1
|
Rosenberger DC, Mennicken E, Schmieg I, Medkour T, Pechard M, Sachau J, Fuchtmann F, Birch J, Schnabel K, Vincent K, Baron R, Bouhassira D, Pogatzki-Zahn EM. A systematic literature review on patient-reported outcome domains and measures in nonsurgical efficacy trials related to chronic pain associated with endometriosis: an urgent call to action. Pain 2024:00006396-990000000-00641. [PMID: 38968394 DOI: 10.1097/j.pain.0000000000003290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/12/2024] [Indexed: 07/07/2024]
Abstract
ABSTRACT Endometriosis, a common cause for chronic pelvic pain, significantly affects quality of life, fertility, and overall productivity of those affected. Therapeutic options remain limited, and collating evidence on treatment efficacy is complicated. One reason could be the heterogeneity of assessed outcomes in nonsurgical clinical trials, impeding meaningful result comparisons. This systematic literature review examines outcome domains and patient-reported outcome measures (PROMs) used in clinical trials. Through comprehensive search of Embase, MEDLINE, and CENTRAL up until July 2022, we screened 1286 records, of which 191 were included in our analyses. Methodological quality (GRADE criteria), information about publication, patient population, and intervention were assessed, and domains as well as PROMs were extracted and analyzed. In accordance with IMMPACT domain framework, the domain pain was assessed in almost all studies (98.4%), followed by adverse events (73.8%). By contrast, assessment of physical functioning (29.8%), improvement and satisfaction (14.1%), and emotional functioning (6.8%) occurred less frequently. Studies of a better methodological quality tended to use more different domains. Nevertheless, combinations of more than 2 domains were rare, failing to comprehensively capture the bio-psycho-social aspects of endometriosis-associated pain. The PROMs used showed an even broader heterogeneity across all studies. Our findings underscore the large heterogeneity of assessed domains and PROMs in clinical pain-related endometriosis trials. This highlights the urgent need for a standardized approach to both, assessed domains and high-quality PROMs ideally realized through development and implementation of a core outcome set, encompassing the most pivotal domains and PROMs for both, stakeholders and patients.
Collapse
Affiliation(s)
| | - Emilia Mennicken
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Iris Schmieg
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Terkia Medkour
- INSERM U987, UVSQ-Paris-Saclay University, Ambroise Paré Hospital, Boulogne-Billancourt, France
| | - Marie Pechard
- INSERM U987, UVSQ-Paris-Saclay University, Ambroise Paré Hospital, Boulogne-Billancourt, France
| | - Juliane Sachau
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Fabian Fuchtmann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Judy Birch
- Pelvic Pain Support Network, Poole, United Kingdom
| | - Kathrin Schnabel
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Katy Vincent
- Nuffield Department of Women's and Reproductive Health, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, United Kingdom
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Didier Bouhassira
- INSERM U987, UVSQ-Paris-Saclay University, Ambroise Paré Hospital, Boulogne-Billancourt, France
| | - Esther Miriam Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| |
Collapse
|
2
|
Wang L, Li T, Cao WX, Zhao JY, Xu XH, Chai JP, Zhang JX, Liu J, Wang FC. To explore the mechanism of acupoint application in the treatment of primary dysmenorrhea by 16S rDNA sequencing and metabolomics. Front Endocrinol (Lausanne) 2024; 15:1397402. [PMID: 38872962 PMCID: PMC11169635 DOI: 10.3389/fendo.2024.1397402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/16/2024] [Indexed: 06/15/2024] Open
Abstract
Graphene-based warm uterus acupoint paste (GWUAP) is an emerging non-drug alternative therapy for the treatment of primary dysmenorrhea (PD), but the underlying mechanism is still unclear. SD female rats were randomly divided into control group, model group and treatment group to explore the mechanism of GWUAP in the treatment of PD. Combined with 16S rDNA and fecal metabolomics, the diversity of microbiota and metabolites in each group was comprehensively evaluated. In this study, GWUAP reduced the torsion score of PD model rats, improved the pathological morphology of uterine tissue, reduced the pathological damage score of uterine tissue, and reversed the expression levels of inflammatory factors, pain factors and sex hormones. The 16 S rDNA sequencing of fecal samples showed that the abundance of Lactobacillus in the intestinal flora of the model group decreased and the abundance of Romboutsia increased, while the abundance of Lactobacillus in the intestinal flora of the treatment group increased and the abundance of Romboutsia decreased, which improved the imbalance of flora diversity in PD rats. In addition, 32 metabolites related to therapeutic effects were identified by metabolomics of fecal samples. Moreover, there is a close correlation between fecal microbiota and metabolites. Therefore, the mechanism of GWUAP in the treatment of PD remains to be further studied.
Collapse
Affiliation(s)
- Lin Wang
- Department of Acupuncture and Tuina, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Tie Li
- Department of Acupuncture and Tuina, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Wen-Xuan Cao
- Department of Pharmacy, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Jin-Ying Zhao
- Department of Acupuncture and Tuina, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Xiao-Hong Xu
- Department of Acupuncture and Tuina, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Jia-Peng Chai
- Department of Acupuncture and Tuina, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Jia-Xun Zhang
- Department of Acupuncture and Tuina, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Jia Liu
- Department of Pharmacy, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Fu-Chun Wang
- Department of Acupuncture and Tuina, Changchun University of Chinese Medicine, Changchun, Jilin, China
| |
Collapse
|
3
|
Yu YQ, Wang H. Imbalance of Th1 and Th2 Cytokines and Stem Cell Therapy in Pathological Pain. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2024; 23:88-101. [PMID: 36573059 DOI: 10.2174/1871527322666221226145828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 11/05/2022] [Accepted: 11/12/2022] [Indexed: 12/28/2022]
Abstract
The pathophysiological importance of T helper 1 (Th1) and Th2 cell cytokines in pathological pain has been highly debated in recent decades. However, the analgesic strategy targeting individual cytokines still has a long way to go for clinical application. In this review, we focus on the contributions of Th1 cytokines (TNF-α, IFN-γ, and IL-2) and Th2 cytokines (IL-4, IL-5, IL-10, and IL-13) in rodent pain models and human pain-related diseases. A large number of studies have shown that Th1 and Th2 cytokines have opposing effects on pain modulation. The imbalance of Th1 and Th2 cytokines might determine the final effect of pain generation or inhibition. However, increasing evidence indicates that targeting the individual cytokine is not sufficient for the treatment of pathological pain. It is practical to suggest a promising therapeutic strategy against the combined effects of Th1 and Th2 cytokines. We summarize the current advances in stem cell therapy for pain-related diseases. Preclinical and clinical studies show that stem cells inhibit proinflammatory cytokines and release enormous Th2 cytokines that exhibit a strong analgesic effect. Therefore, a shift of the imbalance of Th1 and Th2 cytokines induced by stem cells will provide a novel therapeutic strategy against intractable pain. It is extremely important to reveal the cellular and molecular mechanisms of stem cell-mediated analgesia. The efficiency and safety of stem cell therapy should be carefully evaluated in animal models and patients with pathological pain.
Collapse
Affiliation(s)
- Yao-Qing Yu
- Institute for Biomedical Sciences of Pain, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Huan Wang
- Department of Dermatology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| |
Collapse
|
4
|
Mantha KB. An opinion on H1-antihistamines as a potential avenue for endometriosis management. AJOG GLOBAL REPORTS 2023; 3:100274. [PMID: 37941601 PMCID: PMC10628608 DOI: 10.1016/j.xagr.2023.100274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023] Open
Abstract
Endometriosis is a chronic inflammatory gynecologic condition among women of reproductive age causing a plethora of symptoms that significantly affect their quality of life and mental health. Recent literature reports mounting evidence for several inflammation-mediated pathways for endometriosis pathogenesis, where elevated levels of proinflammatory factors, such as intercellular adhesion molecule 1, tumor necrosis factor-alpha, and nuclear factor kappa B have been established. Simultaneously, the prevalent clinical use of H1-antihistamines for other pathologies along with active research into its action pathways has led to our current understanding that H1-antihistamines counteract several inflammation mediators, including intercellular adhesion molecule 1, tumor necrosis factor-alpha, and nuclear factor kappa B. Although a wide range of existing drug-based endometriosis managements act via the estrogen-dependent pathways, along with some newer ones attempting to use antagonists of targeted inflammation-modulating factors, investigations into the direct use of H1-antihistamines in the context of endometriosis are currently lacking. In this brief perspective opinion essay, correlative evidence has been placed forward that points toward a potential avenue of H1-antihistamines for endometriosis management, and some ideas have been highlighted for future research considerations.
Collapse
|
5
|
Fan D, Wang X, Shi Z, Jiang Y, Zheng B, Xu L, Zhou S. Understanding endometriosis from an immunomicroenvironmental perspective. Chin Med J (Engl) 2023; 136:1897-1909. [PMID: 37439327 PMCID: PMC10431529 DOI: 10.1097/cm9.0000000000002649] [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: 11/18/2022] [Indexed: 07/14/2023] Open
Abstract
ABSTRACT Endometriosis, a heterogeneous, inflammatory, and estrogen-dependent gynecological disease defined by the presence and growth of endometrial tissues outside the lining of the uterus, affects approximately 5-10% of reproductive-age women, causing chronic pelvic pain and reduced fertility. Although the etiology of endometriosis is still elusive, emerging evidence supports the idea that immune dysregulation can promote the survival and growth of retrograde endometrial debris. Peritoneal macrophages and natural killer (NK) cells exhibit deficient cytotoxicity in the endometriotic microenvironment, leading to inefficient eradication of refluxed endometrial fragments. In addition, the imbalance of T-cell subtypes results in aberrant cytokine production and chronic inflammation, which contribute to endometriosis development. Although it remains uncertain whether immune dysregulation represents an initial cause or merely a secondary enhancer of endometriosis, therapies targeting altered immune pathways exhibit satisfactory effects in preventing disease onset and progression. Here, we summarize the phenotypic and functional alterations of immune cells in the endometriotic microenvironment, focusing on their interactions with microbiota and endocrine and nervous systems, and how these interactions contribute to the etiology and symptomology of endometriosis.
Collapse
Affiliation(s)
- Dian Fan
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, West China Second Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan 610041, China
| | - Xu Wang
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, West China Second Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan 610041, China
| | - Zhixian Shi
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, West China Second Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan 610041, China
| | | | - Bohao Zheng
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, West China Second Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan 610041, China
- Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu 214122, China
| | - Lian Xu
- Department of Pathology, West China Second Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Shengtao Zhou
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, West China Second Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan 610041, China
| |
Collapse
|
6
|
Malinauskiene V, Zuzo A, Liakina V, Kazenaite E, Stundiene I. Menstrual cycle abnormalities in women with inflammatory bowel disease and effects of biological therapy on gynecological pathology. World J Clin Cases 2023; 11:4989-4995. [PMID: 37583859 PMCID: PMC10424016 DOI: 10.12998/wjcc.v11.i21.4989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/14/2023] [Accepted: 06/30/2023] [Indexed: 07/26/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic condition that affects young individuals in their reproductive years. It may have long-term implications on their reproductive, sexual, and mental health. IBD has been related to menstrual abnormalities. Furthermore, the administration of biological therapy can also result in gynecological issues in addition to the disease itself. The purpose of this review was to present potential menstrual cycle problems in patients with IBD, as well as the impact of adalimumab and other anti-tumor necrosis factor medications on gynecological pathology.
Collapse
Affiliation(s)
- Vaidota Malinauskiene
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
| | - Anastasija Zuzo
- Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
| | - Valentina Liakina
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
- Department of Chemistry and Bioengineering, Faculty of Fundamental Sciences, Vilnius Tech, Vilnius 10223, Lithuania
| | - Edita Kazenaite
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
| | - Ieva Stundiene
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
| |
Collapse
|
7
|
Tan Z, Gong X, Li Y, Hung SW, Huang J, Wang CC, Chung JPW. Impacts of endometrioma on ovarian aging from basic science to clinical management. Front Endocrinol (Lausanne) 2023; 13:1073261. [PMID: 36686440 PMCID: PMC9848590 DOI: 10.3389/fendo.2022.1073261] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/08/2022] [Indexed: 01/06/2023] Open
Abstract
Endometriosis is a common reproductive disorder characterized by the presence of endometrial implants outside of the uterus. It affects ~1 in 10 women of reproductive age. Endometriosis in the ovary, also known as endometrioma (OMA), is the most frequent implantation site and the leading cause of reproductive failure in affected women. Ovarian aging is one of the characteristic features of OMA, however its underlying mechanism yet to be determined. Accumulated evidence has shown that pelvic and local microenvironments in women with OMA are manifested, causing detrimental effects on ovarian development and functions. Whilst clinical associations of OMA with poor ovarian reserve, premature ovarian insufficiency, and early menopause have been reported. Moreover, surgical ablation, fenestration, and cystectomy of OMA can further damage the normal ovarian reservoir, and trigger hyperactivation of primordial follicles, subsequently resulting in the undesired deterioration of ovarian functions. Nevertheless, there is no effective treatment to delay or restore ovarian aging. This review comprehensively summarised the pathogenesis and study hypothesis of ovarian aging caused by OMA in order to propose potential therapeutic targets and interventions for future studies.
Collapse
Affiliation(s)
- Zhouyurong Tan
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Xue Gong
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yiran Li
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Sze Wan Hung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Jin Huang
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Obstetrics and Gynaecology, The Second Affiliated Hospital, The Chinese University of Hong Kong, Shenzhen, China
| | - Chi Chiu Wang
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Reproduction and Development, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
- School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Chinese University of Hong Kong-Sichuan University Joint Laboratory in Reproductive Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Jacqueline Pui Wah Chung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| |
Collapse
|
8
|
Hartner G, Husslein H, Kuessel L, Gstoettner M, Tiringer D, Wenzl R, Perricos A. The latest advances in the pharmacological management of endometriosis. Expert Opin Pharmacother 2023; 24:121-133. [PMID: 35232316 DOI: 10.1080/14656566.2022.2045274] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Endometriosis is a benign disease, characterized by a wide range of symptoms and different degrees of severity, which is why therapy should be individually adapted to the patient's needs. Over the years, a lot of research has gone into finding new therapeutic approaches for this enigmatic disease. AREAS COVERED This review presents the latest advances in pharmacological management of endometriosis and is solely focused on studies published from 2010 to 2021. EXPERT OPINION Clinicians and researchers are constantly searching for new therapeutic strategies for endometriosis patients. As there are well-established treatments, however, any new medication should fulfill at least one of the three criteria: increased efficacy, comparable efficacy but a better safety profile, or treatments that have a lack of accompanying contraceptive effects that are seen in most endometriosis treatments. While some new substances show promising results, further studies are needed to demonstrate the fulfillment of one of the above-mentioned criteria.
Collapse
Affiliation(s)
- Gabriel Hartner
- Department of Obstetrics and Gynecology, Medical University of Vienna Vienna Austria
| | - Heinrich Husslein
- Department of Obstetrics and Gynecology, Medical University of Vienna Vienna Austria
| | - Lorenz Kuessel
- Department of Obstetrics and Gynecology, Medical University of Vienna Vienna Austria
| | - Manuela Gstoettner
- Department of Obstetrics and Gynecology, Medical University of Vienna Vienna Austria
| | - Denise Tiringer
- Department of Obstetrics and Gynecology, Medical University of Vienna Vienna Austria
| | - René Wenzl
- Department of Obstetrics and Gynecology, Medical University of Vienna Vienna Austria
| | - Alexandra Perricos
- Department of Obstetrics and Gynecology, Medical University of Vienna Vienna Austria
| |
Collapse
|
9
|
Dolmans MM, Donnez J. Emerging Drug Targets for Endometriosis. Biomolecules 2022; 12:biom12111654. [PMID: 36359004 PMCID: PMC9687824 DOI: 10.3390/biom12111654] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022] Open
Abstract
Endometriosis is a chronic inflammatory disease causing distressing symptoms and requiring a life-long management strategy. The objective of this review is to evaluate endometriosis-related pathways and identify novel therapies to treat it. We focused on the crucial role of inflammation and inflammatory molecules in order to define new perspectives for non-hormonal treatment of the disease by targeting inflammation, nuclear factor kappa B and cytokines, or reactive oxygen species, apoptotic and autophagic pathways, regulators of epithelial-mesenchymal transition, and angiogenesis and neuroangiogenesis. Novel non-steroidal therapies targeting these pathways for endometriosis were explored, but multiple challenges remain. While numerous agents have been investigated in preclinical trials, few have reached the clinical testing stage because of use of inappropriate animal models, with no proper study design or reporting of preclinical strategies. Targeting estrogens is still the best way to control endometriosis progression and inflammation.
Collapse
Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
- Gynecology Research Laboratory, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, 1200 Brussels, Belgium
| | - Jacques Donnez
- Department of Gynaecology, Université Catholique de Louvain, 1200 Brussels, Belgium
- Société de Recherche pour l’Infertilité (SRI), 143 Avenue Grandchamp, 1150 Brussels, Belgium
- Correspondence:
| |
Collapse
|
10
|
Park Y, Han SJ. Interferon Signaling in the Endometrium and in Endometriosis. Biomolecules 2022; 12:biom12111554. [PMID: 36358904 PMCID: PMC9687697 DOI: 10.3390/biom12111554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/21/2022] [Indexed: 12/04/2022] Open
Abstract
Endometriosis is an estrogen-dependent inflammatory disease that develops in reproductive-aged women who experience pelvic pain and infertility. Even though endometriosis is not a new disease, its molecular etiology has not been clearly elucidated. Defects in the immune system might be one of the factors that promote endometriosis progression. For example, elevated levels of proinflammatory cytokines are associated with endometriosis. Interferon is one of the cytokines that is elevated in endometriotic tissues compared with normal endometrium. Therefore, high interferon levels play a crucial role in endometriosis progression. In addition to endometriosis, however, interferon has a critical role in endometrial function, particularly in the initiation and maintenance of pregnancy. Therefore, this review describes the double-edged sword of interferon signaling in normal endometrial function versus endometriosis progression and also discusses interferon targeting as a new nonhormonal therapy for endometriosis. This approach may increase the efficacy of endometriosis treatment and reduce the adverse effects associated with current hormonal therapy for this disease.
Collapse
Affiliation(s)
- Yuri Park
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Sang Jun Han
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX 77030, USA
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA
- Reproductive Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Correspondence:
| |
Collapse
|
11
|
Koninckx P, Ussia A, Alsuwaidi S, Amro B, Keckstein J, Adamyan L, Donnez J, Dan M, Wattiez A. Reconsidering evidence-based management of endometriosis. Facts Views Vis Obgyn 2022; 14:225-233. [DOI: 10.52054/fvvo.14.3.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Without an adequate animal model permitting experiments the pathophysiology of endometriosis remains unclear and without a non-invasive diagnosis, information is limited to symptomatic women. Lesions are macroscopically and biochemically variable. Hormonal medical therapy cannot be blinded since recognised by the patient and the evidence of extensive surgery is limited because of the combination of low numbers of interventions of variable difficulty with variable surgical skills. Experience is spread among specialists in imaging, medical therapy, infertility, pain and surgery. In addition, the limitations of traditional statistics and p-values to interpret results and the complementarity of Bayesian inference should be realised.
Objectives: To review and discuss evidence in endometriosis management
Materials and Methods: A PubMed search for blinded randomised controlled trials in endometriosis.
Results: Good-quality evidence is limited in endometriosis.
Conclusions: Clinical experience remains undervalued especially for surgery.
What is new? Evidence-based medicine should integrate traditional statistical analysis and the limitations of P-values, with the complementary Bayesian inference which is predictive and sequential and more like clinical medicine. Since clinical experience is important for grading evidence, specific experience in the different disciplines of endometriosis should be used to judge trial designs and results. Finally, clinical medicine can be considered as a series of experiments controlled by the outcome. Therefore, the clinical opinion of many has more value than an opinion.
Collapse
|
12
|
Hao M, Liu X, Guo SW. Activation of α7 nicotinic acetylcholine receptor retards the development of endometriosis. Reprod Biol Endocrinol 2022; 20:85. [PMID: 35658970 PMCID: PMC9166516 DOI: 10.1186/s12958-022-00955-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women with endometriosis have been shown to have a reduced vagal tone as compared with controls and vagotomy promoted while vagus nerve stimulation (VNS) decelerated the progression of endometriosis in mice. Extensive research also has shown that the activation of the cholinergic anti-inflammatory pathway by VNS activates α7 nicotinic acetylcholine receptor (α7nAChR), potently reducing inflammation. Yet whether α7nAChR plays any role in endometriosis is unknown. We evaluated its expression in normal endometrium, ovarian and deep endometriotic lesions, and evaluated its role in the development of endometriosis. METHODS Immunohistochemistry analyses of α7nAChR in endometriotic lesions as well as control endometrium, and quantification of tissue fibrosis by Masson trichrome staining were performed. Mouse experiments were conducted to evaluate the impact of α7nAChR activation or suppression on lesional progression and possible therapeutic effect. Finally, in vitro experiments were conducted to evaluate the effect of activation of α7nAChR on epithelial-mesenchymal transition (EMT), fibroblast-to-myofibroblast transdifferentiation (FMT), smooth muscle metaplasia (SMM) and fibrogenesis in an endometriotic epithelial cell line and primary endometriotic stromal cells derived from ovarian endometrioma tissue samples. RESULTS Immunostaining of α7nAChR was significantly reduced in human endometriotic epithelial cells as compared with their counterpart in normal endometrium. Lesional α7nAChR staining levels correlated negatively with lesional fibrosis and the severity of dysmenorrhea. The α7nAChR agonist significantly impeded the development of endometriotic lesions in mouse models possibly through hindrance of EMT and FMT. It also demonstrated therapeutic effects in mice with induced deep endometriosis. Treatment of endometriotic epithelial and stromal cells with an α7nAChR agonist significantly abrogated platelet-induced EMT, FMT and SMM, and suppressed cellular contractility and collagen production. CONCLUSIONS α7nAChR is suppressed in endometriotic lesions, and its activation by pharmacological means can impede EMT, FMT, SMM, and fibrogenesis of endometriotic lesions. As such, α7nAChR can be rightfully viewed as a potential target for therapeutic invention. TRIAL REGISTRATION Not applicable.
Collapse
Affiliation(s)
- Meihua Hao
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, 200011, China
| | - Xishi Liu
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, 200011, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China
| | - Sun-Wei Guo
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, 200011, China.
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China.
| |
Collapse
|
13
|
Kalaitzopoulos DR, Samartzis N, Kolovos GN, Mareti E, Samartzis EP, Eberhard M, Dinas K, Daniilidis A. Treatment of endometriosis: a review with comparison of 8 guidelines. BMC Womens Health 2021; 21:397. [PMID: 34844587 PMCID: PMC8628449 DOI: 10.1186/s12905-021-01545-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/18/2021] [Indexed: 02/07/2023] Open
Abstract
Background Endometriosis, the presence of endometrial-like tissue outside the uterus, is a common clinical entity between women of reproductive age, with a prevalence of about 10%. Due to the variety of endometriosis-associated symptoms, a great variety of treatments have been implemented. The aim of this review is to give an overview on therapeutical approaches of eight national and international widely used guidelines.
Methods Six national (College National des Gynecologues et Obstetriciens Francais, National German Guideline (S2k), Society of Obstetricians and Gynaecologists of Canada, American College of Obstetricians (ACOG) and Gynecologists, American Society for Reproductive Medicine (ASRM) and National Institute for Health and Care (NICE) and two international (World Endometriosis Society, European Society of Human Reproduction and Embryology) guidelines are included in this review. Conclusion All the above-mentioned guidelines agree that the combined oral contraceptive pill, progestogens are therapies recommended for endometriosis associated pain. Concerning infertility, there is no clear consensus about surgical treatment. Discrepancies are also found on recommendation of the second- and third-line treatments.
Collapse
Affiliation(s)
- Dimitrios Rafail Kalaitzopoulos
- Department of Gynecology and Obstetrics, Cantonal Hospital Schaffhausen, Geissbergstrasse 81, 8208, Schaffhausen, Switzerland. .,Department of Gynecology, University Hospital Zurich, Zurich, Switzerland.
| | - Nicolas Samartzis
- Department of Gynecology and Obstetrics, Cantonal Hospital Schaffhausen, Geissbergstrasse 81, 8208, Schaffhausen, Switzerland
| | - Georgios N Kolovos
- Department of Gynecology and Obstetrics, Cantonal Hospital Schaffhausen, Geissbergstrasse 81, 8208, Schaffhausen, Switzerland
| | - Evangelia Mareti
- Department of Obstetrics and Gynecology, Hippokratio Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Markus Eberhard
- Department of Gynecology and Obstetrics, Cantonal Hospital Schaffhausen, Geissbergstrasse 81, 8208, Schaffhausen, Switzerland
| | - Kostantinos Dinas
- Department of Obstetrics and Gynecology, Hippokratio Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Angelos Daniilidis
- Department of Obstetrics and Gynecology, Hippokratio Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
14
|
Sánchez-Robles EM, Girón R, Paniagua N, Rodríguez-Rivera C, Pascual D, Goicoechea C. Monoclonal Antibodies for Chronic Pain Treatment: Present and Future. Int J Mol Sci 2021; 22:ijms221910325. [PMID: 34638667 PMCID: PMC8508878 DOI: 10.3390/ijms221910325] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 12/20/2022] Open
Abstract
Chronic pain remains a major problem worldwide, despite the availability of various non-pharmacological and pharmacological treatment options. Therefore, new analgesics with novel mechanisms of action are needed. Monoclonal antibodies (mAbs) are directed against specific, targeted molecules involved in pain signaling and processing pathways that look to be very effective and promising as a novel therapy in pain management. Thus, there are mAbs against tumor necrosis factor (TNF), nerve growth factor (NGF), calcitonin gene-related peptide (CGRP), or interleukin-6 (IL-6), among others, which are already recommended in the treatment of chronic pain conditions such as osteoarthritis, chronic lower back pain, migraine, or rheumatoid arthritis that are under preclinical research. This narrative review summarizes the preclinical and clinical evidence supporting the use of these agents in the treatment of chronic pain.
Collapse
|
15
|
Martone S, Troìa L, Marcolongo P, Luisi S. Role of medical treatment of endometriosis. Minerva Obstet Gynecol 2021; 73:304-316. [PMID: 34008385 DOI: 10.23736/s2724-606x.21.04784-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Endometriosis is a chronic benign disease that affects women of reproductive age. Medical therapy is often the first line of management for women with endometriosis in order to ameliorate symptoms or to prevent post-surgical disease recurrence. Currently, there are several medical options for the management of patients with endometriosis and long-term treatments should balance clinical efficacy (controlling pain symptoms and preventing recurrence of disease after surgery) with an acceptable safety-profile. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in the treatment of chronic inflammatory conditions, being efficacious in relieving primary dysmenorrhea. Combined oral contraceptives and progestins, available for multiple routes of administration, are commonly administered as first-line hormonal therapies. Several studies demonstrated that they succeed in improving pain symptoms in the majority of patients; moreover, they are well tolerated and not expensive. Gonadotropin-releasing hormone-agonists are prescribed when first line therapies are ineffective, not tolerated or contraindicated. Even if these drugs are efficacious in treating women not responding to COCs or progestins, they are not orally available and have a less favorable tolerability profile (needing an appropriate add-back therapy). Because few data are available on long-term efficacy and safety of aromatase inhibitors they should be reserved only for women with symptoms who are refractory to other treatments only in a research environment. Almost all of the currently available treatment options for endometriosis suppress ovarian function and are not curative. For this reason, research into new drugs is unsurprisingly demanding. Amongst the drugs currently under investigation, gonadotropin-releasing hormone antagonists have shown most promise, currently in late-stage clinical development. There is a number of potential future therapies currently tested only in vitro, in animal models of endometriosis or in early clinical studies with a small sample size. Further studies are necessary to conclude whether these treatments would be of value for the treatment of endometriosis.
Collapse
Affiliation(s)
- Simona Martone
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Libera Troìa
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Paola Marcolongo
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Stefano Luisi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecology, University of Siena, Siena, Italy -
| |
Collapse
|
16
|
Peng B, Alotaibi FT, Sediqi S, Bedaiwy MA, Yong PJ. Role of interleukin-1β in nerve growth factor expression, neurogenesis and deep dyspareunia in endometriosis. Hum Reprod 2021; 35:901-912. [PMID: 32240297 DOI: 10.1093/humrep/deaa017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/21/2019] [Indexed: 02/07/2023] Open
Abstract
STUDY QUESTION Does interleukin-1β (IL-1β) play a role in promoting nerve growth factor expression, neurogenesis and deep dyspareunia in endometriosis? SUMMARY ANSWER IL-1β directly stimulates nerve growth factor (NGF) expression in endometriosis and is associated with local neurogenesis around endometriosis and more severe deep dyspareunia. WHAT IS KNOWN ALREADY Local nerve density around endometriosis (using the pan-neuronal marker PGP9.5) is associated with deep dyspareunia in endometriosis, mediated in part by NGF expression. STUDY DESIGN, SIZE, DURATION This in vitro study included endometriotic tissue samples from 45 patients. PARTICIPANTS/MATERIALS, SETTING, METHODS This study was conducted in a university hospital affiliated research institute and included 45 women with surgically excised deep uterosacral/rectovaginal endometriosis (DIE, n = 12), ovarian endometriomas (OMA, n = 14) or superficial peritoneal uterosacral/cul-de-sac endometriosis (SUP, n = 19). Immunolocalisation of IL-1β, IL-1 receptor type 1 (IL-1R1), NGF and PGP9.5 in endometriotic tissues was examined by immunohistochemistry (IHC), and the intensity of IHC staining in the endometriotic epithelium and stroma was semi-quantitatively evaluated using the Histoscore method (H-score). For each case, deep dyspareunia was pre-operatively rated by the patient on an 11-point numeric rating scale (0-10). In addition, primary endometriosis stromal cells were isolated and cultured from surgically excised endometriosis. These cells were treated with IL-1β alone or in combination of Anakinra (an inhibitor of IL-1R1), small inference RNA (siRNA) against IL-1R1, siRNA against c-FOS or NGF neutralising antibody. The mRNA and protein levels of target genes (NGF and c-FOS) were assessed by reverse-transcription qPCR and western blot/ELISA, respectively. Furthermore, immunofluorescent microscopy was used to examine the neurite growth of rat pheochromocytoma PC-12 cells, as an in vitro model of neurogenesis. MAIN RESULTS AND THE ROLE OF CHANCE For IHC, IL-1β expression in the endometriosis epithelium was significantly associated with more severe deep dyspareunia (r = 0.37, P = 0.02), higher nerve fibre bundle density around endometriosis (r = 0.42, P = 0.01) and greater NGF expression by the endometriosis epithelium (r = 0.42, P = 0.01) and stroma (r = 0.45, P = 0.01). In primary endometriosis stromal cells, treatment with exogenous IL-1β significantly increased the mRNA and protein levels of NGF and c-FOS. Pre-treatment with Anakinra, siRNA against IL-1R1, or siRNA against c-FOS, each attenuated IL-1 β-induced increases of NGF expression. In addition, supernatants from IL-1β treated endometriosis stromal cells significantly stimulated PC-12 neurite growth compared to controls, and these effects could be attenuated by pre-treatment with NGF neutralising antibody or Anakinra. LARGE-SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION We did not have data from cultures of endometriosis glandular epithelium, due to the known difficulties with primary cultures of this cell type. WIDER IMPLICATIONS OF THE FINDINGS Our study revealed a mechanism for deep dyspareunia in endometriosis, whereby IL-1β stimulates NGF expression, promoting local neurogenesis around endometriosis, which in turn leads to tender pelvic anatomic sites and thus deep-hitting dyspareunia. There may also be potential for drug targeting of IL-1β and/or NGF in the management of endometriosis-associated pain. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by grants from the Canadian Institutes of Health Research (MOP-142273 and PJT-156084). P.Y. is also supported by a Health Professional Investigator Award from the Michael Smith Foundation for Health Research. MB has financial affiliations with Abbvie and Allergan. Otherwise, there are no conflicts of interest to declare.
Collapse
Affiliation(s)
- Bo Peng
- Department of Obstetrics and Gynaecology, University of British Columbia, BC Children's Hospital Research Institute and Women's Health Research Institute, Vancouver, British Columbia, Canada, V6H3N1
| | - Fahad T Alotaibi
- Department of Obstetrics and Gynaecology, University of British Columbia, BC Children's Hospital Research Institute and Women's Health Research Institute, Vancouver, British Columbia, Canada, V6H3N1
| | - Sadaf Sediqi
- Department of Obstetrics and Gynaecology, University of British Columbia, BC Children's Hospital Research Institute and Women's Health Research Institute, Vancouver, British Columbia, Canada, V6H3N1
| | - Mohamed A Bedaiwy
- Department of Obstetrics and Gynaecology, University of British Columbia, BC Children's Hospital Research Institute and Women's Health Research Institute, Vancouver, British Columbia, Canada, V6H3N1
| | - Paul J Yong
- Department of Obstetrics and Gynaecology, University of British Columbia, BC Children's Hospital Research Institute and Women's Health Research Institute, Vancouver, British Columbia, Canada, V6H3N1
| |
Collapse
|
17
|
Reduced vagal tone in women with endometriosis and auricular vagus nerve stimulation as a potential therapeutic approach. Sci Rep 2021; 11:1345. [PMID: 33446725 PMCID: PMC7809474 DOI: 10.1038/s41598-020-79750-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 12/11/2020] [Indexed: 12/14/2022] Open
Abstract
Sensory and sympathetic nerves have been shown to promote the progression of endometriosis through the release of neuromediators and the lesional activation of respective receptors. The role of vagus nerves (VN) in lesional progression, however, is completely unclear, despite the signs suggestive of increased sympathetic tone in women with endometriosis. This study was undertaken to investigate whether VN plays any role in the progression of endometriosis. We recruited 45 patients with endometriosis and 42 healthy women, who were given electrocardiogram test and their heart rate variability was evaluated. In addition, three prospective, and randomized mouse experiments were conducted that evaluated, respectively, the effect of vagotomy, the effect of VN stimulation (VNS), and the therapeutic potential of VNS after the endometriosis was well established. All lesions were excised, weighed, and processed for immunohistochemistry and histochemistry analysis of select markers for lesional progression and fibrosis. We found that endometriosis patients exhibited reduced vagal activity as compared with controls, indicative of disrupted autonomic balance. Vagotomy increased while VNS decreased the lesion weight as compared with control mice, concomitant with more progressive and retarded lesion development and fibrogenesis, respectively. In addition, VNS demonstrated promising therapeutic effect, as evidenced by significantly reduced lesion weight, more attenuated lesional progression concomitant with improved hyperalgesia. Taken together, our data indicate that VN activity may play a dampening role in the progression of endometriosis. Consequently, boosting the VN activity may have therapeutic potentials for patients with endometriosis.
Collapse
|
18
|
Kolanska K, Alijotas-Reig J, Cohen J, Cheloufi M, Selleret L, d'Argent E, Kayem G, Valverde EE, Fain O, Bornes M, Darai E, Mekinian A. Endometriosis with infertility: A comprehensive review on the role of immune deregulation and immunomodulation therapy. Am J Reprod Immunol 2020; 85:e13384. [PMID: 33278837 DOI: 10.1111/aji.13384] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/30/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Endometriosis is a multifactorial pathology dependent on intrinsic and extrinsic factors, but the immune deregulation seems to play a pivotal role. In endometriosis-associated infertility, this could raise the benefit of immunomodulatory strategies to improve the results of ART. In this review, we will describe (1) sera and peritoneal fluid cytokines and immune markers; (2) autoantibodies; and (3) immunomodulatory treatments in endometriosis with infertility. METHODS The literature research was conducted in MEDLINE, Embase, and Cochrane Library with the following keywords: "endometriosis", "unexplained miscarriage", "implantation failure", "recurrent implantation failure » and « IVF-ICSI », « biomarkers of autoimmunity", "TNF-α", "TNF-α antagonists", "infliximab", "adalimumab", "etanercept", "immunomodulatory treatment", "steroids", "intralipids", "intravenous immunoglobulins", "G-CSF", "pentoxyfylline". RESULTS Several studies analyzed the levels of pro-inflammatory cytokines in sera and peritoneal fluid of endometriosis-associated infertility, in particular TNF-α. Various autoantibodies have been found in peritoneal fluid and sera of infertile endometriosis women even in the absence of clinically defined autoimmune disease, as antinuclear, anti-SSA, and antiphospholipid autoantibodies. In few uncontrolled studies, steroids and TNF-α antagonists could increase the pregnancy rates in endometriosis-associated infertility, but well-designed trials are lacking. CONCLUSION Endometriosis is characterized by increased levels of cytokines and autoantibodies. This suggests the role of inflammation and immune cell deregulation in infertility associated with endometriosis. The strategies of immunomodulation to regulate these immune deregulations are poorly studied, and well-designed studies are necessary.
Collapse
Affiliation(s)
- Kamila Kolanska
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Jaume Alijotas-Reig
- Department of Internal Medicine, Sant Joan de Deu Hospital, Althaia Healthcare University Network of Manresa, Barcelona, Spain
| | - Jonathan Cohen
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Meryem Cheloufi
- Sorbonne Université, AP-HP, Hôpital Trousseau, service d'Obstétrique, Université Paris 06, Paris, France
| | - Lise Selleret
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Emmanuelle d'Argent
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Gilles Kayem
- Sorbonne Université, AP-HP, Hôpital Trousseau, service d'Obstétrique, Université Paris 06, Paris, France
| | - Enrique E Valverde
- Department of Internal Medicine, Sant Joan de Deu Hospital, Althaia Healthcare University Network of Manresa, Barcelona, Spain
| | - Olivier Fain
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, service de Médecine Interne and Inflammation, Paris, France
| | - Marie Bornes
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Emile Darai
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Arsene Mekinian
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, service de Médecine Interne and Inflammation, Paris, France
| |
Collapse
|
19
|
Xiao F, Liu X, Guo SW. Platelets and Regulatory T Cells May Induce a Type 2 Immunity That Is Conducive to the Progression and Fibrogenesis of Endometriosis. Front Immunol 2020; 11:610963. [PMID: 33381124 PMCID: PMC7767909 DOI: 10.3389/fimmu.2020.610963] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/13/2020] [Indexed: 12/18/2022] Open
Abstract
Endometriosis is a hormonal disease, as well as a chronic inflammatory disease. While various immune cells are documented to be involved in endometriosis, there is a wanton lack of a bigger picture on how these cells are coordinated to work concertedly. Since endometriotic lesions experience cyclical bleeding, they are fundamentally wounds that undergo repeated tissue injury and repair (ReTIAR). In this study, we attempted to characterize the role of platelets and regulatory T cells (Tregs) in modulating the lesional immune microenvironment and its subsequent effects on lesional progression and fibrogenesis. Through two mouse experiments, we show that, by disrupting predominantly a type 2 immune response in lesional microenvironment, both platelets and Tregs depletion decelerated lesional progression and fibrogenesis, likely through the suppression of the TGF-β1/Smad3 and PDGFR-β/PI3K/Akt signaling pathways. In particular, platelet depletion resulted in significantly reduced lesional expression of thymic stromal lymphopoietin (TSLP), leading to reduced aggregation of macrophages and alternatively activated (M2) macrophages, and of Tregs, T helper 2 (Th2) and Th17 cells but increased aggregation of Th1 cells, in lesions, which, in turn, yields retarded fibrogenesis. Similarly, Tregs depletion resulted in suppression of platelet aggregation, and reduced aggregation of M2 macrophages, Th2 and Th17 cells but increased aggregation of Th1 cells, in lesions. Thus, both platelet and Tregs depletion decelerated lesional progression and fibrogenesis by disrupting predominantly a type 2 immunity in lesional microenvironment. Taken together, this suggests that both platelets and Tregs may induce a type 2 immunity in lesional microenvironment that is conducive to lesional progression and fibrogenesis.
Collapse
Affiliation(s)
- Fengyi Xiao
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, China
| | - Xishi Liu
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China
| | - Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China
| |
Collapse
|
20
|
Luddi A, Marrocco C, Governini L, Semplici B, Pavone V, Capaldo A, Tosti C, Greco S, Luisi S, Ciarmela P, Petraglia F, Piomboni P. Increased expression of neurogenic factors in uterine fibroids. Hum Reprod 2020; 34:2153-2162. [PMID: 31732726 DOI: 10.1093/humrep/dez182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 07/05/2019] [Indexed: 12/18/2022] Open
Abstract
STUDY QUESTION Are selective markers for the neuronal differentiation such as microtubule-associated protein 2 (MAP-2) and synaptophysin (SYP) as well as the nerve growth factor (NGF) expressed by fibroids, myometrium and eutopic endometrium? SUMMARY ANSWER Neuronal markers NGF, MAP-2 and SYP are highly expressed in fibroids compared with matched myometrium, and this neurogenic pathway is upregulated by tumor necrosis factor (TNF) alpha in cultured smooth muscle cells (SMCs). WHAT IS KNOWN ALREADY Uterine fibroids or leiomyomas are the most common benign tumors, accounting for approximately one-third of hysterectomies. The present trend is to improve the medical treatment avoiding surgery, also for fertility sparing; hence, the pathogenic mechanisms are investigated, aiming to develop new therapeutic strategy. STUDY DESIGN, SIZE, DURATION This laboratory-based case-control study is focused on fibroids and myometrial specimens obtained between 2015 and 2017 from 15 women of reproductive age at the proliferative phase of the menstrual cycle. Leiomyomas, matched myometrium and endometrium from each woman were analyzed. Control endometrium was obtained from women undergoing surgery for ovarian cyst (n = 15). PARTICIPANTS/MATERIALS, SETTING, METHODS qRT-PCR, western blotting and immunostaining were applied to evaluate the expression of neurogenic markers; the effects of TNF on NGF, MAP-2 and SYP expression in cultured SMCs from leiomyomas and matched myometrium were analyzed. MAIN RESULTS AND THE ROLE OF CHANCE qRT-PCR analyses using tissues from clinical patients showed that the levels of NGF, MAP-2 and SYP mRNA were significantly higher in uterine leiomyomas compared with their matched myometrium (P < 0.05), whereas only NGF was significantly increased in eutopic endometrium compared with healthy endometrium. In primary SMCs, isolated from fibroids or from the adjacent myometrium, NGF, MAP-2 and SYP mRNA expression were significantly increased by TNF treatment (P < 0.05). Finally, human endometrial stromal cells prepared from the endometrium of patients affected by uterine fibroids display higher TNF expression (P < 0.001). LIMITATIONS, REASONS FOR CAUTION qRT-PCR analysis and immunofluorescence validation are robust methods demonstrating a clear upregulation of neurogenic factors in leiomyomas, even though additional studies are needed to establish a correlation between increased neuronal gene expression and degree of pain, as well as the involvement of inflammation mediators in the development of the neurogenic unhinge. Therefore, more in vivo studies are needed to confirm the results achieved from primary cultured SMCs. WIDER IMPLICATIONS OF THE FINDINGS The increased expression of neurogenic factors in uterine fibroids and endometrium may contribute to explain the painful stimuli. Accordingly, these neurogenic pathways may represent potential therapeutic avenues to treat the fibroid-related disorders. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by research grants from the University of Siena. The authors declare no conflict of interest. TRIAL REGISTRATION NUMBER N/A.
Collapse
Affiliation(s)
- Alice Luddi
- Dept. of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Camilla Marrocco
- Dept. of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Laura Governini
- Dept. of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Bianca Semplici
- Dept. of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Valentina Pavone
- Dept. of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Angela Capaldo
- Dept. of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Claudia Tosti
- Dept. of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Stefania Greco
- Dept. of Experimental and Clinical Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Stefano Luisi
- Dept. of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Pasquapina Ciarmela
- Dept. of Experimental and Clinical Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Felice Petraglia
- Dept. of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Paola Piomboni
- Dept. of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| |
Collapse
|
21
|
D'Hooghe T, Fukaya T, Osuga Y, Besuyen R, López B, Holtkamp GM, Miyazaki K, Skillern L. Efficacy and safety of ASP1707 for endometriosis-associated pelvic pain: the phase II randomized controlled TERRA study. Hum Reprod 2020; 34:813-823. [PMID: 31067329 PMCID: PMC6505452 DOI: 10.1093/humrep/dez028] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 01/10/2019] [Accepted: 03/18/2019] [Indexed: 12/05/2022] Open
Abstract
STUDY QUESTION Does the GnRH antagonist, ASP1707, reduce endometriosis-associated pelvic pain? SUMMARY ANSWER ASP1707 significantly reduced endometriosis-associated pelvic pain in a dose-related manner WHAT IS KNOWN ALREADY GnRH agonists are an effective therapeutic option for endometriosis that is refractory to non-steroidal anti-inflammatory drugs, oral contraceptives, and progestins. However, GnRH agonists cause complete suppression of estradiol (E2), resulting in hypoestrogenic side-effects such as bone loss that may increase the future risk of osteoporotic fractures. STUDY DESIGN, SIZE, DURATION This was a Phase II, multicenter, double-blind, randomized, parallel-group, placebo-controlled study conducted in 540 women from 04 December 2012 to 30 July 2015 in Europe and Japan. A sample size of 504 (84 subjects per group) was calculated to provide ≥80% power to detect a dose-related treatment effect among placebo and ASP1707 doses in change from baseline in pelvic pain, assuming different dose–response curves after 12 weeks of treatment. PARTICIPANTS/MATERIALS, SETTING, METHODS Of 912 women with endometriosis-associated pelvic pain screened, 540 were enrolled, and 532 received ≥1 dose of study drug (placebo, n = 88; ASP1707 3 mg, n = 86; ASP1707 5 mg, n = 91; ASP1707 10 mg, n = 90; ASP1707 15 mg, n = 88; leuprorelin, n = 89) for 24 weeks. MAIN RESULTS AND THE ROLE OF CHANCE After 12 weeks of treatment with ASP1707, the mean (95% CI) changes in numeric rating score (NRS) for overall pelvic pain (OPP) were −1.56 (−1.91, −1.21), −1.63 (−1.99, −1.27), −1.93 (−2.27, −1.60), −2.29 (−2.64, −1.94), and −2.13 (−2.47, −1.79) for placebo, ASP1707 3 mg, ASP1707 5 mg, ASP1707 10 mg, and ASP1707 15 mg, respectively. Mean (95% CI) changes in NRS for dysmenorrhea were −1.50 (−2.00, −1.00), −2.72 (−3.22, −2.21), −2.85 (−3.33, −2.38), −3.97 (−4.46, −3.48), and −4.18 (−4.66, −3.70), respectively. Mean (95% CI) changes in NRS for non-menstrual pelvic pain (NMPP) were −1.53 (−1.88, −1.19), −1.51 (−1.87, −1.16), −1.80 (−2.14, −1.47), −2.03 (−2.37, −1.68), and −1.86 (−2.20, −1.52), respectively. Statistically significant dose-related treatment effects in reduction in NRS for OPP (P = 0.001), dysmenorrhea (P < 0.001), and NMPP (P = 0.029) were observed after 12 weeks among ASP1707 doses and were maintained through 24 weeks. Serum estradiol and bone mineral density decreased dose dependently with ASP1707 through 24 weeks, however, to a lesser extent than with leuprorelin. LIMITATIONS, REASON FOR CAUTION This study was not powered for pairwise comparison of each ASP1707 group versus placebo. WIDER IMPLICATIONS OF THE FINDINGS All doses of ASP1707 reduced serum E2 levels to within the target range and to a lesser extent than leuprorelin. ASP1707 is a potential alternative treatment to leuprorelin for endometriosis-associated pelvic pain with lower impact on bone health. STUDY FUNDING/COMPETING INTEREST(s) This study was funded by Astellas Pharma Inc. T.D’.H is Vice President and Head of Global Medical Affairs Fertility at Merck, Darmstadt, Germany since October 1, 2015. At the time that the TERRA study was conducted, he served as Principal Investigator in his role as Coordinator of the Leuven University Fertility Center. Since October 2015, T.D’.H has left Leuven University Hospital Gasthuisberg, but continues to serve as Professor in Reproductive Medicine and Biology at KU Leuven (University of Leuven) Belgium and at the Dept of Obstetrics, Gynecology and Reproduction at Yale University, New Haven, USA. T. Fukaya and Y. Osuga report personal consulting fees from Astellas Pharma Inc. during the conduct of the study and outside the submitted work. G.M. Holtkamp, and L. Skillern are employed by Astellas Pharma Europe B.V.; K. Miyazaki is employed by Astellas Pharma Inc.; B. López, was a biostatistician for Astellas Pharma Europe B.V. during conduct of the study; R. Besuyen was a contract Associate Director of Medical Science for Astellas during conduct of the study. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, www.clinicaltrials.gov, NCT01767090. EudraCT number 2012-002791-14. TRIAL REGISTRATION DATE 18 December 2012. DATE OF FIRST SUBJECT’S ENROLLMENT One subject signed informed consent on 04 December 2012; the first subject was randomized on 16 April 2013.
Collapse
Affiliation(s)
- Thomas D'Hooghe
- Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium.,Global Medical Affairs Fertility, Research and Development, Merck KGaA, Darmstadt, Germany
| | - Takao Fukaya
- Tohoku Medical and Pharmaceutical University, 4-4-1 Komatsushima, Aobaku, Sendai, Miyagi, Japan
| | - Yutaka Osuga
- The University of Tokyo, Graduate School of Medicine, 7-3-1, Hongo, Bunkyo, Tokyo, Japan
| | - Robin Besuyen
- Astellas Pharma Europe B.V., Sylviusweg 62, Leiden, the Netherlands
| | - Beatriz López
- Astellas Pharma Europe B.V., Sylviusweg 62, Leiden, the Netherlands
| | | | - Kentaro Miyazaki
- Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo, Japan
| | | |
Collapse
|
22
|
Matsuzaki S, Pouly JL, Canis M. Dose-dependent pro- or anti-fibrotic responses of endometriotic stromal cells to interleukin-1β and tumor necrosis factor α. Sci Rep 2020; 10:9467. [PMID: 32528066 PMCID: PMC7289797 DOI: 10.1038/s41598-020-66298-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/19/2020] [Indexed: 12/25/2022] Open
Abstract
Endometriosis are characterized by dense fibrous tissue. Numerous studies have investigated roles of inflammation on the pathophysiology of endometriosis. However, the interplay of inflammation and fibrosis remains to be clarified. Here we show that low levels of interleukin-1β (IL-1β) and tumor necrosis factor-alpha (TNFα) promoted a fibrotic phenotype, whereas high levels of IL-1β and TNFα inactivated the fibrotic phenotype of endometriotic stromal cells (Ectopic-ES). IL-1β 10 pg/mL and TNFα 100 and 1,000 pg/mL had minimal effects, whereas the highest dose of IL-1β (100 pg/mL) significantly decreased collagen gel contraction in Ectopic-ES. Furthermore, in Ectopic-ES, low levels of IL-1β (1 pg/mL) and/or TNFα 10 pg/mL significantly increased Col I mRNA expression, whereas higher doses of IL-1β (10 and/or 100 pg/mL) and/or TNFα (100 and/or 1,000 pg/mL) significantly decreased Col I and/or αSMA mRNA expression and the percentage of cells with Col I + and/or αSMA + stress fibers. In contrast, in either menstrual endometrial stromal cells of patients with endometriosis or those of healthy women, varying doses of IL-1β and/or TNFα had no significant effects on either Col I or αSMA mRNA/protein expression. The present findings bring into question whether we should still continue to attempt anti-inflammatory treatment strategies for endometriosis.
Collapse
Affiliation(s)
- Sachiko Matsuzaki
- CHU Clermont-Ferrand, Chirurgie Gynécologique, Clermont-Ferrand, France.
- Université Clermont Auvergne, Institut Pascal, UMR6602, CNRS/UCA/SIGMA, Clermont-Ferrand, France.
- CHU Clermont-Ferrand, Chirurgie Gynécologique, 1, Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France.
| | - Jean-Luc Pouly
- CHU Clermont-Ferrand, Chirurgie Gynécologique, Clermont-Ferrand, France
- Université Clermont Auvergne, Institut Pascal, UMR6602, CNRS/UCA/SIGMA, Clermont-Ferrand, France
| | - Michel Canis
- CHU Clermont-Ferrand, Chirurgie Gynécologique, Clermont-Ferrand, France
- Université Clermont Auvergne, Institut Pascal, UMR6602, CNRS/UCA/SIGMA, Clermont-Ferrand, France
| |
Collapse
|
23
|
Peritoneal Fluid Cytokines Reveal New Insights of Endometriosis Subphenotypes. Int J Mol Sci 2020; 21:ijms21103515. [PMID: 32429215 PMCID: PMC7278942 DOI: 10.3390/ijms21103515] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/08/2020] [Accepted: 05/10/2020] [Indexed: 02/06/2023] Open
Abstract
Endometriosis is a common inflammatory gynecological disorder which causes pelvic scarring, pain, and infertility, characterized by the implantation of endometrial-like lesions outside the uterus. The peritoneum, ovaries, and deep soft tissues are the commonly involved sites, and endometriotic lesions can be classified into three subphenotypes: superficial peritoneal endometriosis (PE), ovarian endometrioma (OE), and deep infiltrating endometriosis (DIE). In 132 women diagnosed laparoscopically with and without endometriosis (n = 73, 59 respectively), and stratified into PE, OE, and DIE, peritoneal fluids (PF) were characterized for 48 cytokines by using multiplex immunoassays. Partial-least-squares-regression analysis revealed distinct subphenotype cytokine signatures—a six-cytokine signature distinguishing PE from OE, a seven-cytokine signature distinguishing OE from DIE, and a six-cytokine-signature distinguishing PE from DIE—each associated with different patterns of biological processes, signaling events, and immunology. These signatures describe endometriosis better than disease stages (p < 0.0001). Pathway analysis revealed the association of ERK1 and 2, AKT, MAPK, and STAT4 linked to angiogenesis, cell proliferation, migration, and inflammation in the subphenotypes. These data shed new insights on the pathophysiology of endometriosis subphenotypes, with the potential to exploit the cytokine signatures to stratify endometriosis patients for targeted therapies and biomarker discovery.
Collapse
|
24
|
Nirgianakis K, McKinnon B, Ma L, Imboden S, Bersinger N, Mueller MD. Peritoneal fluid biomarkers in patients with endometriosis: a cross-sectional study. Horm Mol Biol Clin Investig 2020; 42:113-122. [PMID: 32926606 DOI: 10.1515/hmbci-2019-0064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 03/31/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Elevated concentrations of numerous molecules have been reported in the peritoneal cavity of women with endometriosis. Until now, no factor proved sufficiently specific to endometriosis. We aimed to investigate several biomarkers in endometriosis and report their association with the menstrual cycle in a large sample size study. METHODS Patients of reproductive age undergoing laparoscopic procedures for benign pathology in the Department of Obstetrics and Gynaecology, University of Bern between 2007 and 2018 were included. Exclusion criteria were the use of hormonal treatment in the three months prior to surgery, patients suffering from other inflammatory diseases, pregnancy, malignancy and surgery performed in an emergency. The concentrations of 13 different biomarkers in the peritoneal fluid (PF) were compared between patients with and without endometriosis both in the proliferative and the secretory cycle phase. RESULTS Out of 1,256 patients in the database, 521 met the inclusion and exclusion criteria. Glycodelin (PP14) and Midkine concentrations were significantly higher in patients with endometriosis compared to controls irrespective of the cycle phase in which the PF was collected. Interleukin-8 (IL-8), regulated on activation normal T cell expressed and secreted (RANTES) and osteoprotegerin (OPG) concentrations were higher in patients with endometriosis only in the proliferative cycle phase. Monocyte chemoattractant protein 1, CCL2 (MCP-1) and Defensin concentrations were higher in patients with endometriosis only in the secretory cycle phase. CONCLUSIONS Certain pathophysiological processes may take place only in the one cycle phase leading to a temporary increase of specific PF biomarkers. Correlation with clinical outcomes is mandatory to establish their potential as prognostic or therapeutic tools in endometriosis.
Collapse
Affiliation(s)
- Konstantinos Nirgianakis
- Department of Obstetrics and Gynaecology, University Hospital of Bern, Inselspital, Friedbühlstrasse 19, 3010, Bern, Switzerland
| | - Brett McKinnon
- Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Obstetrics and Gynaecology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lijuan Ma
- Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Obstetrics and Gynaecology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sara Imboden
- Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Obstetrics and Gynaecology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nick Bersinger
- Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Obstetrics and Gynaecology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael D Mueller
- Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Obstetrics and Gynaecology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
25
|
Barra F, Ferro Desideri L, Leone Roberti Maggiore U, Gaetano Vellone V, Maramai M, Scala C, Ferrero S. Endometriosis Classification and The Role of Tumor Necrosis Factor-Alpha Polymorphisms as A Therapeutic Target. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2020; 14:76-77. [PMID: 32112641 PMCID: PMC7139220 DOI: 10.22074/ijfs.2020.5876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 06/02/2019] [Indexed: 12/03/2022]
Abstract
In the recent original research published on International Journal of Fertility and Sterility the association between
tumor necrosis factor-alpha (TNF-α) genetic polymorphisms and endometriosis in 150 Iranian patients suffered this
disease. The authors notably found a lower frequency of TNF-α -863C/A allele A among the affected patients in
comparison with healthy women, although this difference was not significant by adjusting multiple testing. We deem
that the authors should specify, if these patients had peritoneal nodules, ovarian endometrioma/deep infiltrating
endometriosis (DIE) nodules or combination of them, since it has been hypothesized that these phenotypes may represent
three distinct pathogenetic entities of endometriosis.
Collapse
Affiliation(s)
- Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy. Electronic Address: .,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Lorenzo Ferro Desideri
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Umberto Leone Roberti Maggiore
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Valerio Gaetano Vellone
- Department of Surgical and Diagnostic Sciences, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Mattia Maramai
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Carolina Scala
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| |
Collapse
|
26
|
Kotlyar A, Taylor HS, D'Hooghe TM. Use of immunomodulators to treat endometriosis. Best Pract Res Clin Obstet Gynaecol 2019; 60:56-65. [DOI: 10.1016/j.bpobgyn.2019.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/17/2019] [Accepted: 06/24/2019] [Indexed: 12/12/2022]
|
27
|
Melsheimer R, Geldhof A, Apaolaza I, Schaible T. Remicade ® (infliximab): 20 years of contributions to science and medicine. Biologics 2019; 13:139-178. [PMID: 31440029 PMCID: PMC6679695 DOI: 10.2147/btt.s207246] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/16/2019] [Indexed: 12/17/2022]
Abstract
On August 24, 1998, Remicade® (infliximab), the first tumor necrosis factor-α (TNF) inhibitor, received its initial marketing approval from the US Food and Drug Administration for the treatment of Crohn’s disease. Subsequently, Remicade was approved in another five adult and two pediatric indications both in the USA and across the globe. In the 20 years since this first approval, Remicade has made several important contributions to the advancement of science and medicine: 1) clinical trials with Remicade established the proof of concept that targeted therapy can be effective in immune-mediated inflammatory diseases; 2) as the first monoclonal antibody approved for use in a chronic condition, Remicade helped in identifying methods of administering large, foreign proteins repeatedly while limiting the body’s immune response to them; 3) the need to establish Remicade’s safety profile required developing new methods and setting new standards for postmarketing safety studies, specifically in the real-world setting, in terms of approach, size, and duration of follow-up; 4) the study of Remicade has improved our understanding of TNF’s role in the immune system, as well as our understanding of the pathophysiology of a range of diseases characterized by chronic inflammation; and 5) Remicade and other TNF inhibitors have transformed treatment practices in these chronic inflammatory diseases: remission has become a realistic goal of therapy and long-term disability resulting from structural damage can be prevented. This paper reviews how, over the course of its development and 20 years of use in clinical practice, Remicade was able to make these contributions.
Collapse
Affiliation(s)
| | - Anja Geldhof
- Medical Affairs, Janssen Biologics BV, Leiden, the Netherlands
| | - Isabel Apaolaza
- Medical Affairs, Janssen Biologics BV, Leiden, the Netherlands
| | | |
Collapse
|
28
|
Capraş RD, Urda-Cîmpean AE, Bolboacă SD. Is Scientific Medical Literature Related to Endometriosis Treatment Evidence-Based? A Systematic Review on Methodological Quality of Randomized Clinical Trials. MEDICINA-LITHUANIA 2019; 55:medicina55070372. [PMID: 31311075 PMCID: PMC6681304 DOI: 10.3390/medicina55070372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 11/16/2022]
Abstract
Background and objectives: Informed decision-making requires the ability to identify and integrate high-quality scientific evidence in daily practice. We aimed to assess whether randomized controlled trials (RCTs) on endometriosis therapy follow methodological criteria corresponding to the RCTs' specific level in the hierarchy of evidence in such details to allow the reproduction and replication of the study. Materials and Methods: Using the keywords "therapy" and "endometriosis" and "efficacy" three bibliographic databases were searched for English written scientific articles published from 1 January 2008 to 3 March 2018. Only the randomized clinical trials (RCTs) were evaluated in terms of whether they provided the appropriate level of scientific evidence, equivalent to level 1, degree 1b in the hierarchy of evidence. A list of criteria to ensure study replication and reproduction, considering CONSORT guideline and MECIR standards, was developed and used to evaluate RCTs' methodological soundness, and scores were granted. Three types of bias, namely selection bias (random sequence generation and allocation concealment), detection bias (blinding of outcome assessment), and attrition bias (incomplete outcome data) were also evaluated. Results: We found 387 articles on endometriosis therapy, of which 38 were RCTs: 30 double-blinded RCTs and 8 open-label RCTs. No article achieved the maximum score according to the evaluated methodological criteria. Even though 73.3% of the double-blinded RCTs had clear title, abstract, introduction, and objectives, only 13.3% provided precise information regarding experimental design and randomization, and also showed a low risk of bias. The blinding method was poorly reported in 43.3% of the double-blinded RCTs, while allocation concealment and random sequence generation were inadequate in 33.3% of them. Conclusions: None of the evaluated RCTs met all the methodological criteria, none had only a low risk of bias and provided sufficient details on methods and randomization to allow for the reproduction and replication of the study. Consequently, the appropriate level of scientific evidence (level 1, degree 1b) could not be granted. On endometriosis therapy, this study evaluated the quality of reporting in RCTs and not the quality of how the studies were performed.
Collapse
Affiliation(s)
- Roxana-Denisa Capraş
- Department of Medical Informatics and Biostatistics, Faculty of Medicine, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania
- Department of Anatomy and Embryology, Faculty of Medicine, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- "Dominic Stanca" Gynaecology Clinic, 400124 Cluj-Napoca, Romania
| | - Andrada Elena Urda-Cîmpean
- Department of Medical Informatics and Biostatistics, Faculty of Medicine, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania.
| | - Sorana D Bolboacă
- Department of Medical Informatics and Biostatistics, Faculty of Medicine, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania.
| |
Collapse
|
29
|
|
30
|
Zhou WJ, Yang HL, Shao J, Mei J, Chang KK, Zhu R, Li MQ. Anti-inflammatory cytokines in endometriosis. Cell Mol Life Sci 2019; 76:2111-2132. [PMID: 30826860 PMCID: PMC11105498 DOI: 10.1007/s00018-019-03056-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/29/2019] [Accepted: 02/25/2019] [Indexed: 02/07/2023]
Abstract
Although the pathogenesis of endometriosis is not fully understood, it is often considered to be an inflammatory disease. An increasing number of studies suggest that differential expression of anti-inflammatory cytokines (e.g., interleukin-4 and -10, and transforming growth factor-β1) occurs in women with endometriosis, including in serum, peritoneal fluid and ectopic lesions. These anti-inflammatory cytokines also have indispensable roles in the progression of endometriosis, including by promoting survival, growth, invasion, differentiation, angiogenesis, and immune escape of the endometriotic lesions. In this review, we provide an overview of the expression, origin, function and regulation of anti-inflammatory cytokines in endometriosis, with brief discussion and perspectives on their future clinical implications in the diagnosis and therapy of the disease.
Collapse
Affiliation(s)
- Wen-Jie Zhou
- Laboratory for Reproductive Immunology, NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and Gynecology, Fudan University, Shanghai, 200090, People's Republic of China
- Clinical and Translational Research Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 200040, China
| | - Hui-Li Yang
- Laboratory for Reproductive Immunology, NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and Gynecology, Fudan University, Shanghai, 200090, People's Republic of China
| | - Jun Shao
- Laboratory for Reproductive Immunology, NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and Gynecology, Fudan University, Shanghai, 200090, People's Republic of China
- Department of Gynecology, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai, 200011, People's Republic of China
| | - Jie Mei
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Reproductive Medicine Center, The Affiliated Hospital of Nanjing University Medicine School, Nanjing, 210000, People's Republic of China
| | - Kai-Kai Chang
- Department of Gynecology, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai, 200011, People's Republic of China
| | - Rui Zhu
- Center for Human Reproduction and Genetics, Suzhou Municipal Hospital, Suzhou, 215008, People's Republic of China
| | - Ming-Qing Li
- Laboratory for Reproductive Immunology, NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and Gynecology, Fudan University, Shanghai, 200090, People's Republic of China.
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai, 200011, People's Republic of China.
| |
Collapse
|
31
|
Barra F, Grandi G, Tantari M, Scala C, Facchinetti F, Ferrero S. A comprehensive review of hormonal and biological therapies for endometriosis: latest developments. Expert Opin Biol Ther 2019; 19:343-360. [DOI: 10.1080/14712598.2019.1581761] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Fabio Barra
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Giovanni Grandi
- Department of Obstetrics, Gynecology and Pediatrics, Obstetrics and Gynecology Unit, Azienda Ospedaliero-Universitaria Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - Matteo Tantari
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Carolina Scala
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Fabio Facchinetti
- Department of Obstetrics, Gynecology and Pediatrics, Obstetrics and Gynecology Unit, Azienda Ospedaliero-Universitaria Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| |
Collapse
|
32
|
Barra F, Laganà AS, Casarin J, Ghezzi F, Ferro Desideri L, Scala C, Ferrero S. Molecular Targets for Endometriosis Therapy: Where We Are and Where We Are Going? INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2019; 13:89-92. [PMID: 31037916 PMCID: PMC6500084 DOI: 10.22074/ijfs.2019.5736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/10/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Fabio Barra
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Largo R. Benzi, Genoa, Italy,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa,
Genoa, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, Varese, Italy,Department of Obstetrics and GynecologyFilippo
Del Ponte HospitalUniversity of InsubriaPiazza BiroldiVareseItaly
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Lorenzo Ferro Desideri
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Largo R. Benzi, Genoa, Italy,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa,
Genoa, Italy
| | - Carolina Scala
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Largo R. Benzi, Genoa, Italy,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa,
Genoa, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Largo R. Benzi, Genoa, Italy,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa,
Genoa, Italy
| |
Collapse
|
33
|
Ciebiera M, Włodarczyk M, Zgliczyńska M, Łukaszuk K, Męczekalski B, Kobierzycki C, Łoziński T, Jakiel G. The Role of Tumor Necrosis Factor α in the Biology of Uterine Fibroids and the Related Symptoms. Int J Mol Sci 2018; 19:E3869. [PMID: 30518097 PMCID: PMC6321234 DOI: 10.3390/ijms19123869] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 12/20/2022] Open
Abstract
Uterine fibroids (UFs) are the most common benign tumors of the female genital tract. The incidence of UFs has been estimated at 25⁻80% depending on selected population. The pathophysiology of UFs remains poorly understood. The transformation of smooth muscle cells of the uterus into abnormal, immortal cells, capable of clonal division, is the main component of all pathways leading to UF tumor formation and tumor necrosis factor α (TNF-α) is believed to be one of the key factors in this field. TNF-α is a cell signaling protein involved in systemic inflammation and is one of the cytokines responsible for the acute phase reaction. This publication presents current data about the role of tumor necrosis factor α in the biology of UFs and the related symptoms. TNF-α is an extremely important cytokine associated with the biology of UFs, UF-related symptoms and complaints. Its concentration has been proven to be elevated in women with clinically symptomatic UFs. The presented data suggest the presence of an "inflammation-like" state in women with UFs where TNF-α is a potent inflammation inducer. The origin of numerous symptoms reported by women with UFs can be traced back to the TNF-α influence. Nevertheless, our knowledge on this subject remains limited and TNF-α dependent pathways in UF pathophysiology should be investigated further.
Collapse
Affiliation(s)
- Michał Ciebiera
- Second Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education, 01-809 Warsaw, Poland.
| | - Marta Włodarczyk
- Department of Biochemistry and Clinical Chemistry, Department of Pharmacogenomics, Medical University of Warsaw, 02-097 Warsaw, Poland.
| | - Magdalena Zgliczyńska
- Students' Scientific Association at the I Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-015 Warsaw, Poland.
| | - Krzysztof Łukaszuk
- Department of Obstetrics and Gynecological Nursing, Faculty of Health Sciences, Medical University of Gdansk, 80-210 Gdansk, Poland.
- INVICTA Fertility and Reproductive Center, 80-172 Gdansk, Poland.
| | - Błażej Męczekalski
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, 60-513 Poznan, Poland.
| | - Christopher Kobierzycki
- Division of Histology and Embryology, Department of Human Morphology and Embryology, Wroclaw Medical University, 50-368 Wroclaw, Poland.
| | - Tomasz Łoziński
- Department of Obstetrics and Gynecology Pro-Familia Hospital, 35-001 Rzeszów, Poland.
| | - Grzegorz Jakiel
- First Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education, 01-004 Warsaw, Poland.
| |
Collapse
|
34
|
Chronic Niche Inflammation in Endometriosis-Associated Infertility: Current Understanding and Future Therapeutic Strategies. Int J Mol Sci 2018; 19:ijms19082385. [PMID: 30104541 PMCID: PMC6121292 DOI: 10.3390/ijms19082385] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 08/05/2018] [Accepted: 08/09/2018] [Indexed: 12/13/2022] Open
Abstract
Endometriosis is an estrogen-dependent inflammatory disease that affects up to 10% of women of reproductive age and accounts for up to 50% of female infertility cases. It has been highly associated with poorer outcomes of assisted reproductive technology (ART), including decreased oocyte retrieval, lower implantation, and pregnancy rates. A better understanding of the pathogenesis of endometriosis-associated infertility is crucial for improving infertility treatment outcomes. Current theories regarding how endometriosis reduces fertility include anatomical distortion, ovulatory dysfunction, and niche inflammation-associated peritoneal or implantation defects. This review will survey the latest evidence on the role of inflammatory niche in the peritoneal cavity, ovaries, and uterus of endometriosis patients. Nonhormone treatment strategies that target these inflammation processes are also included. Furthermore, mesenchymal stem cell-based therapies are highlighted for potential endometriosis treatment because of their immunomodulatory effects and tropism toward inflamed lesion foci. Potential applications of stem cell therapy in treatment of endometriosis-associated infertility in particular for safety and efficacy are discussed.
Collapse
|
35
|
Wendel JRH, Wang X, Hawkins SM. The Endometriotic Tumor Microenvironment in Ovarian Cancer. Cancers (Basel) 2018; 10:cancers10080261. [PMID: 30087267 PMCID: PMC6115869 DOI: 10.3390/cancers10080261] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 12/15/2022] Open
Abstract
Women with endometriosis are at increased risk of developing ovarian cancer, specifically ovarian endometrioid, low-grade serous, and clear-cell adenocarcinoma. An important clinical caveat to the association of endometriosis with ovarian cancer is the improved prognosis for women with endometriosis at time of ovarian cancer staging. Whether endometriosis-associated ovarian cancers develop from the molecular transformation of endometriosis or develop because of the endometriotic tumor microenvironment remain unknown. Additionally, how the presence of endometriosis improves prognosis is also undefined, but likely relies on the endometriotic microenvironment. The unique tumor microenvironment of endometriosis is composed of epithelial, stromal, and immune cells, which adapt to survive in hypoxic conditions with high levels of iron, estrogen, and inflammatory cytokines and chemokines. Understanding the unique molecular features of the endometriotic tumor microenvironment may lead to impactful precision therapies and/or modalities for prevention. A challenge to this important study is the rarity of well-characterized clinical samples and the limited model systems. In this review, we will describe the unique molecular features of endometriosis-associated ovarian cancers, the endometriotic tumor microenvironment, and available model systems for endometriosis-associated ovarian cancers. Continued research on these unique ovarian cancers may lead to improved prevention and treatment options.
Collapse
Affiliation(s)
- Jillian R Hufgard Wendel
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Xiyin Wang
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Shannon M Hawkins
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| |
Collapse
|
36
|
From pathogenesis to clinical practice: Emerging medical treatments for endometriosis. Best Pract Res Clin Obstet Gynaecol 2018; 51:92-101. [DOI: 10.1016/j.bpobgyn.2018.01.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 01/23/2018] [Indexed: 12/12/2022]
|
37
|
Ferrero S, Evangelisti G, Barra F. Current and emerging treatment options for endometriosis. Expert Opin Pharmacother 2018; 19:1109-1125. [DOI: 10.1080/14656566.2018.1494154] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Giulio Evangelisti
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| |
Collapse
|
38
|
Guo SW, Groothuis PG. Is it time for a paradigm shift in drug research and development in endometriosis/adenomyosis? Hum Reprod Update 2018; 24:577-598. [DOI: 10.1093/humupd/dmy020] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/21/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China
| | - Patrick G Groothuis
- Principal Scientist Pharmacology, Preclinical Department, Synthon Biopharmaceuticals bv, Nijmegen, The Netherlands
| |
Collapse
|
39
|
Barra F, Scala C, Mais V, Guerriero S, Ferrero S. Investigational drugs for the treatment of endometriosis, an update on recent developments. Expert Opin Investig Drugs 2018; 27:445-458. [PMID: 29708812 DOI: 10.1080/13543784.2018.1471135] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Endometriosis is a hormone-dependent benign chronic disease that requires a chronic medical therapy. Although currently available drugs are efficacious in treating endometriosis-related pain, some women experience partial or no improvement. Moreover, the recurrence of symptoms is expected after discontinuation of the therapies. Currently, new drugs are under intense clinical investigation for the treatment of endometriosis. AREAS COVERED This review aims to offer the reader a complete and updated overview on new investigational drugs and early molecular targets for the treatment of endometriosis. The authors describe the pre-clinical and clinical development of these agents. EXPERT OPINION Among the drugs under investigation, late clinical trials on gonadotropin-releasing hormone antagonists (GnRH-ant) showed the most promising results for the treatment of endometriosis. Aromatase inhibitors (AIs) are efficacious in treating endometriosis related pain symptoms but they cause significant adverse effects that limit their long-term use. New targets have been identified to produce drugs for the treatment of endometriosis, but the majority of these new compounds have only been investigated in laboratory studies or early clinical trials. Thus, further clinical research is required in order to elucidate their efficacy and safety in human.
Collapse
Affiliation(s)
- Fabio Barra
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Carolina Scala
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Valerio Mais
- c Department of Obstetrics and Gynecology , University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato , Cagliari , Italy
| | - Stefano Guerriero
- c Department of Obstetrics and Gynecology , University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato , Cagliari , Italy
| | - Simone Ferrero
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| |
Collapse
|
40
|
Cho YJ, Lee SH, Park JW, Han M, Park MJ, Han SJ. Dysfunctional signaling underlying endometriosis: current state of knowledge. J Mol Endocrinol 2018; 60:R97-R113. [PMID: 29330150 DOI: 10.1530/jme-17-0227] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 01/11/2018] [Indexed: 12/18/2022]
Abstract
Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. It affects approximately 5-10% of women of reproductive age. Endometriosis is associated with dysmenorrhea, dyspareunia and, often, severe pelvic pain. In addition to pain, women with endometriosis often experience infertility. Defining the molecular etiology of endometriosis is a significant challenge for improving the quality of women's lives. Unfortunately, the pathophysiology of endometriosis is not well understood. Here, we summarize the potential causative factors of endometriosis in the following three categories: (1) dysregulation of immune cells in the peritoneal fluid and endometriotic lesions; (2) alteration of apoptotic signaling in retrograde menstrual tissue and cytotoxic T cells involved in endometriosis progression and (3) dysregulation of oxidative stress. Determining the molecular etiology of these dysregulated cellular signaling pathways should provide crucial clues for understanding initiation and progression of endometriosis. Moreover, improved understanding should suggest new molecular therapeutic targets that could improve the specificity of endometriosis treatments and reduce the side effects associated with current approaches.
Collapse
Affiliation(s)
- Yeon Jean Cho
- Department of Obstetrics and Gynecology, Dong-A University, College of Medicine, Busan, Republic of Korea
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, USA
| | - Seung Hyun Lee
- Department of Obstetrics and Gynecology, Dong-A University, College of Medicine, Busan, Republic of Korea
| | - Jung Woo Park
- Department of Obstetrics and Gynecology, Dong-A University, College of Medicine, Busan, Republic of Korea
| | - Myoungseok Han
- Department of Obstetrics and Gynecology, Dong-A University, College of Medicine, Busan, Republic of Korea
| | - Mi Jin Park
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, USA
| | - Sang Jun Han
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, USA
- Center for Reproductive Medicine, Baylor College of Medicine, Houston, Texas, USA
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
- Center for Drug Discovery, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
41
|
Transcription regulatory factor expression in T-helper cell differentiation pathway in eutopic endometrial tissue samples of women with endometriosis associated with infertility. Cent Eur J Immunol 2018; 43:90-96. [PMID: 29736151 PMCID: PMC5927178 DOI: 10.5114/ceji.2018.74878] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 01/03/2017] [Indexed: 11/17/2022] Open
Abstract
Endometriosis is a disease of epidemiological gravity of unknown primary reason. A complex of constitutional factors including the immune system has been considered as its background. The aim of the study was to identify Th1 and Th2 cells as well as the T-regulatory subset in the endometrium of women with endometriosis associated with infertility upon transcription factors expression. Expression of T-bet, GATA3, and Foxp3 genes was examined using a method of polymerase chain reaction (PCR) in the eutopic endometrial samples of 20 women with endometriosis associated with infertility and 20 women with infertility of tubal origin. An increase in mRNA expression for T-bet and GATA3 with prevailing mRNA level for T-bet and a decrease in Foxp3 expression were observed. In conclusion, the revealed changes in expression of transcription factors may indicate the imbalance between T-helper cells of the Th1 and Th2 type and elimination of regulatory function of T-cells, which can be one of the causes of endometriosis predisposing to the development of infertility associated with this disease.
Collapse
|
42
|
Koninckx PR, Ussia A, Keckstein J, Adamyan LV, Zupi E, Wattiez A, Gomel V. Evidence-Based Medicine: Pandora's Box of Medical and Surgical Treatment of Endometriosis. J Minim Invasive Gynecol 2018; 25:360-365. [DOI: 10.1016/j.jmig.2017.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 11/18/2017] [Indexed: 02/06/2023]
|
43
|
Guo SW. Fibrogenesis resulting from cyclic bleeding: the Holy Grail of the natural history of ectopic endometrium. Hum Reprod 2018; 33:353-356. [DOI: 10.1093/humrep/dey015] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Indexed: 12/17/2022] Open
Affiliation(s)
- Sun-Wei Guo
- Institute of Obstetric and Gynecological Research, Shanghai Obstetrics and Gynecology Hospital, Fudan University, 419 Fangxie Road, Shanghai 200011, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, 413 Zhaozhou Road, Shanghai 200011, China
| |
Collapse
|
44
|
Kotlyar A, Shue S, Liu X, Falcone T. Effect of disease-modifying anti-rheumatic drugs on therapeutic outcomes among women with endometriosis. Int J Gynaecol Obstet 2018; 141:228-233. [DOI: 10.1002/ijgo.12416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/10/2017] [Accepted: 12/01/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Alexander Kotlyar
- Department of Obstetrics and Gynecology and Women's Health Institute; The Cleveland Clinic; Cleveland OH USA
| | - Shirley Shue
- Case Western Reserve University School of Medicine; Cleveland OH USA
| | - Xiaobo Liu
- Department of Quantitative Health Sciences; The Cleveland Clinic; Cleveland OH USA
| | - Tommaso Falcone
- Department of Obstetrics and Gynecology and Women's Health Institute; The Cleveland Clinic; Cleveland OH USA
| |
Collapse
|
45
|
Geoffron S, Legendre G, Daraï E, Chabbert-Buffet N. [Medical treatment of endometriosis: Hormonal treatment of pain, impact on evolution and future perspectives]. Presse Med 2017; 46:1199-1211. [PMID: 29133081 DOI: 10.1016/j.lpm.2017.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 10/03/2017] [Accepted: 10/03/2017] [Indexed: 11/30/2022] Open
Abstract
CONTEXT Endometriosis is a chronic painful disease, for which hormone therapy is usually offered as a first line option to women not willing to conceive. OBJECTIVES To analyse and synthesize the literature, from 2006 onwards, on pain control, and disease evolution in oemn using combined hormonal contraceptives, progestins and GnRH analogs. Data on other current and future treatment perspectives is included as well. SOURCES Medline (Pubmed), the Cochrane Library, and endometriosis treatment recommendations published by European Society of Human Reproduction and Embryology (ESHRE), National Institute for health and Care Excellence (NICE), American College of Obstetricians and Gynecologists (ACOG), Royal College of Obstetricians and Gynaecologists (RCOG) and Société des Obstétriciens et Gynécologues du Canada (SOGC). STUDY SELECTION Meta-analysis and clinical trials are included. RESULTS Study quality is heterogeneous in general. Hormone therapy inconstantly allows pain relief and prevention of endometrioma and rectovaginal wall nodules recurrence. Available molecules and routes of administration as well as risk benefit balance are evaluated. Data on future perspectives are limited to date and do not allow use in routine. CONCLUSION Hormonal treatment of endometriosis relies on combined hormonal contraceptives (using different routes of administration), progestins and particularly the levonorgestrel-releasing IUS, and GnRH analogs as a last option, in combination with an add-back therapy. Promising alternatives are currently under preclinical and clinical evaluation.
Collapse
Affiliation(s)
- Sophie Geoffron
- AP-HP, université Pierre-et-Marie-Curie Paris 6, hôpital Tenon, service de gynécologie-obstétrique, médecine de la reproduction, 75020 Paris, France
| | - Guillaume Legendre
- CHU d'Angers, service de gynécologie-obstétrique, 49000 Angers, France; Université Paris Sud, CESP-Inserm, U1018, équipe 7, genre, santé sexuelle et reproductive, 75000 Paris, France
| | - Emile Daraï
- AP-HP, université Pierre-et-Marie-Curie Paris 6, hôpital Tenon, service de gynécologie-obstétrique, médecine de la reproduction, 75020 Paris, France; AP-HP, hôpital Tenon, centre expert en endométriose (C3E), 75020 Paris, France; UPMC, groupe de recherche clinique GRC-6, 75020 Paris, France
| | - Nathalie Chabbert-Buffet
- AP-HP, université Pierre-et-Marie-Curie Paris 6, hôpital Tenon, service de gynécologie-obstétrique, médecine de la reproduction, 75020 Paris, France; AP-HP, hôpital Tenon, centre expert en endométriose (C3E), 75020 Paris, France; UPMC, groupe de recherche clinique GRC-6, 75020 Paris, France.
| |
Collapse
|
46
|
Abstract
Endometriosis is a chronic medical condition that affects around 6% to 10% of reproductive age women. Pelvic pain, dysmenorrhea, and infertility are the most common presenting symptoms. The disease is characterized by estrogen-dependent growth of the endometrial glands and stroma outside the endometrial cavity. The diagnosis requires a high degree of suspicion and can be only confirmed on histopathology. Treatment includes medical and surgical options. Both hormonal and nonhormonal medical options are available and are tried at first with a goal to control pain and stop the growth of the endometriotic lesions. Nonsteroidal anti-inflammatory drugs, oral contraceptive pills, gonadotropin-releasing hormone (GnRH) agonists, aromatase inhibitors are some of the commonly used medications. With more research on the molecular and biochemical aspects of endometriosis, newer targets of therapy are being developed like selective progesterone receptor modulators, antiangiogenic factors and immunomodulators. In women who do not respond to medical therapy or have severe symptoms, surgical excision of the endometrial lesions and adhesions is often helpful and offers confirmatory diagnosis by histopathology.
Collapse
Affiliation(s)
- Saima Rafique
- Howard University Hospital, Department of Obstetrics and Gynecology, Washington, DC, 20060
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health
| | - Alan H DeCherney
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health
| |
Collapse
|
47
|
Goenka L, George M, Sen M. A peek into the drug development scenario of endometriosis – A systematic review. Biomed Pharmacother 2017; 90:575-585. [DOI: 10.1016/j.biopha.2017.03.092] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/18/2017] [Accepted: 03/27/2017] [Indexed: 12/28/2022] Open
|
48
|
Koninckx PR, Ussia A, Zupi E, Gomel V. Evidence-Based Medicine in Endometriosis Surgery: Double-Blind Randomized Controlled Trial Versus the Consensus Opinion of Experts. J Minim Invasive Gynecol 2017; 24:692-694. [PMID: 28479171 DOI: 10.1016/j.jmig.2017.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Philippe R Koninckx
- Department of Obstetrics and Gynecology, Catholic University Leuven, University Hospital, Leuven, Belgium.
| | - Anastasia Ussia
- Gruppo Italo Belga, Villa del Rosario and Gemelli Hospitals Università Cattolica, Rome, Italy
| | - Errico Zupi
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Victor Gomel
- Department of Obstetrics and Gynecology, University of British Columbia, Women's Hospital, Vancouver, British Columbia, Canada
| |
Collapse
|
49
|
Sipak-Szmigiel O, Włodarski P, Ronin-Walknowska E, Niedzielski A, Karakiewicz B, Słuczanowska-Głąbowska S, Laszczyńska M, Malinowski W. Serum and peritoneal fluid concentrations of soluble human leukocyte antigen, tumor necrosis factor alpha and interleukin 10 in patients with selected ovarian pathologies. J Ovarian Res 2017; 10:25. [PMID: 28376925 PMCID: PMC5381140 DOI: 10.1186/s13048-017-0320-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 03/22/2017] [Indexed: 12/21/2022] Open
Abstract
Background Although immune system plays a key role in the pathogenesis of both endometriosis and ovarian cancer, its function is different. Therefore, we hypothesized, that selected immune parameters can serve as diagnostic markers of these two conditions. The aim of this study was to compare serum and peritoneal fluid concentrations of sHLA-G, IL-10 and TNF-alpha in women with selected ovarian pathologies: benign serous cysts, endometrioma and malignant tumors. Clinical significance of using them for diagnostic purposes in women with serous ovarian cysts, endometriosis, and ovarian cancer, which in the future may improve the early diagnosis of ovarian diseases. Case Presentation The study included women treated surgically for benign serous ovarian cysts, ovarian endometrioma and serous ovarian adenocarcinomas. Peripheral blood and peritoneal fluid samples were obtained intraoperatively. Patients with benign serous cysts, endometrioma and ovarian malignancies did not differ significantly in terms of their serum and peritoneal fluid concentrations of sHLA-G. Ovarian cancer patients presented with significantly higher median serum concentrations of IL-10 and TNF-alpha than other study subjects. Median concentrations of IL-10 and TNF-alpha in peritoneal fluid turned out to be the highest in ovarian cancer patients, followed by women with endometrioma and subjects with benign serous cysts. All these intergroup differences were statistically significant. Irrespective of the group, median concentrations of sHLA-G, IL-10 and TNF-alpha in peritoneal fluid were higher than serum levels of these markers. Conclusions Elevated serum and peritoneal fluid concentrations of IL-10 and TNF-alpha distinguish ovarian malignancies and endometriomas from benign serous ovarian cysts. In contrast to endometriosis, ovarian malignancies are characterized by elevated peritoneal fluid concentrations of IL-10 and TNF-alpha, elevated serum concentrations of IL-10 and low serum levels of TNF-alpha. Serum and peritoneal fluid concentrations of sHLA-G have no diagnostic value in differentiating between ovarian malignancies and endometriomas.
Collapse
Affiliation(s)
- Olimpia Sipak-Szmigiel
- Department of Obstetrical and Gynecological Nursing, Pomeranian Medical University, 48 Żołnierska, 71-210, Szczecin, Poland.
| | - Piotr Włodarski
- Clinical Hospital SPS ZOZ "Zdroje", Mączna 4, 70-780, Szczecin, Poland
| | - Elżbieta Ronin-Walknowska
- Clinic of Maternofetal Medicine and Gynecology, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1, 71-242, Szczecin, Poland
| | | | - Beata Karakiewicz
- Public Health Department, Pomeranian Medical University in Szczecin, Żołnierska 48, 71-210, Szczecin, Poland
| | - Sylwia Słuczanowska-Głąbowska
- Deparment of Physiology, Pomeranian Medical University in Szczecin, al. Powstańców Wlkp. 72, 70-111, Szczecin, Poland
| | - Maria Laszczyńska
- Department of Histology and Developmental Biology, Pomeranian Medical University in Szczecin, Żołnierska 48, 71-210, Szczecin, Poland
| | - Witold Malinowski
- Department of Obstetrical and Gynecological Nursing, Pomeranian Medical University, 48 Żołnierska, 71-210, Szczecin, Poland
| |
Collapse
|
50
|
Trummer D, Walzer A, Groettrup-Wolfers E, Schmitz H. Efficacy, safety and tolerability of the CCR1 antagonist BAY 86-5047 for the treatment of endometriosis-associated pelvic pain: a randomized controlled trial. Acta Obstet Gynecol Scand 2017; 96:694-701. [DOI: 10.1111/aogs.13105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/30/2017] [Indexed: 01/04/2023]
Affiliation(s)
- Dietmar Trummer
- R&D Statistics; Bayer Pharma AG; Global Development; Berlin Germany
| | - Anja Walzer
- Global Clinical Development; Bayer Pharma AG; Global Development; Berlin Germany
| | | | - Heinz Schmitz
- Global Clinical Development; Bayer Pharma AG; Global Development; Berlin Germany
| |
Collapse
|