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Markowska A, de Mezer M, Kurzawa P, Bednarek W, Gryboś A, Krzyżaniak M, Markowska J, Gryboś M, Żurawski J. Analysis of Expression of the ANG1, CaSR and FAK Proteins in Uterine Fibroids. Int J Mol Sci 2024; 25:7164. [PMID: 39000274 PMCID: PMC11241732 DOI: 10.3390/ijms25137164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/11/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024] Open
Abstract
Understanding the molecular factors involved in the development of uterine myomas may result in the use of pharmacological drugs instead of aggressive surgical treatment. ANG1, CaSR, and FAK were examined in myoma and peripheral tissue samples taken from women after myoma surgery and in normal uterine muscle tissue samples taken from the control group. Tests were performed using tissue microarray immunohistochemistry. No statistically significant differences in ANG1 expression between the tissue of the myoma, the periphery, and the normal uterine muscle tissue of the control group were recorded. The CaSR value was reduced in the myoma and peripheral tissue and normal in the group of women without myomas. FAK expression was also lower in the myoma and periphery compared to the healthy uterine myometrium. Calcium supplementation could have an effect on stopping the growth of myomas.
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Affiliation(s)
- Anna Markowska
- Department of Perinatology and Women's Diseases, Poznan University of Medical Sciences, 60-535 Poznan, Poland
| | - Mateusz de Mezer
- Medical Biology, Department of Immunobiology, Poznan University of Medical Sciences, 60-806 Poznan, Poland
| | - Paweł Kurzawa
- Department of Clinical Pathology and Immunology, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Department of Oncological Pathology, University Clinical Hospital in Poznan, Poznan University of Medical Sciences, 61-848 Poznan, Poland
| | - Wiesława Bednarek
- Department of Oncological Gynecology and Gynecology, Medical University of Lublin, 20-059 Lublin, Poland
| | - Anna Gryboś
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Monika Krzyżaniak
- Department of Clinical Pathology and Immunology, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Department of Oncological Pathology, University Clinical Hospital in Poznan, Poznan University of Medical Sciences, 61-848 Poznan, Poland
| | | | - Marian Gryboś
- Institute of Health Sciences, University of Opole, 45-040 Opole, Poland
| | - Jakub Żurawski
- Medical Biology, Department of Immunobiology, Poznan University of Medical Sciences, 60-806 Poznan, Poland
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Greco S, Pinheiro J, Cardoso-Carneiro D, Giantomassi F, Pellegrino P, Scaglione G, Delli Carpini G, Ciavattini A, Zannoni GF, Goteri G, Martinho O, Ciarmela P. Raf kinase inhibitor protein expression in smooth muscle tumours of the uterus: a diagnostic marker for leiomyosarcoma? Reprod Biomed Online 2024; 48:103816. [PMID: 38608337 DOI: 10.1016/j.rbmo.2024.103816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 04/14/2024]
Abstract
RESEARCH QUESTION What is the expression pattern of Raf kinase inhibitory protein (RKIP) in different subtypes of leiomyoma (usual type, cellular, apoplectic or haemorrhagic leiomyoma, leiomyoma with bizarre nuclei and lipoleiomyoma) and leiomyosarcoma specimens, and what is its biological role in leiomyosarcoma cells? DESIGN Leiomyoma and leiomyosarcoma specimens underwent immunohistochemistry staining. Leiomyosarcoma SK-LMS-1 cell line was RKIP knocked down and RKIP overexpressed, and cell viability, wound healing migration and clonogenicity assays were carried out. RESULTS A higher immunohistochemical expression of RKIP was observed in bizarre leiomyomas, than in usual-type leiomyomas. Decreased expression was also found in cellular leiomyoma, with generally absent staining in leiomyosarcomas. Upon RKIP expression manipulation in SK-LMS-1 cell line, no major differences were observed in cell viability and migration capacity over time. RKIP knockout, however, resulted in a significant increase in the cell's ability to form colonies (P = 0.011). CONCLUSION RKIP distinct expression pattern among leiomyoma histotype and leiomyosarcoma, and its effect on leiomyosarcoma cells on colony formation, encourages further studies of RKIP in uterine smooth muscle disorders.
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Affiliation(s)
- Stefania Greco
- Department of Experimental and Clinical Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Joana Pinheiro
- Life and Health Sciences Research Institute (ICVS), Health Sciences School, University of Minho, Braga, Portugal.; ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Diana Cardoso-Carneiro
- Life and Health Sciences Research Institute (ICVS), Health Sciences School, University of Minho, Braga, Portugal.; ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Federica Giantomassi
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Pamela Pellegrino
- Department of Experimental and Clinical Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Giulia Scaglione
- Department of Woman and Child Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Delli Carpini
- Department of Specialist and Odontostomatological Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Andrea Ciavattini
- Department of Specialist and Odontostomatological Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Gian Franco Zannoni
- Department of Woman and Child Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gaia Goteri
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Olga Martinho
- Life and Health Sciences Research Institute (ICVS), Health Sciences School, University of Minho, Braga, Portugal.; ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Pasquapina Ciarmela
- Department of Experimental and Clinical Medicine, Università Politecnica delle Marche, Ancona, Italy..
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Vitale SG, Moore O, Riemma G, Carugno J, Yarto ML, Haimovich S. Hysteroscopic laser ablation of symptomatic uterine fibroids: insights from a prospective study. Climacteric 2023; 26:497-502. [PMID: 37165870 DOI: 10.1080/13697137.2023.2205581] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE This study aimed to evaluate the feasibility and efficacy of in-office hysteroscopic ablation of submucous uterine fibroids using a diode laser. METHOD A pilot study was conducted between January 2018 and January 2019 in a tertiary care university hospital. Patients with at least one symptomatic, class 0-2 FIGO classification, uterine fibroid ≤7 cm in size were eligible for inclusion. Evaluation of the changes in fibroid size and vascularity was performed using three-dimensional Doppler ultrasonography. Vaporization of the fibroid core was conducted using a 980-1470 nm wavelength diode laser inserted through the hysteroscope's working channel. The primary outcome was evaluation of the fibroid volume before and at 2 months after the procedure. RESULTS Twenty women were enrolled in the study. At 2-month follow-up, the volume of the fibroids was significantly reduced (51.6 ± 22.5 vs. 33.4 ± 17.1 mm3; p < 0.001). A major reduction of three-dimensional sonographic color Doppler vascularity (observed by the same operator and confirmed by four blind reviewers) was also achieved in 12/20 patients (60%; p = 0.03) while a reported symptom of heavy menstrual bleeding decreased from 18/20 (90%) to 2/18 (10%; p < 0.01). CONCLUSION Hysteroscopic laser ablation represents a feasible and effective alternative for treating women with symptomatic submucous fibroids in the office setting. Further studies with larger sample size and longer follow-up periods are needed to validate this promising technique.Key messageThis pilot study shows that in-office hysteroscopic laser ablation (HLA) could be a feasible alternative to treat symptomatic submucous uterine fibroids by coagulating their core, reducing their size and vascularization.
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Affiliation(s)
- S G Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - O Moore
- Department of Obstetrics and Gynecology, Laniado University Hospital, Netanya, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
| | - G Riemma
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - J Carugno
- Minimally Invasive Gynecology Unit, Obstetrics, Gynecology and Reproductive Sciences Department, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - M L Yarto
- Department of Obstetrics and Gynecology, Del Mar University Hospital, Barcelona, Spain
| | - S Haimovich
- Department of Obstetrics and Gynecology, Laniado University Hospital, Netanya, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
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Greco S, Zannotti A, Pellegrino P, Giantomassi F, Delli Carpini G, D'Agostino M, Goteri G, Ciavattini A, Donati C, Bernacchioni C, Petraglia F, La Teana A, Ciarmela P. High levels of hypusinated eIF5A in leiomyoma and leiomyosarcoma pathologies: a possible novel therapeutic target. Reprod Biomed Online 2023; 47:15-25. [PMID: 37137790 DOI: 10.1016/j.rbmo.2023.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/03/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
Abstract
RESEARCH QUESTION Is the hypusinated form of the eukaryotic translation initiation factor 5A (EIF5A) present in human myometrium, leiomyoma and leiomyosarcoma, and does it regulate cell proliferation and fibrosis? DESIGN The hypusination status of eIF5A in myometrial and leiomyoma patient-matched tissues was evaluated by immunohistochemistry and Western blotting as well as in leiomyosarcoma tissues by immunohistochemistry. Myometrial, leiomyoma and leiomyosarcoma cell lines were treated with N1-guanyl-1,7-diaminoheptane (GC-7), responsible for the inhibition of the first step of eIF5A hypunization, and the proliferation rate was determined by MTT assay; fibronectin expression was analysed by Western blotting. Finally, expression of fibronectin in leiomyosarcoma tissues was detected by immunohistochemistry. RESULTS The hypusinated form of eIF5A was present in all tissues examined, with an increasing trend of hypusinated eIF5A levels from normal myometrium to neoplastic benign leiomyoma up to neoplastic malignant leiomyosarcoma. The higher levels in leiomyoma compared with myometrium were confirmed by Western blotting (P = 0.0046). The inhibition of eIF5A hypusination, with GC-7 treatment at 100 nM, reduced the cell proliferation in myometrium (P = 0.0429), leiomyoma (P = 0.0030) and leiomyosarcoma (P = 0.0044) cell lines and reduced the expression of fibronectin in leiomyoma (P = 0.0077) and leiomyosarcoma (P = 0.0280) cells. The immunohistochemical staining of leiomyosarcoma tissue revealed that fibronectin was highly expressed in the malignant aggressive (central) part of the leiomyosarcoma lesion, where hypusinated eIF5A was also highly represented. CONCLUSIONS These data support the hypothesis that eIF5A may be involved in the pathogenesis of myometrial benign and malignant pathologies.
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Affiliation(s)
- Stefania Greco
- Department of Experimental and Clinical Medicine, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Alessandro Zannotti
- Department of Experimental and Clinical Medicine, Università Politecnica delle Marche, 60126 Ancona, Italy; Department of Specialist and Odontostomatological Clinical Sciences, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Pamela Pellegrino
- Department of Experimental and Clinical Medicine, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Federica Giantomassi
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Giovanni Delli Carpini
- Department of Specialist and Odontostomatological Clinical Sciences, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Mattia D'Agostino
- Department of Life and Environmental Sciences, New York-Marche Structural Biology Center (NY, MaSBIC), Università Politecnica delle Marche, 60131 Ancona, Italy
| | - Gaia Goteri
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Andrea Ciavattini
- Department of Specialist and Odontostomatological Clinical Sciences, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Chiara Donati
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", Università di Firenze, 50134 Firenze, Italy
| | - Caterina Bernacchioni
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", Università di Firenze, 50134 Firenze, Italy
| | - Felice Petraglia
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", Università di Firenze, 50134 Firenze, Italy
| | - Anna La Teana
- Department of Life and Environmental Sciences, New York-Marche Structural Biology Center (NY, MaSBIC), Università Politecnica delle Marche, 60131 Ancona, Italy
| | - Pasquapina Ciarmela
- Department of Experimental and Clinical Medicine, Università Politecnica delle Marche, 60126 Ancona, Italy.
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Reply of the Authors: Understanding and managing the anatomy of a fibroid during myomectomy. Fertil Steril 2022; 118:997. [PMID: 36182624 DOI: 10.1016/j.fertnstert.2022.08.845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 01/13/2023]
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Cai L, Liao Z, Li S, Wu R, Li J, Ren F, Zhang H. PLP1 may serve as a potential diagnostic biomarker of uterine fibroids. Front Genet 2022; 13:1045395. [PMID: 36386836 PMCID: PMC9662689 DOI: 10.3389/fgene.2022.1045395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/14/2022] [Indexed: 12/05/2022] Open
Abstract
Objective: We aim to identify the crucial genes or potential biomarkers associated with uterine fibroids (UFs), which may provide clinicians with evidence about the diagnostic biomarker of UFs and reveal the mechanism of its progression. Methods: The gene expression and genome-wide DNA methylation profiles were obtained from Gene Expression Omnibus database (GEO). GSE45189, GSE31699, and GSE593 datasets were included. GEO2R and Venn diagrams were used to analyze the differentially expressed genes (DEGs) and extract the hub genes. Gene Ontology (GO) analysis was performed by the online tool Database for Annotation, Visualization, and Integrated Discovery (DAVID). The mRNA and protein expression of hub genes were validated by RT-qPCR, western blot, and immunohistochemistry. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value. Results: We detected 22 DEGs between UFs and normal myometrium, which were enriched in cell maturation, apoptotic process, hypoxia, protein binding, and cytoplasm for cell composition. By finding the intersection of the data between differentially expressed mRNA and DNA methylation profiles, 3 hub genes were identified, including transmembrane 4 L six family member 1 (TM4SF1), TNF superfamily member 10 (TNFSF10), and proteolipid protein 1 (PLP1). PLP1 was validated to be up-regulated significantly in UFs both at mRNA and protein levels. The area under the ROC curve (AUC) of PLP1 was 0.956, with a sensitivity of 79.2% and a specificity of 100%. Conclusion: Overall, our results indicate that PLP1 may be a potential diagnostic biomarker for uterine fibroids.
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Affiliation(s)
- Lei Cai
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiqi Liao
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiyu Li
- Institute of Digestive Disease and Department of Medicine and Therapeutics, State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Ruxing Wu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Li
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fang Ren
- Department of Gynecology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Hanwang Zhang, ; Fang Ren,
| | - Hanwang Zhang
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Hanwang Zhang, ; Fang Ren,
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Carbajo-García MC, de Miguel-Gómez L, Juárez-Barber E, Trelis A, Monleón J, Pellicer A, Flanagan JM, Ferrero H. Deciphering the Role of Histone Modifications in Uterine Leiomyoma: Acetylation of H3K27 Regulates the Expression of Genes Involved in Proliferation, Cell Signaling, Cell Transport, Angiogenesis and Extracellular Matrix Formation. Biomedicines 2022; 10:biomedicines10061279. [PMID: 35740301 PMCID: PMC9219820 DOI: 10.3390/biomedicines10061279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 11/21/2022] Open
Abstract
Uterine leiomyoma (UL) is a benign tumor arising from myometrium (MM) with a high prevalence and unclear pathology. Histone modifications are altered in tumors, particularly via histone acetylation which is correlated with gene activation. To identify if the acetylation of H3K27 is involved in UL pathogenesis and if its reversion may be a therapeutic option, we performed a prospective study integrating RNA-seq (n = 48) and CHIP-seq for H3K27ac (n = 19) in UL vs MM tissue, together with qRT-PCR of SAHA-treated UL cells (n = 10). CHIP-seq showed lower levels of H3K27ac in UL versus MM (p-value < 2.2 × 10−16). From 922 DEGs found in UL vs. MM (FDR < 0.01), 482 presented H3K27ac. A differential acetylation (FDR < 0.05) was discovered in 82 of these genes (29 hyperacetylated/upregulated, 53 hypoacetylated/downregulated). Hyperacetylation/upregulation of oncogenes (NDP,HOXA13,COL24A1,IGFL3) and hypoacetylation/downregulation of tumor suppressor genes (CD40,GIMAP8,IL15,GPX3,DPT) altered the immune system, the metabolism, TGFβ3 and the Wnt/β-catenin pathway. Functional enrichment analysis revealed deregulation of proliferation, cell signaling, transport, angiogenesis and extracellular matrix. Inhibition of histone deacetylases by SAHA increased expression of hypoacetylated/downregulated genes in UL cells (p < 0.05). Conclusively, H3K27ac regulates genes involved in UL onset and maintenance. Histone deacetylation reversion upregulates the expression of tumor suppressor genes in UL cells, suggesting targeting histone modifications as a therapeutic approach for UL.
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Affiliation(s)
- María Cristina Carbajo-García
- Fundación IVI, IIS La Fe, 46026 Valencia, Spain; (M.C.C.-G.); (L.d.M.-G.); (E.J.-B.); (A.P.)
- Departamento de Pediatría, Obstetricia y Ginecología, Universidad de Valencia, 46010 Valencia, Spain
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
| | - Lucia de Miguel-Gómez
- Fundación IVI, IIS La Fe, 46026 Valencia, Spain; (M.C.C.-G.); (L.d.M.-G.); (E.J.-B.); (A.P.)
| | - Elena Juárez-Barber
- Fundación IVI, IIS La Fe, 46026 Valencia, Spain; (M.C.C.-G.); (L.d.M.-G.); (E.J.-B.); (A.P.)
| | | | | | - Antonio Pellicer
- Fundación IVI, IIS La Fe, 46026 Valencia, Spain; (M.C.C.-G.); (L.d.M.-G.); (E.J.-B.); (A.P.)
- IVIRMA Rome, 00197 Rome, Italy
| | - James M. Flanagan
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
| | - Hortensia Ferrero
- Fundación IVI, IIS La Fe, 46026 Valencia, Spain; (M.C.C.-G.); (L.d.M.-G.); (E.J.-B.); (A.P.)
- Correspondence: ; Tel.: +34-963-903-305
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Di Giuseppe J, Grelloni C, Giuliani L, Delli Carpini G, Giannella L, Ciavattini A. Recurrence of Uterine Smooth Muscle Tumor of Uncertain Malignant Potential: A Systematic Review of the Literature. Cancers (Basel) 2022; 14:cancers14092323. [PMID: 35565452 PMCID: PMC9104240 DOI: 10.3390/cancers14092323] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 04/30/2022] [Accepted: 05/05/2022] [Indexed: 02/05/2023] Open
Abstract
Background: This study aimed to systematically review the existing literature on uterine smooth muscle tumor of uncertain malignant potential (STUMP) to provide information about characteristics and outcomes of patients and the risk factors for recurrence over a period of 60 years (1960−2021). Methods: According to PRISMA guidelines, we searched for "uterine smooth muscle tumor of uncertain malignant potential" in PubMed (all fields) and Scopus (Title/Abstract/Keywords) databases (accessed on 1 January 2022). Relevant articles were obtained in full-text format and screened for additional references. The only filter used was the English language. Studies including full case description of patients with histopathological diagnosis of STUMP in accordance with Stanford criteria were included. Results: Thirty-four studies, including 189 cases, were included. The median age was 43 years, and in 21.5% of cases there was a recurrence of the disease. Bivariate analysis showed a significant association between use of morcellation without bag and risk of recurrence (p = 0.001). Unprotected morcellation during demolitive or conservative surgery was independently associated with a higher risk of disease recurrence with a relative risk of 2.94 (p < 0.001). A significant progressive decrease in the recurrence rate was observed over time (r = −0.671, p = 0.008). The percentage of patients who underwent surgery followed by in-bag protected morcellation significantly increased after the publication of the U.S. Food and Drug Administration alert about the risk linked to this procedure (p = 0.01). Conclusions: Unprotected morcellation of the lesion is associated with the relapse of the disease. However, this clinical condition showed a drastic decrease over time. This could likely be due to the increased awareness by surgeons of the importance of customizing surgical treatment.
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