The genetics of uterine leiomyomata: what clinicians need to know

Long-term risk of uterine malignancies in women with uterine fibroids confirmed by myomectomy: a population-based study

Leiomyosarcomas may originate from pre-existing uterine fibroids. However, recent studies showed that leiomyosarcomas do not arise from malignant changes in fibroids. Epidemiological data on the long-term risk of uterine malignancy with uterine fibroids are lacking. We aimed to determine whether uterine fibroids are a risk factor for uterine cancer. Patient data (2007-2020) from the Korean Health Insurance program were obtained. Using the procedure and diagnostic codes, data from patients who underwent myomectomy and appendicitis (control group) were extracted Using 1:1 propensity-score matching, 84,507 women were each allocated to the uterine fibroids and control groups. Endometrial cancer occurred in 36 44 and 44 36 women in the uterine fibroids and control groups (p = .371), respectively; 6/36 46 and 4 5/44 37 cases of uterine corpus cancer sarcoma occurred in the respective groups. Total uterine cancer (excluding cervical cancer) occurred in 46 and 39 37patients in the uterine fibroids and control groups, respectively (p = .323). A higher risk of uterine malignancy was not found in women with uterine fibroids confirmed by myomectomy. If surgery is indicated, a myomectomy can be safely performed without increasing the cancer risk. IMPACT STATEMENTWhat is already known on this subject? Traditionally, leiomyosarcomas were considered to originate from pre-existing uterine fibroids. However, recent studies suggest that leiomyosarcomas do not arise from the malignant change of fibroids. Meanwhile, there is a dearth of real-world evidence on the risk of uterine cancer in patients with uterine fibroids.What do the results of this study add? No evidence of a higher risk of uterine malignancy was found in women having uterine fibroids confirmed by myomectomy in this population-based study. In our cohort of women with uterine fibroids, tissue injury by myomectomy does not appear to cause malignant transformation.What are the implications of these findings for clinical practice and/or further research? Uterine fibroids doesn't appear to be a risk factor for uterine malignancies, and tissue injury by myomectomy does not appear to cause malignant transformation. If surgery is indicated, myomectomy can be performed safely, given that the long-term risk of uterine malignancy does not increase.

MiR-93 blocks cell cycle progression and promotes apoptosis in uterine leiomyoma cells by targeting CCND1

Uterine leiomyoma (UL) is the most common type of benign tumor in the women's reproductive system. A number of genes has been found to play an important role in the initiation and progression of UL, including miRNAs. In this study, our results exhibited that miR-93, a member of mir-106b-25 cluster, significantly reduced the cell viability, promoted cell cycle arrest, caused apoptosis, and inhibited migration in UL cells (p < .01). Moreover, our results have provided experimental evidence that miR-93 regulated the biological functions of UL cells by targeting CCND1.

Abnormal Uterine Bleeding: Current Classification and Clinical Management

Abnormal uterine bleeding is now classified and categorized according to the International Federation of Gynecology and Obstetrics classification system: PALM-COEIN. This applies to nongravid women during their reproductive years and allows more clear designation of causes, thus aiding clinical care and future research.

Facteurs génétiques à prendre en considération dans le cadre de l'examen gynécologique annuel

OBJECTIF

Offrir aux médecins un survol des troubles génétiques courants qui devraient être pris en considération dans le cadre de l'examen gynécologique annuel d'une patiente, et ce, afin de déterminer le risque que court celle-ci ou d'en venir à procéder à des examens particuliers ou à orienter la patiente vers un autre service de sous-spécialité, en fonction de ses antécédents personnels ou familiaux.

OPTIONS

Ces renseignements d'ordre génétique peuvent être utilisés aux fins de la sensibilisation des patientes et du dépistage ou du diagnostic de possibles maladies et/ou mutations.

ISSUES

L'utilisation de ces renseignements d'ordre génétique pourrait mener à l'amélioration de l'évaluation des risques et des avantages et à celle de la prise en charge dans le cadre de l'examen gynécologique annuel. RéSULTATS: Les études publiées en anglais, jusques et y compris en mai 2010, ont été récupérées par l'intermédiaire de recherches menées dans PubMed et la Cochrane Library au moyen d'un vocabulaire contrôlé (« gynaecological diagnosis », « genetic inheritance ») et de mots clés (« genetic risk », « genetic mutation », « inheritance », « family history », « uterus », « ovary », « endometrial », « vagina », « colon », « gastric », « renal », « breast », « cardiac », « thrombophilia », « diabetes », « epilepsy », « leiomyomata uteri ») appropriés. D'autres sources ont été identifiées par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales.

VALEURS

Le niveau des résultats ne permet pas la formulation de recommandations factuelles. AVANTAGES, DéSAVANTAGES ET COûTS: La présente opinion de comité améliorera l'utilisation de nouvelles connaissances génétiques et leur application aux soins gynécologiques offerts annuellement aux femmes. Les occasions de gestion du risque et de diagnostic, pour ce qui est des troubles gynécologiques génétiques, s'en trouveront améliorées. Une compréhension plus exhaustive des troubles génétiques pourrait entraîner une hausse de l'anxiété et du stress psychologique chez les femmes et les membres de leur famille.

COMMANDITAIRE

Société des obstétriciens et gynécologues du Canada.

RECOMMANDATIONS

Le niveau des résultats ne permet pas la formulation de recommandations factuelles.

Leiomyoma and leiomyoma cellulare of the fallopian tube: review of the literature and case reports

Introduction

Leiomyoma of the fallopian tube is extremely rare, and its version – leiomyoma cellulare (LC) of the fallopian tube is absolutely unique. Aim of the study was to review literature reports on leiomyomas of the fallopian tubes, and to present cases of leiomyoma and LC of the fallopian tubes in the patients operated on in our ward.

Material and methods

There were fewer than 100 cases of leiomyomas of the fallopian tubes discussed in the literature up to 1993. Case 1. Leiomyoma of the left fallopian tube was detected postoperatively in a 68-year-old patient, G.K., on histopathological examination after laparoscopic total hysterectomy with bilateral adnexa. Case 2. A 56-year-old patient, K.T., with LC of the fallopian tube was qualified for laparoscopy. At operation, the procedure was converted to microlaparotomy due to the tumor size. The adnexa on the right side with the tumor of the fallopian tube were excised, and the left fallopian tube was excised, too. Histopathological microscopy found leiomyoma cellulare partim epithelioides.

Results

In the presented cases, the extent of operation was connected with the clinical picture, and in the case of LC of the right fallopian tube, with intraoperative histopathological findings. In both cases the postoperative course was uneventful.

Conclusions

Diagnosis of leiomyoma and LC of the fallopian tube, like in the other organs of the female genital tract, is possible only due to results of histopathological microscopy.

Epidemiology of Uterine Fibroids: From Menarche to Menopause

Uterine leiomyomata (UL) have a substantial impact on women's health, but relatively few studies have identified opportunities for primary prevention of these neoplasms. Most established risk factors are not modifiable, including premenopausal age, African ancestry, age at menarche, and childbearing history. The main challenge in studying UL is that a large proportion of tumors are asymptomatic. Herein, we review the epidemiology of UL from published studies to date. We highlight the advantages of ultrasound screening studies and the ways in which their innovative methods have helped clarify the etiology of disease. We conclude with a discussion of promising new hypotheses.

Halofuginone suppresses growth of human uterine leiomyoma cells in a mouse xenograft model

STUDY QUESTION

Does halofuginone (HF) inhibit the growth of human uterine leiomyoma cells in a mouse xenograft model?

SUMMARY ANSWER

HF suppresses the growth of human uterine leiomyoma cells in a mouse xenograft model through inhibiting cell proliferation and inducing apoptosis.

WHAT IS KNOWN ALREADY

Uterine leiomyomas are the most common benign tumors of the female reproductive tract. HF can suppress the growth of human uterine leiomyoma cells in vitro. The mouse xenograft model reflects the characteristics of human leiomyomas.

STUDY DESIGN, SIZE, DURATION

Primary leiomyoma smooth muscle cells from eight patients were xenografted under the renal capsule of adult, ovariectomized NOD-scid IL2Rγ(null) mice (NSG). Mice were treated with two different doses of HF or vehicle for 4 weeks with six to eight mice per group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mouse body weight measurements and immunohistochemical analysis of body organs were carried out to assess the safety of HF treatment. Xenografted tumors were measured and analyzed for cellular and molecular changes induced by HF. Ovarian steroid hormone receptors were evaluated for possible modulation by HF.

MAIN RESULTS AND THE ROLE OF CHANCE

Treatment of mice carrying human UL xenografts with HF at 0.25 or 0.50 mg/kg body weight for 4 weeks resulted in a 35-40% (P < 0.05) reduction in tumor volume. The HF-induced volume reduction was accompanied by increased apoptosis and decreased cell proliferation. In contrast, there was no significant change in the collagen content either at the transcript or protein level between UL xenografts in control and HF groups. HF treatment did not change the expression level of ovarian steroid hormone receptors. No adverse pathological effects were observed in other tissues from mice undergoing treatment at these doses.

LIMITATIONS, REASONS FOR CAUTION

While this study did test the effects of HF on human leiomyoma cells in an in vivo model, HF was administered to mice whose tolerance and metabolism of the drug may differ from that in humans. Also, the longer term effects of HF treatment are yet unclear.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study showing the effectiveness of HF in reducing UL tumor growth by interfering with the main cellular processes regulating cell proliferation and apoptosis are in agreement with previous studies on the effects of HF on other fibrotic diseases. HF can be considered as a candidate for reducing the size of leiomyomas, particularly prior to surgery.

STUDY FUNDING/COMPETING INTERESTS

This project was funded by NIH PO1HD057877 and R01 HD064402. Authors report no competing interests.

Effects of miRNA-197 overexpression on proliferation, apoptosis and migration in levonorgestrel treated uterine leiomyoma cells

BACKGROUND/AIMS

Uterine leiomyoma is the ahead benign tumor of the female genital tract, which resulted in menstrual abnormalities, recurrent pregnancy loss, and other serious gynecological disorders in women. Recently, as the process of exploring the brief molecular mechanisms of tumorgenesis, microRNAs (miRNAs) have attracted much more attention.

METHODS

In this study, we first confirmed that microRNA-197 (miR-197) was down-regulated significantly in human uterus leiomyoma by quantity real-time polymerase chain reaction, compared to normal uterus myometrium. Then we observed the potential effects of miR-197 overexpression on human uterus leiomyoma cells by cell counting kit 8, wound healing assay, and flow cytometric assessment separately.

RESULTS

The data showed that miR-197 could inhibit cell proliferation, induce cell apoptosis, and block cell migration in vitro. Coincidently, levonorgestrel (LNG), a well-known uterus leiomyoma therapy, could induce miR-197 expression in human uterus leiomyoma cells, and over-expression of miR-197 showed a synergy effect on human uterus leiomyoma cell proliferation and apoptosis with LNG.

CONCLUSION

In this study, the data showed that miR-197 could play an anti-oncogenic role in human uterus leiomyoma cells, and cooperate with LNG on the cell proliferation and apoptosis, which suggested that miR-197 might be a potential target and provided database for clinical treatment.

Hyperplasia and fibrosis in mice with conditional loss of the TSC2 tumor suppressor in Müllerian duct mesenchyme-derived myometria

Uterine leiomyomata are the most common tumors found in the female reproductive tract. Despite the high prevalence and associated morbidities of these benign tumors, little is known about the molecular basis of uterine leiomyoma development and progression. Loss of the Tuberous Sclerosis 2 (TSC2) tumor suppressor has been proposed as a mechanism important for the etiology of uterine leiomyomata based on the Eker rat model. However, conflicting evidence showing increased TSC2 expression has been reported in human uterine leiomyomata, suggesting that TSC2 might not be involved in the pathogenesis of this disorder. We have produced mice with conditional deletion of the Tsc2 gene in the myometria to determine whether loss of TSC2 leads to leiomyoma development in murine uteri. Myometrial hyperplasia and increased collagen deposition was observed in Tsc2(cKO) mice compared with control mice, but no leiomyomata were detected by post-natal week 24. Increased signaling activity of mammalian target of rapamycin complex 1, which is normally repressed by TSC2, was also detected in the myometria of Tsc2(cKO) mice. Treatment of the mutant mice with rapamycin significantly inhibited myometrial expansion, but treatment with the progesterone receptor modulator, mifepristone, did not. The ovaries of the Tsc2(cKO) mice appeared normal, but half the mice were infertile and most of the other half became infertile after a single litter, which was likely due to oviductal blockage. Our study shows that although TSC2 loss alone does not lead to leiomyoma development, it does lead to myometrial hyperplasia and fibrosis.

MED12 and HMGA2 mutations: two independent genetic events in uterine leiomyoma and leiomyosarcoma

Recent identification of somatic MED12 mutations in most uterine leiomyomas brings a new venue for the study of the tumorigenesis of leiomyomas. We are particularly interested in the correlation of MED12 and HMGA2 gene products in leiomyomas and leiomyosarcomas with and without MED12 mutations. To address these issues, in this study we examined MED12 mutations in a large cohort of usual type leiomyomas (178 cases) and uterine leiomyosarcomas (32 cases). We found that 74.7% (133/178) of leiomyomas had MED12 mutations, which was consistent with several independent studies. In contrast, only 9.7% (3/32) of leiomyosarcomas harbored MED12 mutations. Expression analysis by western blot and immunohistochemistry revealed that those leiomyomas with complex MED12 mutations had significantly lower protein products than the matched myometrium. Interestingly, most leiomyosarcomas without MED12 mutations also had very low levels of MED12 expression in comparison to the matched myometrium. These findings suggest a potential functional role of MED12 in both benign and malignant uterine smooth muscle tumors. When we further examined HMGA2 expression in all leiomyomas and leiomyosarcomas, we found that HMGA2 overexpression was exclusively present in those leiomyomas with no MED12 mutation, accounting for 10.1% (18/178) of total leiomyomas and 40% (18/45) of non-MED12 mutant leiomyomas. Twenty-five percent (8/32) of leiomyosarcomas had HMGA2 overexpression, and no MED12 mutations were found in HMGA2 positive leiomyosarcoma. These findings strongly suggest that MED12 mutations and HMGA2 overexpression are independent genetic events that occur in leiomyomas, and they may act differently in the tumorigenesis of uterine leiomyomas.

MicroRNA and gynecological reproductive diseases

MicroRNAs (miRNAs) are a class of small non-coding RNAs estimated to regulate the translation of mRNAs in 30% of all genes in animals by inhibiting translation. Aberrant miRNA expression is associated with many human diseases, including gynecological diseases, cancer, inflammatory diseases, and cardiovascular disorders. Abnormal expression of miRNAs has been observed in multiple human reproductive tract diseases including preeclampsia, endometrioid endometrial adenocarcinoma, uterine leiomyomata, ovarian carcinoma, endometriosis, and recurrent pregnancy loss. In the following review, an update of the role of microRNA and gynecological diseases is performed covering, not only impact of microRNA dysregulation in the origin of each disease, but also showing the potential useful diagnostic and therapeutic tool that miRNA may play in these gynecological pathologies.

The health disparities of uterine fibroid tumors for African American women: a public health issue

Uterine fibroid tumors (leiomyomas) are the most common benign pelvic tumors in women and are the major indication for hysterectomy. Fibroid tumors are more common and more severe among African American women. Although this disease disproportionately affects the African American population, we understand little about what causes the disparity. Fibroid tumors should be considered a public health issue, given the magnitude of the problem and the costs of health care for this disease. In this review, we examine the burden of disease from fibroid tumors in the African American population and review the natural history, diagnosis, and treatment of uterine fibroid tumors, with emphasis on how these can differ, depending on race. We also focus on the socioeconomic burden caused by the disease and describe the anticipated influence of new health care reforms and funding mechanisms for fibroid tumor research.

Clinical predictors of successful magnetic resonance-guided focused ultrasound (MRgFUS) for uterine leiomyoma

Background

Magnetic resonance-guided focused ultrasound (MRgFUS) is a relatively new minimally invasive treatment, approved by the US Food and Drug Administration in 2004 for treatments of symptomatic uterine leiomyomas (fibroids). The purpose of this work is to present retrospective cohort analysis of women that underwent commercial MRgFUS treatment between 2005 and 2009 at a single center, to identify baseline patient characteristics that predict successful MRgFUS fibroid treatment. Identifying these clinical predictors of MRgFUS would be helpful to clinicians choosing the optimal patient for this treatment modality.

Methods

One hundred thirty women with symptomatic uterine leiomyomas who underwent MRgFUS were followed up with a mean length of follow up of 17.4 ± 10.3 months. The main outcome measure of the follow-up was to identify patients who required additional fibroid treatment due to continued fibroid symptoms. Additionally, patient medical history and radiological findings obtained prior to MRgFUS were reviewed, and statistical analysis was performed to identify factors associated with reduced risk of having additional fibroid treatment.

Results

Twenty-nine patients (22.3%) underwent additional fibroid treatment due to continued or recurrent fibroid symptoms during the follow up. Cumulative incidence of additional fibroid treatment was 9.7%, 29.3%, and 44.7% at 1, 2, and 3 years following MRgFUS, respectively. In multivariable Cox proportional hazard regression analyses, older age (hazard ratio (HR) 0.54 per 5-year increase in age, 95% confidence interval 0.39 to 0.76, p < 0.001), greater number of fibroids (HR 0.19 for more than three vs. one fibroid, 95% CI 0.05 to 0.67, p = 0.033), and greater fibroid volume (HR 0.70 per doubling in volume, 95% CI 0.51 to 0.96, p = 0.025) were significantly associated with less risk of having additional fibroid treatment.

Conclusions

Older age at treatment and having multiple fibroids with larger volume are associated with a lower risk of additional intervention following MRgFUS treatment for uterine fibroids.

Loss of the repressor REST in uterine fibroids promotes aberrant G protein-coupled receptor 10 expression and activates mammalian target of rapamycin pathway

Uterine fibroids (leiomyomas) are the most common tumors of the female reproductive tract, occurring in up to 77% of reproductive-aged women, yet molecular pathogenesis remains poorly understood. A role for atypically activated mammalian target of rapamycin (mTOR) pathway in the pathogenesis of uterine fibroids has been suggested in several studies. We identified that G protein-coupled receptor 10 [GPR10, a putative signaling protein upstream of the phosphoinositide 3-kinase-protein kinase B/AKT-mammalian target of rapamycin (PI3K/AKT-mTOR) pathway] is aberrantly expressed in uterine fibroids. The activation of GPR10 by its cognate ligand, prolactin releasing peptide, promotes PI3K-AKT-mTOR pathways and cell proliferation specifically in cultured primary leiomyoma cells. Additionally, we report that RE1 suppressing transcription factor/neuron-restrictive silencing factor (REST/NRSF), a known tumor suppressor, transcriptionally represses GPR10 in the normal myometrium, and that the loss of REST in fibroids permits GPR10 expression. Importantly, mice overexpressing human GPR10 in the myometrium develop myometrial hyperplasia with excessive extracellular matrix deposition, a hallmark of uterine fibroids. We demonstrate previously unrecognized roles for GPR10 and its upstream regulator REST in the pathogenesis of uterine fibroids. Importantly, we report a unique genetically modified mouse model for a gene that is misexpressed in uterine fibroids.

African ancestry and genetic risk for uterine leiomyomata

Rates of uterine leiomyomata (UL) are 2-3 times higher in African Americans than in European Americans. It is unclear whether inherited factors explain the ethnic disparity. To investigate the presence of risk alleles for UL that are highly differentiated in frequency between African Americans and European Americans, the authors conducted an admixture-based genome-wide scan of 2,453 UL cases confirmed by ultrasound or surgery in the Black Women's Health Study (1997-2009), a national prospective cohort study. Controls (n = 2,102) were women who did not report a UL diagnosis through 2009. Mean percentage of European ancestry was significantly lower among cases (20.00%) than among controls (21.63%; age-adjusted mean difference = -1.76%, 95% confidence interval: -2.40, -1.12; P < 0.0001), and the association was stronger in younger cases. Admixture analyses showed suggestive evidence of association at chromosomes 2, 4, and 10. The authors also genotyped a dense set of tag single nucleotide polymorphisms at different loci associated with UL in Japanese women but failed to replicate the associations. This suggests that genetic variation for UL differs in populations with and without African ancestry. The admixture findings further indicate that no single highly differentiated locus is responsible for the ethnic disparity in UL, raising the possibility that multiple variants jointly contribute to the higher incidence of UL in African Americans.

Genetic considerations for a woman's annual gynaecological examination

OBJECTIVE

To provide the physician with an overview of common genetic conditions that should be considered during a women's annual gynaecological assessment to determine the patient's risk or to initiate specific testing or referral to another subspecialty service, depending on personal or family history.

OPTIONS

This genetic information can be used for patient education and possible disease and/or mutation screening or diagnosis.

OUTCOMES

The use of this genetic information may allow improved risk-benefit assessment and management at the annual gynaecological examination.

EVIDENCE

Studies published in English up to and including May 2010 were retrieved through searches of PubMed and the Cochrane Library, using appropriate controlled vocabulary (gynaecological diagnosis, genetic inheritance) and key words (genetic risk, genetic mutation, inheritance, family history, uterus, ovary, endometrial, vagina, colon, gastric, renal, breast, cardiac, thrombophilia, diabetes, epilepsy, leiomyomata uteri). Other literature sources were identified through searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The levels of evidence are not adequate for evidence-based recommendations to be made.

BENEFITS, HARMS, AND COSTS

This committee opinion will enhance the use of new genetic knowledge and its application to the annual gynaecological care of women. Risk management and diagnostic opportunities for genetic gynaecological conditions will be improved. A more complete understanding of genetic conditions may increase anxiety and psychological stress for women and their families.

SPONSORS

Society of Obstetricians and Gynaecologists of Canada.

RECOMMENDATIONS

The levels of evidence are not adequate for evidence-based recommendations to be made.

Hair relaxer use and risk of uterine leiomyomata in African-American women

Hair relaxers are used by millions of black women, possibly exposing them to various chemicals through scalp lesions and burns. In the Black Women's Health Study, the authors assessed hair relaxer use in relation to uterine leiomyomata incidence. In 1997, participants reported on hair relaxer use (age at first use, frequency, duration, number of burns, and type of formulation). From 1997 to 2009, 23,580 premenopausal women were followed for incident uterine leiomyomata. Multivariable Cox regression was used to estimate incidence rate ratios and 95% confidence intervals. During 199,991 person-years, 7,146 cases of uterine leiomyomata were reported as confirmed by ultrasound (n = 4,630) or surgery (n = 2,516). The incidence rate ratio comparing ever with never use of relaxers was 1.17 (95% confidence interval (CI): 1.06, 1.30). Positive trends were observed for frequency of use (P(trend) < 0.001), duration of use (P(trend) = 0.015), and number of burns (P(trend) < 0.001). Among long-term users (≥10 years), the incidence rate ratios for frequency of use categories 3-4, 5-6, and ≥7 versus 1-2 times/year were 1.04 (95% CI: 0.92, 1.19), 1.12 (95% CI: 0.99, 1.27), and 1.15 (95% CI: 1.01, 1.31), respectively (P(trend) = 0.002). Risk was unrelated to age at first use or type of formulation. These findings raise the hypothesis that hair relaxer use increases uterine leiomyomata risk.

Personality and illness: genetic connections?

Illness is strongly influenced by genetics. Personality traits are influenced by genetics and have linkages with, at least, affective illness. Because genetics influences both personality and illness, we studied by literature review the genes that illness and personality traits share and, by office assessment, our patient population's illnesses and personality traits. This led to the following hypothesis: illness is related to more Submissive than Dominant personality trait and thus to lower norepinephrine activity. Patient affect and personality are often noted to be subdued in chronic illness, but whether from cause or effect is difficult to determine. After reviewing the literature on wellness, personality and genes, we endeavored to explore and better delineate our impressions of illness and personality relationships and to set the stage for a genetic hypothesis by using an online personality test in an ob-gyn practice to determine which traits could be used as proxies for personality trait genes. We thus confirmed our clinical impression that women with psychiatric and/or medical illness have more Submissive personality. The medical literature on gene markers shared by Submissive personality and illness in our population suggests the hypothesis that this relationship could be mediated by genetically lower neurotransmitter activity. Both norepinephrine activity and monoamine oxidase A, the enzyme controlling its catabolism, are in concert to blunt neuronal activity in such diverse states as depression, asthma, obesity, autoimmune illness, and in smokers. Conversely, norepinephrine activity is enhanced in breastfeeders and in other settings known to be related to good health. A point for possible divergence from the hypothesis is that African-Americans have enhanced norepinephrine activity yet poorer health outcomes although the effect of environmental risk factors in African-Americans is considered prominent by researchers. The possible importance of this hypothesis is that it changes emphasis slightly from one of splitting diagnoses to one of grouping them to achieve fresh insight. If we assess what is found in common in diverse illnesses of mind and body, we have yet another tool to assess causation. Although this hypothesis is offered somewhat in a boldness of spirit to take a new look at our many perplexing clinical problems, it is also offered with humility in light of the complexity with which we deal in patient care.

A Clinicopathologic Study of Uterine Smooth Muscle Tumours of Uncertain Malignant Potential (STUMP)

Introduction: The clinical management of Smooth Muscle Tumours of Uncertain Malignant Potential (STUMPs) remains controversial because little is known about the natural history of these tumours and pathological classifications do not correlate well with clinical outcomes and therefore cannot direct management. The objective of this study was to review a single institution’s experience with STUMP and recommend a rational clinical approach to the management of patients with this histological diagnosis. Materials and Methods: A systematic review of all diagnoses of STUMP and leiomyosarcoma from the gynaecologic oncology and pathology databases between January 1970 and February 2006. Results: A total of 18 diagnoses of STUMP and 72 diagnoses of Ieiomyosarcoma were made during the study period. None of these 72 cases of leiomyosarcoma had a prior diagnosis of STUMP. There were no recurrences in the 18 cases of STUMP with all 18 cases being registered as disease-free after 5 years. Conclusions: We recommend that patients with a diagnosis of STUMP be expectantly managed given the low likelihood of leiomyosarcomatous transformation, the lack of any evidence that adjuvant treatments result in better long-term outcomes and that recurrences are amenable to surgical resection with good outcomes. Key Words: Atypical leiomyoma, Clinical management, Leiomyosarcoma, Malignant transformation

Mesenchymal Tumors of the Female Genital Tract: Treatment

Mesenchymal tumors of the female genital tract include various benign and malignant neoplasms. Mesenchymal tumors may arise from the stroma or associated elements of the organ of origin, such as connective tissue, vascular or neural structures, or others. Malignant mesenchymal tumors of the female genital tract represent a rare group of gynecologic cancers. They are generally aggressive tumors, with a propensity for local and distant recurrence. The mainstay of treatment usually involves surgical excision of the primary tumor. Malignant mesenchymal tumors of the female genital tract are generally refractory to systemic chemotherapy and radiation therapy. This review highlights the treatment options for the most common types of mesenchymal tumors of the female genital tract.

Molecular Genetics of Mesenchymal Tumors of the Female Genital Tract

Mesenchymal tumors of the female genital tract are a heterogeneous group of neoplasms that can be classified based on cellular differentiation into 3 main groups: smooth muscle tumors, endometrial stromal tumors, and other differentiated and undifferentiated tumors. Genomic analysis techniques have revealed important genetic aberrations such as the t(7;17) translocation, resulting in JAZF1-JJAZ1 gene fusion, characteristic of endometrial stromal tumors. These analyses have demonstrated genetic complexity and heterogeneity in many mesenchymal tumor types. This article focuses on current understanding of the molecular genetics of mesenchymal tumors of the female genital tract, with emphasis on diagnostic and prognostic molecular features.

Uterine leiomyomata and decreased height: a common HMGA2 predisposition allele

Uterine leiomyomata (UL) are the most common female pelvic tumors and the primary indication for hysterectomy in the United States. We assessed genetic liability for UL by a known embryonic proliferation modulator, HMGA2, in 248 families ascertained through medical record-confirmed affected sister-pairs. Using a (TC)( n ) repeat in the 5' UTR and 17 SNPs spanning HMGA2, permutation-based association tests identified a significant increase in transmission of a single TC repeat allele (TC227) with UL (allele-specific P = 0.00005, multiple testing corrected min-P = 0.0049). The hypothesis that TC227 is a pathogenic variant is supported by a trend towards higher HMGA2 expression in TC227 allele-positive compared with non-TC227 UL tissue as well as by absence of culpable exonic sequence variants. HMGA2 has also been suggested recently by three genome-wide SNP studies to influence human height variation, and our examination of the affected sister-pair families revealed a significant association of TC227 with decreased height (allele-specific P = 0.00033, multiple testing corrected min-P = 0.016). Diminished stature and elevated risk of UL development have both been correlated with an earlier age of menarche, which may be the biological mechanism for TC227 effects as a tendency of women with TC227 to have an earlier onset of menarche was identified in our study population. These results indicate HMGA2 has a role in two growth-related phenotypes, UL predisposition and height, of which the former may affect future medical management decisions for many women.

Locally relapsed and metastatic uterine leiomyoma: a case report

Introduction

Benign metastasising leiomyoma refers to a type of lesion characterised by leiomyomatous alterations without any indication of malignancy. It presents as either a singular nodule or multiple nodules of proliferating smooth muscle cells and is generally found in the lungs of women who have undergone a hysterectomy. The purpose of this case report is to contribute to the knowledge of this rare disease by presenting evidence and experience of a patient case. In particular, this report seeks to investigate the therapeutic approaches in order to understand whether a standard of care can be prescribed and whether the use of prophylaxis therapy with progesterone as a follow-up to surgery serves as a reasonable treatment in certain cases diagnosed as benign metastasising leiomyoma.

Case presentation

We present the case of a 52-year-old Caucasian woman who developed a pelvic relapse and a pulmonary localisation of benign metastasising leiomyoma following a hysterectomy for myomatous uterus.

Conclusion

Our literature review revealed a single case of the use of chemoprophylaxis as treatment of a benign metastasising leiomyoma. The role of chemoprophylaxis in preventing future recurrences remains unclear. The use of progesterone as an adjuvant therapy for benign metastasising leiomyoma could simply be palliative, with associated psychological benefits, or it could be of therapeutic significance.

Lack of hypoxic response in uterine leiomyomas despite severe tissue hypoxia

Hypoxia is now established as a key factor influencing the pathophysiology of malignant growth. Among other effects, hypoxia modulates the expression of a multitude of genes through the induction of hypoxia-inducible transcription factors. This differential gene expression favors angiogenesis, cell survival, an invasive/metastatic phenotype, and resistance to anticancer therapies. Because benign tumors do not exhibit these traits, one might expect these entities to be neither hypoxic nor to induce the genetic hypoxia response program. To test this hypothesis, an investigation of the oxygenation status of 17 leiomyomas and 1 leiomyosarcoma of the uterus using polarographic needle electrodes (Eppendorf pO(2) sensor) and the expression of hypoxia-related markers in biopsy specimens of the same tumors was carried out. Marker expression in eight additional archival leiomyosarcomas was also assessed. Leiomyoma tissue was generally found to be severely hypoxic, with median oxygen (O(2)) partial pressure values ranging from 1 to 5 mm Hg. In contrast, none of the hypoxia-related markers hypoxia-inducible factor (HIF)-1alpha, HIF-2alpha, glucose transporter-1, or carbonic anhydrase IX were expressed in any leiomyoma. Larger intercapillary distances were correlated with a poorer oxygenation status. Conversely, the expression of hypoxia-related markers was abundant in the leiomyosarcomas and they also exhibited a high-turnover phenotype (significantly increased proliferation and apoptosis). Uterine leiomyoma might therefore represent a state of oxygen-limited proliferation. Malignancy in the same organ system is associated with growth and metabolism beyond tissue-inherent limitations leading to the induction of hypoxia-related markers, thereby contributing to a self-perpetuating aggressive phenotype.

Activating transcription factor 3 gene expression suggests that tissue stress plays a role in leiomyoma development

OBJECTIVE

To determine whether expression of the stress response gene ATF3 and related members of activator protein complex-1, cJun and cFos, were altered in leiomyoma compared with myometrium, and whether this difference might correlate with leiomyoma size or race.

DESIGN

Laboratory study.

SETTING

University hospital.

PATIENT(S)

Fifteen women undergoing hysterectomy for symptomatic leiomyoma.

INTERVENTION(S)

Tissue procurement, RNA isolation, reverse-transcriptase polymerase chain reaction, real-time reverse-transcriptase polymerase (RT-PCR) chain reaction, immunohistochemistry, Western blot.

MAIN OUTCOME MEASURE(S)

Expression of mRNA and protein in leiomyoma and patient-matched myometrium.

RESULT(S)

mRNA transcripts of ATF3 were decreased in leiomyoma compared with matched myometrium by both RT-PCR and real-time RT-PCR. The decrease was greater than fivefold in a majority of samples. The reduction seen in ATF3 mRNA expression did not show a correlation with race and leiomyoma size. Surprisingly, immunohistochemistry and Western blot analysis demonstrated an elevation of ATF3 protein expression by a mean of 2.9-fold. Transcripts of related AP-1 genes, cJun and cFos, were significantly decreased by a mean of -29.57 for cJun and -23.78 for cFos, but there was no significant change in protein expression of the two transcription factors.

CONCLUSIONS

Alterations in ATF3 gene expression resemble the response to mechanical and ischemic stress reported in other tissues. Results suggested that ATF3 protein expression was increased in leiomyoma, and may reflect increased tissue stress.

Gene expression profiling of multiple leiomyomata uteri and matched normal tissue from a single patient

OBJECTIVE

To identify differentially expressed genes between fibroid and adjacent normal myometrium in an identical hormonal and genetic background.

DESIGN

Array analysis of three leiomyomata and matched adjacent normal myometrium in a single patient.

SETTING

University of Colorado Hospital.

PATIENT(S)

A single female undergoing medically indicated hysterectomy for symptomatic fibroids.

INTERVENTIONS(S)

mRNA isolation and microarray analysis, reverse-transcriptase polymerase chain reaction, Western blotting, and immunohistochemistry.

MAIN OUTCOME MEASURE(S)

Changes in mRNA and protein levels in leiomyomata and matched normal myometrium.

RESULT(S)

Expression of 197 genes was increased and 619 decreased significantly by at least twofold, in leiomyomata relative to normal myometrium. Expression profiles between tumors were similar and normal myometrial samples showed minimal variation. Changes in, and variation of, expression of selected genes were confirmed in additional normal and leiomyoma samples from multiple patients.

CONCLUSION(S)

Analysis of multiple tumors from a single patient confirmed changes in expression of genes described in previous, apparently disparate, studies, and identified novel targets. Gene expression profiles in leiomyomata are consistent with increased activation of mitogenic pathways and inhibition of apoptosis. Down-regulation of genes implicated in invasion and metastasis, of cancers, was observed in fibroids. This expression pattern may underlie the benign nature of uterine leiomyomata and may aid in the differential diagnosis of leiomyosarcoma.

Differential expression of microRNA species in human uterine leiomyoma versus normal myometrium

OBJECTIVE

To determine whether microRNAs (miRNAs) are differentially expressed in human leiomyoma versus matched myometrial tissue.

DESIGN

Microarray with real-time polymerase chain reaction (PCR) validation.

SETTING

Academic medical center.

PATIENT(S)

Premenopausal subjects (n = 15), who were undergoing hysterectomies for leiomyoma-related symptoms.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Statistically differential expression of miRNAs in leiomyoma versus myometrium.

RESULT(S)

Forty-six miRNA species were differentially expressed in leiomyoma versus normal myometrium. Of these, 19 were overexpressed and 27 were underexpressed in leiomyomas. The changes ranged from 1.2-fold to 11.8-fold. These findings were confirmed using real-time reverse transcriptase PCR for selected miRNAs (miRNAs 21, 34a, 125b, 139, and 323).

CONCLUSION(S)

Our findings indicate that miRNAs are differentially expressed between human leiomyoma and matched myometrium. Given this differential expression, miRNAs may play a role in the pathogenesis of uterine leiomyoma and may serve as future therapeutic targets for the treatment of these tumors.

Progestin-releasing intrauterine systems and leiomyoma

Review of the existing published literature suggests that, in women with uterine fibroids, with or without menorrhagia, the high contraceptive efficacy of the levornorgestrel intrauterine system (LNG-IUS) remains intact. In such women, the LNG-IUS reduces menstrual blood loss and likely reduces menstrual pain. However, use of the LNG-IUS does not appear to reduce overall uterine dimensions or those of uterine fibroids. In women with uterine fibroids and menorrhagia, LNG-IUS expulsion rates may be somewhat higher than in women without fibroids. Although symptomatic relief is not guaranteed, these findings indicate that insertion of a LNG-IUS represents an appropriate therapeutic option for selected women with menstrual symptoms associated with uterine fibroids. Questions remain regarding the usefulness of routine preinsertion evaluation of the endometrial cavity as well as ultrasound-guided LNG-IUS insertion. Clinicians who candidly inform their patients regarding what we do and do not know regarding the benefits and risks of the LNG-IUS in women with fibroids should selectively make this therapy available prior to resorting to surgical therapies.