies support the key role of epigenetics in the regulation of the expression of ERs and PRs, which may provide new molecules and targets for the diagnosis and treatment of endometriosis.
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Affiliation(s)
- Huixi Chen
- Obstetrics and Gynecology Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
- International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Francesca Malentacchi
- Obstetrics and Gynecology Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Massimiliano Fambrini
- Obstetrics and Gynecology Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Abdel Halim Harrath
- Department of Zoology, College of Science, King Said University, Riyadh, Saudi Arabia
| | - Hefeng Huang
- International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Felice Petraglia
- Obstetrics and Gynecology Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy.
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Hong CH, Ho JC, Lee CH. Steroid Receptor RNA Activator, a Long Noncoding RNA, Activates p38, Facilitates Epithelial-Mesenchymal Transformation, and Mediates Experimental Melanoma Metastasis. J Invest Dermatol 2020; 140:1355-1363.e1. [DOI: 10.1016/j.jid.2019.09.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 09/10/2019] [Accepted: 09/14/2019] [Indexed: 02/06/2023]
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Bilgic E, Guzel E, Kose S, Aydin MC, Karaismailoglu E, Akar I, Usubutun A, Korkusuz P. Endocannabinoids modulate apoptosis in endometriosis and adenomyosis. Acta Histochem 2017; 119:523-532. [PMID: 28549792 DOI: 10.1016/j.acthis.2017.05.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 12/15/2022]
Abstract
Adenomyosis that is a form of endometriosis is the growth of ectopic endometrial tissue within the muscular wall of the uterus (myometrium), which may cause dysmenorrhea and infertility. Endocannabinoid mediated apoptotic mechanisms of endometriosis and adenomyosis are not known. We hypothesized that the down regulation of endocannabinoid receptors and/or alteration in their regulatory enzymes may have a direct role in the pathogenesis of endometriosis and adenomyosis through apoptosis. Endocannabinoid receptors CB1 and CB2, their synthesizing and catabolizing enzymes (FAAH, NAPE-PLD, DAGL, MAGL) and the apoptotic indexes were immunohistochemically assessed in endometriotic and adenomyotic tissues. Findings were compared to normal endometrium and myometrium. Endometrial adenocarcinoma (Ishikawa) and ovarian endometriosis cyst wall stromal (CRL-7566) cell lines were furthermore cultured with or without cannabinoid receptor agonists. The IC50 value for CB1 and CB2 receptor agonists was quantified. Cannabinoid agonists on cell death were investigated by Annexin-V/Propidium iodide labeling with flow cytometry. CB1 and CB2 receptor levels decreased in endometriotic and adenomyotic tissues compared to the control group (p=0,001 and p=0,001). FAAH, NAPE-PLD, MAGL and DAGL enzyme levels decreased in endometriotic and adenomyotic tissues compared to control (p=0,001, p=0,001, p=0,001 and p=0,002 respectively). Apoptotic cell indexes both in endometriotic and adenomyotic tissues also decreased significantly, compared to the control group (p=0,001 and p=0,001). CB1 and CB2 receptor agonist mediated dose dependent fast anti-proliferative and pro-apoptotic effects were detected in Ishikawa and ovarian endometriosis cyst wall stromal cell lines (CRL-7566). Endocannabinoids are suggested to increase apoptosis mechanisms in endometriosis and adenomyosis. CB1 and CB2 antagonists can be considered as potential medical therapeutic agents for endometriosis and adenomyosis.
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Choi JY, Han HH, Kim YT, Lee JH, Kim BG, Kang S, Cho NH. Ovarian Clear Cell Carcinoma Sub-Typing by ARID1A Expression. Yonsei Med J 2017; 58:59-66. [PMID: 27873496 PMCID: PMC5122653 DOI: 10.3349/ymj.2017.58.1.59] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/03/2016] [Accepted: 06/08/2016] [Indexed: 01/27/2023] Open
Abstract
PURPOSE Loss of AT-rich DNA-interacting domain 1A (ARID1A) has been identified as a driving mutation of ovarian clear cell carcinoma (O-CCC), a triple-negative ovarian cancer that is intermediary between serous and endometrioid subtypes, in regards to molecular and clinical behaviors. However, about half of O-CCCs still express BAF250a, the protein encoded by ARID1A. Herein, we aimed to identify signatures of ARID1A-positive O-CCC in comparison with its ARID1A-negative counterpart. MATERIALS AND METHODS Seventy cases of O-CCC were included in this study. Histologic grades and patterns of primary tumor, molecular marker immunohistochemistry profiles, and clinical outcomes were analyzed. RESULTS Forty-eight (69%) O-CCCs did not express BAF250a, which were designated as "ARID1A-negative." The other 22 (31%) O-CCCs were designated as "ARID1A-positive." ARID1A-positive tumors were more likely to be histologically of high grades (41% vs. 10%, p=0.003), ERβ-positive (45% vs. 17%, p=0.011), and less likely to be HNF1β-positive (77% vs. 96%, p=0.016) and E-cadherin-positive (59% vs. 83%, p=0.028) than ARID1A-negative tumors. Patient age, parity, tumor stage were not significantly different in between the two groups. Cancer-specific survival was not significantly different either. CONCLUSION We classified O-CCCs according to ARID1A expression status. ARID1A-positive O-CCCs exhibited distinct immunohistochemical features from ARID1A-negative tumors, suggesting a different underlying molecular event during carcinogenesis.
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Affiliation(s)
- Jae Yoon Choi
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ho Han
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 Plus Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Young Tae Kim
- Department of Gynecology, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Hyun Lee
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 Plus Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Baek Gil Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 Plus Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Suki Kang
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
- Severance Biomedical Science Institute (SBSI), Yonsei University College of Medicine, Seoul, Korea
| | - Nam Hoon Cho
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 Plus Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
- Severance Biomedical Science Institute (SBSI), Yonsei University College of Medicine, Seoul, Korea.
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Xu P, Ding S, Zhu L, Le F, Huang X, Tian Y, Zhang X. Elevated RON protein expression in endometriosis and disease-associated ovarian cancers. Arch Gynecol Obstet 2016; 295:631-639. [PMID: 27888297 DOI: 10.1007/s00404-016-4248-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 11/22/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Recepteur d'origine nantais (RON) protein expression has been demonstrated to correlate with tumor progression, metastasis, and prognosis, and its mRNA expression increases in deeply infiltrating endometriotic lesions. However, it remains unclear whether RON protein expression also increases in endometriotic lesions, and may be a risk factor of malignant transformation in endometriotic lesions. METHODS The protein expression of RON in control (n = 19), eutopic (n = 16), and ectopic (n = 51) endometria, as well as in endometriosis-associated ovarian cancers (EAOC, n = 16) was determined by immunohistochemical (IHC) staining. RESULTS Endometriotic lesions expressed low levels of RON protein, but no RON protein expression appeared in matched eutopic or control endometrium. EAOC exhibited high levels of RON protein. The frequency and IHC score of RON protein expression were both significantly higher in EAOC [100.0% (14/14), 5.37 ± 0.74] than those in endometriotic lesions [51.0% (26/51), 2.15 ± 1.12; P = 0.002, 0.001]. Multivariate analysis of covariance only revealed a correlation of RON protein expression and EAOC (P = 0.006), but no correlations of RON protein expression and clinical parameters (P > 0.05). CONCLUSIONS These obtained results suggest that increased RON expression might be involved in the pathogenesis of endometriosis and disease-associated ovarian cancers.
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Affiliation(s)
- Ping Xu
- The Department of Gynecology, Women's Hospital School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang, 310006, People's Republic of China
| | - Shaojie Ding
- The Department of Gynecology, Women's Hospital School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang, 310006, People's Republic of China
| | - Libo Zhu
- The Department of Gynecology, Women's Hospital School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang, 310006, People's Republic of China
| | - Fang Le
- The Department of Gynecology, Women's Hospital School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang, 310006, People's Republic of China
| | - Xiufeng Huang
- The Department of Gynecology, Women's Hospital School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang, 310006, People's Republic of China
| | - Yonghong Tian
- The Department of Gynecology, Women's Hospital School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang, 310006, People's Republic of China
| | - Xinmei Zhang
- The Department of Gynecology, Women's Hospital School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang, 310006, People's Republic of China.
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Lin K, Zhan H, Ma J, Xu K, Wu R, Zhou C, Lin J. Silencing of SRA1 Regulates ER Expression and Attenuates the Growth of Stromal Cells in Ovarian Endometriosis. Reprod Sci 2016; 24:836-843. [PMID: 27694140 DOI: 10.1177/1933719116670036] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Estradiol and its nuclear receptors, estrogen receptor (ER) α and ER-β, have important functions in endometriosis, and the transcriptional activity of these receptors is modulated by coactivators and corepressors. The steroid receptor RNA activator 1 (SRA1) produces SRA long noncoding RNA (lncRNA) and SRA protein (SRAP), which regulate ER expression at the RNA and protein levels in some hormone-dependent tumors via an alternative splicing event. However, only a few are reported on their expressions in endometriosis. Here, we observed that low expression levels of SRA lncRNA and ER-α but relatively high expression levels of SRAP and ER-β were detected in ovarian endometriotic tissues versus normal endometrial tissues. Steroid receptor RNA activator 1-small interfering RNA treatment significantly increased ER-α levels but reduced ER-β levels in endometriotic stromal cells (ESCs). Furthermore, the treatment can also attenuate the proliferation and promote early apoptosis in these cells. Our results indicate that the regulation of ER via SRA in ovarian endometriosis may play a significant role in the growth of ESCs.
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Affiliation(s)
- Kaiqing Lin
- 1 Department of Gynaecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Hong Zhan
- 1 Department of Gynaecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Junyan Ma
- 2 Key Laboratory of Women's Reproductive Health of Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Kaihong Xu
- 1 Department of Gynaecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Ruijin Wu
- 1 Department of Gynaecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Caiyun Zhou
- 3 Department of Pathology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Jun Lin
- 1 Department of Gynaecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
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Obeid JP, Zafar N, El Hokayem J. Steroid Hormone Receptor Coregulators in Endocrine Cancers. IUBMB Life 2016; 68:504-15. [PMID: 27240871 DOI: 10.1002/iub.1517] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/11/2016] [Accepted: 05/11/2016] [Indexed: 01/14/2023]
Abstract
Coregulators span a broad and extensive domain in modulating cellular transcriptional activity. Studies have established a dynamic role for such coregulators in various endocrine cancers. Steroid hormone receptors (SHRs) play a pivotal role in such endocrine cancers, and interact abundantly with transcriptional coregulators in altering gene expression. Several families of coregulators have implications in propagating the development, progression and invasion of breast, prostate, and other hormone-responsive cancers. This mini-review aims to discuss different classes of coregulators involved in endocrine cancers and highlight unique information regarding each family with relevance to mechanism, intervention, and novel directions being investigated. © 2016 IUBMB Life, 68(7):504-515, 2016.
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Affiliation(s)
- Jean-Pierre Obeid
- Department of Biochemistry and Molecular Biology, University of Miami, FL, USA
| | - Nawal Zafar
- Department of Biochemistry and Molecular Biology, University of Miami, FL, USA
| | - Jimmy El Hokayem
- Department of Biochemistry and Molecular Biology, University of Miami, FL, USA
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Ren F, Wang DB, Li T, Chen YH, Li Y. Identification of differentially methylated genes in the malignant transformation of ovarian endometriosis. J Ovarian Res 2014; 7:73. [PMID: 25298284 PMCID: PMC4105232 DOI: 10.1186/1757-2215-7-73] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/07/2014] [Indexed: 12/17/2022] Open
Abstract
Background Key roles for epigenetic mechanisms in tumorigenesis are well accepted, while the relationship between gene methylation and malignant transformation of ovarian endometriosis (EMS) was seldom reported. In this study, we aimed to screen for aberrantly methylated genes associated with the malignant transformation of ovarian EMS and to preliminarily verify the reliability of screened results by detecting the methylation status and protein expression of the candidate gene in a larger scale of formaldehyde-fixed and paraffin-embedded (FFPE) samples. Methods Methylated CpG island amplification coupled with representational difference analysis (MCA-RDA) was performed on 3 couples of endometriosis-associated ovarian carcinoma (EAOC) fresh samples to identify differentially methylated candidate genes related to malignant transformation of ovarian EMS; Methylation-specific PCR (MSP) and immunohistochemistry were performed in 30 EAOC samples to detected the methylation status and protein expression of RASSF2 gene to verify the reliability of MCA-RDA results. Results Nine differentially methylated genes were obtained by MCA-RDA as candidate genes for malignant transformation of EMS; Methylation frequency of RASSF2 in the neoplastic tissues of EAOC group was higher than that in the ectopic endometria (p < 0.05). While protein expression of RASSF2 in the neoplastic tissues was lower than that in the ectopic endometria of the EAOC group (p < 0.05) Absence of protein expression of RASSF2 was significantly correlated with the promoter methylation of the gene (p < 0.05). Conclusions RASSF2, RUNX3, GSTZ1, CYP2A, GBGT1, NDUFS1, SPOCK2, ADAM22, and TRIM36 were candidate genes for malignant transformation of ovarian EMS and epigenetic inactivation of RASSF2 by promoter hypermethylation is an early event in malignant transformation of ovarian EMS. The screen results were reliable and worthy of further study.
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