Analysis of the karyotype and desoxyribonucleic acid content of uterine myomas in premenopausal, menopausal, and gonadotropin-releasing hormone agonist-treated females**Supported by the Belgian program on Interuniversity Poles of Attraction initiated by the Belgian State, Prime Minister’s Office, Science Policy Programming, the Fonds voor Geneeskundig Wetenschappelijk Onderzoek (FGWO grant no. G.3074.90), Belgium and in part by the European Union through the Biomed 1 program “Molecular Cytogenetics of Solid Tumours”, Brussels, Belgium

Cytogenomic Profile of Uterine Leiomyoma: In Vivo vs. In Vitro Comparison

We performed a comparative cytogenomic analysis of cultured and uncultured uterine leiomyoma (UL) samples. The experimental approach included karyotyping, aCGH, verification of the detected chromosomal abnormalities by metaphase and interphase FISH, MED12 mutation analysis and telomere measurement by Q-FISH. An abnormal karyotype was detected in 12 out of 32 cultured UL samples. In five karyotypically abnormal ULs, MED12 mutations were found. The chromosomal abnormalities in ULs were present mostly by complex rearrangements, including chromothripsis. In both karyotypically normal and abnormal ULs, telomeres were ~40% shorter than in the corresponding myometrium, being possibly prerequisite to chromosomal rearrangements. The uncultured samples of six karyotypically abnormal ULs were checked for the detected chromosomal abnormalities through interphase FISH with individually designed DNA probe sets. All chromosomal abnormalities detected in cultured ULs were found in corresponding uncultured samples. In all tumors, clonal spectra were present by the karyotypically abnormal cell clone/clones which coexisted with karyotypically normal ones, suggesting that chromosomal abnormalities acted as drivers, rather than triggers, of the neoplastic process. In vitro propagation did not cause any changes in the spectrum of the cell clones, but altered their ratio compared to uncultured sample. The alterations were unique for every UL. Compared to its uncultured counterpart, the frequency of chromosomally abnormal cells in the cultured sample was higher in some ULs and lower in others. To summarize, ULs are characterized by both inter- and intratumor genetic heterogeneity. Regardless of its MED12 status, a tumor may be comprised of clones with and without chromosomal abnormalities. In contrast to the clonal spectrum, which is unique and constant for each UL, the clonal frequency demonstrates up or down shifts under in vitro conditions, most probably determined by the unequal ability of cells with different genetic aberrations to exist outside the body.

Outcome of patients with uterine fibroids after 3-month ulipristal acetate therapy

OBJECTIVES

To determine the proportion and the characteristics of patients who did or did not respond after 3 months of ulipristal acetate (UPA) therapy.

STUDY DESIGN

In this retrospective cohort study conducted in the University Hospital of Bordeaux (France) and University Medical Center Ljubljana (Slovenia), symptomatic non-menopausal patients with fibroids that qualified for surgery were pretreated by 3 months of oral UPA 5 mg/day. Clinical success was defined by normalization of the bleeding score, and/or regression of pelvic pain, and/or abdominal distension. Imaging success was defined by reduction in fibroid volume ≥ 25%.

RESULTS

The clinical and imaging success rates were 54/66 (82%) and 39/66 (59%) respectively. The absence of previous pregnancy (p = 0.004) and the size of the dominant fibroid ≥ 80 mm (p = 0.004) were independent factors associated with clinical failure. Age <35 years (p = 0.02) was the only independent factor associated with imaging failure.

CONCLUSION

Young women developing fibroids and/or women with large fibroids may be resistant to ulipristal acetate therapy.

Expression of vascular endothelial growth factor mRNA in human leiomyomas

AIM

Growth factors play a major role in the pathogenesis of uterine myomas. The aim of this study was to evaluate vascular endothelial growth factor (VEGF) mRNA expression during leiomyoma growth at different phases of the menstrual cycle with RT-PCR.

METHOD

We studied 56 patients: 43 with myomas, 13 with healthy myometriums. In patients with myomas (secretory phase), VEGF expression was 2.82 times higher than in control patients (p < 0.05). In patients with myomas (phase I), VEGF expression was 2.53 times higher (p < 0.05) than in control patients. For all patients with myomas, those who were in menopause had 1.52 times higher VEGF expression than those who menstruated. For patients with healthy myometriums, those who were in menopause had 1.97 times higher VEGF expression than those who menstruated. A comparison of all the patients in menopause revealed that VEGF expression was 2.03-fold higher in those with myomas than in those with healthy myometriums.

CONCLUSION

We observed the highest VEGF mRNA expression in women with myomas who were in menopause. Among menstruating patients, VEGF expression was significantly higher in those with myomas compared to those with a healthy myometrium. This suggested that VEGF may play a significant role in the pathogenesis of uterine myomas.

Cytogenetics of Mesenchymal Tumors of the Female Genital Tract

A great diversity of chromosome alterations have been reported in mesenchymal tumors of the female genital tract, particularly in the uterus. Some of these alterations specifically identify a certain tumor type. Cytogenetic studies on benign proliferations have not only demonstrated clonal chromosome changes, but have also pointed out clustering of aberrations to specific chromosome regions. For example, distinct cytogenetic subgroups have been described in uterine leiomyomas with overlapping histologic features. These findings may ultimately correlate with specific parameters, such as course of the disease, response to therapy, and recurrence. Moreover, such data may give a clue to an understanding of the biologic basis for distinctive behavior of benign versus malignant mesenchymal proliferations. No specific chromosomal abnormalities have been described in malignant mesenchymal tumors, with the exception of low-grade endometrial stromal sarcomas. This article reviews the information currently available on genetic changes in mesenchymal tumors of the female genital tract and, more specifically, those reported in the uterus, where they have been more frequently studied.

The genetic heterogeneity of uterine leiomyomata

Research investigating the genetics of UL has already been successful in gathering epidemiologic evidence for heritability, establishing the clonal and mosaic nature of these tumors, correlating genotypic and phenotypic characteristics, defining cytogenetic subgroups, and identifying specific genes involved in tumorigenesis. Although UL are known to be benign tumors, the impact they have on the lives of so many women can only be described as "malignant". For this reason, continuing the quest to ascertain the genes, functions, and mechanisms integral to UL development is absolutely imperative. Genetic tests for personalized medical management of women with fibroids is at the threshold for providing the most appropriate treatments (Fig. 3), and combined with developing less invasive therapies portends a brighter future for a major health problem for women.

Preoperative reduction of uterine fibroids in only 16 days by administration of a gonadotrophin-releasing hormone antagonist (Cetrotide)

Ten premenopausal women with symptomatic uterine fibroids confirmed by magnetic resonance imaging (MRI) were treated with four injections (s.c.) of 3 mg of the gonadotrophin-releasing hormone (GnRH) antagonist cetrorelix every 4 days, starting on the first day of cycle. On every fourth day, blood samples were drawn for the measurement of gonadotrophins and sex steroids. On the 17th day of treatment after a final MRI control, myomectomy was performed laparotomically, laparoscopically or hysteroscopically. All patients showed a deep and sustained suppression of gonadotrophins and sex steroids over the treatment time. In three patients, no change or even an increase in uterine fibroids volume was observed according to MRI, and in one patient MRI did not allow a reliable interpretation. However, six patients showed a mean reduction of 31% in fibroid size after only 16 days of hormonal treatment. In nine patients laparoscopic or hysteroscopic myomectomy could be performed, while laparotomy was necessary only in one non-responder. Preparation of the cleavage plane during surgery was easy and blood loss was minimal. Patient compliance was excellent. No side-effects occurred. The GnRH antagonist Cetrotide(R), acting as an intermediate depot preparation at a dose of 3 mg, opens up a new avenue for preoperative short term treatment in a subgroup of patients with uterine fibroids, minimizing treatment time and patient discomfort.

Uterine fibroids

Uterine leiomyomas (fibroids or myomas), benign tumours of the human uterus, are the single most common indication for hysterectomy. They are clinically apparent in up to 25% of women and cause significant morbidity, including prolonged or heavy menstrual bleeding, pelvic pressure or pain, and, in rare cases, reproductive dysfunction. Thus, both the economic cost and the effect on quality of life are substantial. Surgery has been the mainstay of fibroid treatment, and various minimally invasive procedures have been developed in addition to hysterectomy and abdominal myomectomy. Formation of new leiomyomas after these conservative therapies remains a substantial problem. Although medications that manipulate concentrations of steroid hormones are effective, side-effects limit long-term use. A better approach may be manipulation of the steroid-hormone environment with specific hormone antagonists. There has been little evidence-based evaluation of therapy. New research into the basic biology of these neoplasms may add new treatment options for the future as the role of growth factors and genetic mutations in these tumours are better understood.

Correlation between the growth of uterine leiomyomata and estrogen and progesterone receptor content in needle biopsy specimens

OBJECTIVE

To examine the relationship between estrogen receptor (ER) and progesterone receptor (PR) content in needle biopsy specimens and the growth of uterine leiomyomata after biopsy.

DESIGN

Prospective clinical study.

SETTING

University teaching hospital.

PATIENT(S)

Thirty-one women with uterine leiomyomata and a normal menstrual cycle.

INTERVENTION(S)

Transcervical needle biopsy of uterine leiomyomata.

MAIN OUTCOME MEASURE(S)

The relationships between histologic features (smooth muscle content, immunohistochemical expression of ER and PR) and the percent increase over a 12-month observation period in the volume of the largest myoma nodule measured by magnetic resonance imaging were analyzed.

RESULT(S)

Both the density and intensity of immunohistochemical staining of PRs in uterine leiomyoma tissue showed significant positive correlation with leiomyoma growth.

CONCLUSION(S)

The growth of uterine leiomyomata can be determined by histologic and immunohistochemical analysis of needle biopsy specimens from uterine leiomyomata.

Clinical significance of cytogenetic abnormalities in uterine myomas

OBJECTIVE

To investigate the clinical characteristics of uterine myomas with cytogenetic rearrangements.

DESIGN

Comparative study of myomas with normal and abnormal karyotype.

SETTING

University hospital.

PATIENTS

Premenopausal, GnRH-agonist (GnRH-a) treated and menopausal patients.

INTERVENTIONS

Myomectomy or hysterectomy.

MAIN OUTCOME MEASURES

Karyotype analysis and clinical characteristics.

RESULTS

Clonal abnormalities occurred in 29% of uterine myomas but were not related to the age of the patient or, in untreated menopausal patients, to the size of the myoma. In GnRH-a treated and menopausal women, 48% of the myomas larger than 4 cm were associated with clonal abnormalities. Submucous myomas had significantly fewer clonal abnormalities (12%) than subserosal (29%) or intramural myomas (35%).

CONCLUSIONS

The data support the hypothesis that cytogenetic rearrangements in uterine myomas are associated with loss of steroid hormones dependency and alter the growth potential of the tumor.