SIX1 and EWS/FLI1 co-regulate an anti-metastatic gene network in Ewing Sarcoma

Ewing sarcoma (ES), which is characterized by the presence of oncogenic fusion proteins such as EWS/FLI1, is an aggressive pediatric malignancy with a high rate of early dissemination and poor outcome after distant spread. Here we demonstrate that the SIX1 homeoprotein, which enhances metastasis in most tumor types, suppresses ES metastasis by co-regulating EWS/FLI1 target genes. Like EWS/FLI1, SIX1 promotes cell growth/transformation, yet dramatically inhibits migration and invasion, as well as metastasis in vivo. We show that EWS/FLI1 promotes SIX1 protein expression, and that the two proteins share genome-wide binding profiles and transcriptional regulatory targets, including many metastasis-associated genes such as integrins, which they co-regulate. We further show that SIX1 downregulation of integrins is critical to its ability to inhibit invasion, a key characteristic of metastatic cells. These data demonstrate an unexpected anti-metastatic function for SIX1, through coordinate gene regulation with the key oncoprotein in ES, EWS/FLI1.

Adipokine Apelin/APJ Pathway Promotes Peritoneal Dissemination of Ovarian Cancer Cells by Regulating Lipid Metabolism

Adipose tissue, which can provide adipokines and nutrients to tumors, plays a key role in promoting ovarian cancer metastatic lesions in peritoneal cavity. The adipokine apelin promotes ovarian cancer metastasis and progression through its receptor APJ, which regulates cell proliferation, energy metabolism, and angiogenesis. The objective of this study was to investigate the functional role and mechanisms of the apelin-APJ pathway in ovarian cancer metastasis, especially in context of tumor cell-adipocyte interactions. When co-cultured in the conditioned media (AdipoCM) derived from 3T3-L1 adipocytes, which express and secrete high apelin, human ovarian cancer cells with high APJ expression showed significant increases in migration and invasion in vitro. We also found that cells expressing high levels of APJ had increased cell adhesion to omentum ex vivo, and preferentially "home-in" on the omentum in vivo. These apelin-induced pro-metastatic effects were reversed by APJ antagonist F13A in a dose-dependent manner. Apelin-APJ activation increased lipid droplet accumulation in ovarian cancer cells, which was further intensified in the presence of AdipoCM and reversed by F13A or APJ knockdown. Mechanistically, this increased lipid uptake was mediated by CD36 upregulation via APJ-STAT3 activation, and the lipids were utilized in promoting fatty acid oxidation via activation of AMPK-CPT1a axis. Together, our studies demonstrate that adipocyte-derived apelin activates APJ-expressing tumor cells in a paracrine manner, promoting lipid uptake and utilization and providing energy for ovarian cancer cell survival at the metastatic sites. Hence, the apelin-APJ pathway presents a novel therapeutic target to curb ovarian cancer metastasis. IMPLICATIONS: Targeting the APJ pathway in high-grade serous ovarian carcinoma is a novel strategy to inhibit peritoneal metastasis.

VEGF-C mediates tumor growth and metastasis through promoting EMT-epithelial breast cancer cell crosstalk

It is well established that a subset of cells within primary breast cancers can undergo an epithelial-to-mesenchymal transition (EMT), although the role of EMT in metastasis remains controversial. We previously demonstrated that breast cancer cells that had undergone an oncogenic EMT could increase metastasis of neighboring cancer cells via non-canonical paracrine-mediated activation of GLI activity that is dependent on SIX1 expression in the EMT cancer cells. However, the mechanism by which these SIX1-expressing EMT cells activate GLI signaling remained unclear. In this study, we demonstrate a novel mechanism for activation of GLI-mediated signaling in epithelial breast tumor cells via EMT cell-induced production and secretion of VEGF-C. We show that VEGF-C, secreted by breast cancer cells that have undergone an EMT, promotes paracrine-mediated increases in proliferation, migration, and invasion of epithelial breast cancer cells, via non-canonical activation of GLI-signaling. We further show that the aggressive phenotypes, including metastasis, imparted by EMT cells on adjacent epithelial cancer cells can be disrupted by either inhibiting VEGF-C in EMT cells or by knocking down NRP2, a receptor which interacts with VEGF-C, in neighboring epithelial cancer cells. Interrogation of TCGA and GEO public datasets supports the relevance of this pathway in human breast cancer, demonstrating that VEGF-C strongly correlates with activation of Hedgehog signaling and EMT in the human disease. Our study suggests that the VEGF-C/NRP2/GLI axis is a novel and conserved paracrine means by which EMT cells enhance metastasis, and provides potential targets for therapeutic intervention in this heterogeneous disease.

Identification of signature genes associated with therapeutic resistance to anti-VEGF therapy

VEGF-mediated tumor angiogenesis is a validated clinical target in many cancers, but modest efficacy and rapid development of resistance are major challenges of VEGF-targeted therapies. To establish a molecular signature of this resistance in ovarian cancer, we developed preclinical tumor models of adaptive resistance to chronic anti-VEGF treatment. We performed RNA-seq analysis and reverse-phase protein array to compare changes in gene and protein expressions in stroma and cancer cells from resistant and responsive tumors. We identified a unique set of stromal-specific genes that were strongly correlated with resistance phenotypes against two different anti-VEGF treatments, and selected the apelin/APJ signaling pathway for further in vitro validation. Using various functional assays, we showed that activation of apelin/APJ signaling reduces the efficacy of a VEGF inhibitor in endothelial cells. In patients with ovarian cancer treated with bevacizumab, increased expression of apelin was associated with significantly decreased disease-free survival. These findings link signature gene expressions with anti-VEGF response, and may thus provide novel targetable mechanisms of clinical resistance to anti-VEGF therapies.

Abstract TMIM-070: APELIN PROMOTES OMENTAL METASTASIS OF OVARIAN CANCER CELLS

PURPOSE: Ovarian cancer (OvCa) is mainly metastasized to the peritoneal cavity and omentum, an organ primarily composed of adipocytes. Adipocytes produce adipokines including apelin involved in initiating angiogenesis and promote the initial homing of tumor cells to omentum through adipokine secretion. Apelin and its receptor APJ mediates glucose/energy metabolism and angiogenesis. The study objective is to assess the functional role of apelin/APJ pathway in omental metastasis of OvCa and associated benefits from antagonizing this pathway as a novel treatment strategy against OvCa metastasis.

METHODS: Mouse adipocyte cell line 3T3-L1 were used to obtain adipocyte-derived conditioned media (adipo-CM). Apelin concentrations in adipo-CM were quantified using Western blot and ELISA. Migration and invasion of human OvCa cell lines (OVCAR-5APJ and OVCAR-8) were determined in vitro in the presence of adipo-CM. In vivo homing and ex vivo adhesion assays were performed to study the role of apelin/APJ pathway in attracting and attaching APJ-overexpressing OvCa cells to the omentum.

RESULTS: Apelin expression was 2.5 fold higher in mature adipocytes compared to that in pre-adipocytes. Mature adipocytes secreted 0.8-1 ng/mL of apelin in the CM. In vivo, high APJ expression increased 'homing-in' of OvCa cells by 2.75-fold to the omentum. Adipo-CM increased transwell migration (3-3.5 fold) and invasion (3.5-4 fold) of OvCa cells in vitro. Adhesion of APJ high expression OvCa cells to mice omentum ex vivo increased by 1.5 fold. These apelin-induced pro-metastatic effects were reversed by apelin-specific antagonist (F13A) in a dose-dependent manner.

CONCLUSION: We found that apelin/ APJ pathway potentially promotes OvCa metastasis to omentum and F13A effectively inhibited apelin-induced effects.

Citation Format: Samrita Dogra, Deepika Neelakantan, Maulin Mukeshchandra Patel, Beth Griesel, Ann Olson, Florea Lupu, and Sukyung Woo1. APELIN PROMOTES OMENTAL METASTASIS OF OVARIAN CANCER CELLS [abstract]. In: Proceedings of the 12th Biennial Ovarian Cancer Research Symposium; Sep 13-15, 2018; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2019;25(22 Suppl):Abstract nr TMIM-070.

Abstract 5152: EMT cells increase the metastatic potential of neighboring carcinoma cells via non-canonical activation of GLI signaling through secretion of VEGF-C

Breast cancer is a devastating disease that claims around 50 million lives per year worldwide, and almost all of these deaths result from metastatic disease rather than from primary tumor burden. Recent studies clearly demonstrate that there is significant intratumor heterogeneity in breast cancer, and that this heterogeneity contributes to malignant progression. Our laboratories previously demonstrated that breast cancer cells that had undergone an oncogenic epithelial-to-mesenchymal transition (EMT) could increase metastasis of neighboring cells via activation of non-canonical GLI transcription factor activity in a paracrine manner that is dependent on Six1 expression in the EMT cells. However, the mechanism by which these Six1-expressing EMT cells activate GLI signaling thereby imparting aggressive properties on neighboring cells remained unknown. Herein we describe the novel discovery that VEGF-C, which is transcriptionally upregulated by Six1, mediates paracrine non-canonical activation of GLI and resultant enhancement of metastatic properties in cells that do not express Six1. Our data demonstrate that VEGF-C is upregulated in HMLER-Snail1 cells, MCF7-Six1 cells and in Met-1 cells endogenously expressing Six1, in a manner that depends on Six1 expression, and that VEGF-C is secreted into the conditioned media (CM) of these cells. Inhibition of VEGF-C in the HMLER-Snail1, MCF7-Six1, and the Met-1 models abrogates paracrine GLI activation and attenuates non-cell autonomous induction of proliferation, migration, and invasion in vitro. In vivo, we show that cells expressing Six1 can enhance the growth and metastasis of those not expressing Six1, and studies will be discussed that examine whether VEGF-C inhibition in Six1 expressing cells disrupts the crosstalk and inhibits non-cell autonomous induction of metastasis by Six1. Finally, by interrogating the TCGA dataset we find that VEGF-C and GLI1 expression significantly positively correlate in human breast cancer encompassing all molecular subtypes. Taken together, these data suggest that VEGF-C secretion may be a novel and conserved paracrine means by which EMT cells activate GLI in neighboring tumor cells that do not express these EMT-inducing transcription factors (TF), ultimately enhancing overall metastasis of heterogenous breast tumors.

Citation Format: Deguang Kong, Deepika Neelakantan, Hengbo Zhou, Michael T. Lewis, Heide L. Ford. EMT cells increase the metastatic potential of neighboring carcinoma cells via non-canonical activation of GLI signaling through secretion of VEGF-C [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5152.

Multifunctional APJ Pathway Promotes Ovarian Cancer Progression and Metastasis

High mortality rates in ovarian cancer are due to late-stage diagnosis when extensive metastases are present, coupled with the eventual development of resistance to standard chemotherapy. There is, thus, an urgent need to identify targetable pathways to curtail this deadly disease. In this study, we show that the apelin receptor, APJ, is a viable target that promotes tumor progression of high-grade serous ovarian cancer (HGSOC). APJ is specifically overexpressed in tumor tissue, and is elevated in metastatic tissues compared with primary tumors. Importantly, increased APJ expression significantly correlates with decreased median overall survival (OS) by 14.7 months in patients with HGSOC. Using various ovarian cancer model systems, we demonstrate that APJ expression in cancer cells is both necessary and sufficient to increase prometastatic phenotypes in vitro, including proliferation, cell adhesion to various molecules of the extracellular matrix (ECM), anoikis resistance, migration, and invasion; and these phenotypes are efficiently inhibited by the APJ inhibitor, ML221. Overexpression of APJ also increases metastasis of ovarian cancer cells in vivo. Mechanistically, the prometastatic STAT3 pathway is activated downstream of APJ, and in addition to the ERK and AKT pathways, contributes to its aggressive phenotypes. Our findings suggest that the APJ pathway is a novel and viable target, with potential to curb ovarian cancer progression and metastasis. IMPLICATIONS: The APJ pathway is a viable target in HGSOC.

CD147: a small molecule transporter ancillary protein at the crossroad of multiple hallmarks of cancer and metabolic reprogramming

Increased expression of CD147 in pancreatic cancer has been proposed to play a critical role in cancer progression via CD147 chaperone function for lactate monocarboxylate transporters (MCTs). Here, we show for the first time that CD147 interacts with membrane transporters beyond MCTs and exhibits a protective role for several of its interacting partners. CD147 prevents its interacting partner's proteasome-dependent degradation and incorrect plasma membrane localization through the CD147 transmembrane (TM) region. The interactions with transmembrane small molecule and ion transporters identified here indicate a central role of CD147 in pancreatic cancer metabolic reprogramming, particularly with respect to amino acid anabolism and calcium signaling. Importantly, CD147 genetic ablation prevents pancreatic cancer cell proliferation and tumor growth in vitro and in vivo in conjunction with metabolic rewiring towards amino acid anabolism, thus paving the way for future combined pharmacological treatments.

EMT cells increase breast cancer metastasis via paracrine GLI activation in neighbouring tumour cells

Recent fate-mapping studies concluded that EMT is not required for metastasis of carcinomas. Here we challenge this conclusion by showing that these studies failed to account for possible crosstalk between EMT and non-EMT cells that promotes dissemination of non-EMT cells. In breast cancer models, EMT cells induce increased metastasis of weakly metastatic, non-EMT tumour cells in a paracrine manner, in part by non-cell autonomous activation of the GLI transcription factor. Treatment with GANT61, a GLI1/2 inhibitor, but not with IPI 926, a Smoothened inhibitor, blocks this effect and inhibits growth in PDX models. In human breast tumours, the EMT-transcription factors strongly correlate with activated Hedgehog/GLI signalling but not with the Hh ligands. Our findings indicate that EMT contributes to metastasis via non-cell autonomous effects that activate the Hh pathway. Although all Hh inhibitors may act against tumours with canonical Hh/GLI signalling, only GLI inhibitors would act against non-canonical EMT-induced GLI activation.

Clonal cooperativity in heterogenous cancers

Tumor heterogeneity is a major obstacle to the development of effective therapies and is thus an important focus of cancer research. Genetic and epigenetic alterations, as well as altered tumor microenvironments, result in tumors made up of diverse subclones with different genetic and phenotypic characteristics. Intratumor heterogeneity enables competition, but also supports clonal cooperation via cell-cell contact or secretion of factors, resulting in enhanced tumor progression. Here, we summarize recent findings related to interclonal interactions within a tumor and the therapeutic implications of such interactions, with an emphasis on how different subclones collaborate with each other to promote proliferation, metastasis and therapy-resistance. Furthermore, we propose that disruption of clonal cooperation by targeting key factors (such as Wnt and Hedgehog, amongst others) can be an alternative approach to improving clinical outcomes.

Abstract 1586: Breast cancer cells overexpressing EMT-inducing transcription factors mediate metastasis of neighboring tumor cells via secretion of molecules that upregulate Hedgehog signaling

Breast cancers are known to be heterogeneous, and thus it is important to understand how different tumor subpopulations influence each other to mediate metastasis. Epithelial-mesenchymal transition (EMT) is known to facilitate metastasis in breast cancer, via enabling tumor cells to be more motile and invasive (amongst other properties), yet only a small population of cells within a tumor is thought to undergo EMT at any one time. Transcription factors (TFs) such as Twist1, Snail1, and Six1 induce EMT, and are all known to increase metastasis of numerous tumor types, but are not thought to be expressed uniformly throughout tumors. While the cell-autonomous function of these EMT regulators has been extensively studied, how cells expressing these TFs influence neighboring tumor cells remains unknown. We have found that co-culture of HMLER-WT and HMLER-Snail1/Twist1 cells leads to a significant increase in migration of HMLER-WT cells. Importantly, transfer of conditioned media (CM) from HMLER-Twist1 or HMLER-Snail1 cells to HMLER-WT cells leads to increased migration and invasion, and Six1 is required downstream of Twist1 and Snail1 to mediate these non-cell autonomous phenotypes. Similarly, CM from metastatic MCF7-Six1 cells, when placed on MCF7-control (Ctrl) cells, leads to an EMT in the control cells, as observed by downregulation of cytokeratin 18 and membranous E-cadherin and upregulation of fibronectin. Importantly, while MCF7-Ctrl cells are non-metastatic when injected orthotopically into mice, co-injection of metastatic MCF7-Six1 and MCF7-Ctrl cells into nude mice results in increased metastasis of the control cells. These data demonstrate that in a heterogenous tumor where a population of cells express EMT-inducing TFs, these cells can influence their neighbors to also undergo EMT, thus promoting their metastasis. More interestingly, we have found that the non-cell autonomous effects of EMT-inducing TFs Snail1 and Six1 are mediated by Hedgehog signaling, and that the secreted factors that lead to activation of this pathway can be different in different contexts, but all impinge on Gli activation as a critical means by which neighboring cells develop metastatic characteristics. Therefore, our data suggest that treatment of heterogenous tumors with downstream, rather than upstream, inhibitors of the Hedgehog signaling pathway will be more efficacious in treating metastatic progression in breast cancer, as the pathway can be activated by means not dependent on the ligands SHH, IHH, or DHH, nor on the canonical receptors.

Citation Format: Hengbo Zhou, Deepika Neelakantan, Heide L. Ford. Breast cancer cells overexpressing EMT-inducing transcription factors mediate metastasis of neighboring tumor cells via secretion of molecules that upregulate Hedgehog signaling. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1586.

TWIST1-Induced miR-424 Reversibly Drives Mesenchymal Programming while Inhibiting Tumor Initiation

Epithelial-to-mesenchymal transition (EMT) is a dynamic process that relies on cellular plasticity. Recently, the process of an oncogenic EMT, followed by a reverse mesenchymal-to-epithelial transition (MET), has been implicated as critical in the metastatic colonization of carcinomas. Unlike governance of epithelial programming, regulation of mesenchymal programming is not well understood in EMT. Here, we describe and characterize the first microRNA that enhances exclusively mesenchymal programming. We demonstrate that miR-424 is upregulated early during a TWIST1 or SNAI1-induced EMT, and that it causes cells to express mesenchymal genes without affecting epithelial genes, resulting in a mixed/intermediate EMT. Furthermore, miR-424 increases motility, decreases adhesion, and induces a growth arrest, changes associated with a complete EMT that can be reversed when miR-424 expression is lowered, concomitant with an MET-like process. Breast cancer patient miR-424 levels positively associate with TWIST1/2 and EMT-like gene signatures, and miR-424 is increased in primary tumors versus matched normal breast. However, miR-424 is downregulated in patient metastases versus matched primary tumors. Correspondingly, miR-424 decreases tumor initiation and is posttranscriptionally downregulated in macrometastases in mice, suggesting the need for biphasic expression of miR-424 to transit the EMT-MET axis. Next-generation RNA sequencing revealed miR-424 regulates numerous EMT and cancer stemness-associated genes, including TGFBR3, whose downregulation promotes mesenchymal phenotypes, but not tumor-initiating phenotypes. Instead, we demonstrate that increased MAPK-ERK signaling is critical for miR-424-mediated decreases in tumor-initiating phenotypes. These findings suggest miR-424 plays distinct roles in tumor progression, potentially facilitating earlier, but repressing later, stages of metastasis by regulating an EMT-MET axis.

Intratumoral heterogeneity: Clonal cooperation in epithelial-to-mesenchymal transition and metastasis

Although phenotypic intratumoral heterogeneity was first described many decades ago, the advent of next-generation sequencing has provided conclusive evidence that in addition to phenotypic diversity, significant genotypic diversity exists within tumors. Tumor heterogeneity likely arises both from clonal expansions, as well as from differentiation hierarchies existent in the tumor, such as that established by cancer stem cells (CSCs) and non-CSCs. These differentiation hierarchies may arise due to genetic mutations, epigenetic alterations, or microenvironmental influences. An additional differentiation hierarchy within epithelial tumors may arise when only a few tumor cells trans-differentiate into mesenchymal-like cells, a process known as epithelial-to-mesenchymal transition (EMT). Again, this process can be influenced by both genetic and non-genetic factors. In this review we discuss the evidence for clonal interaction and cooperation for tumor maintenance and progression, particularly with respect to EMT, and further address the far-reaching effects that tumor heterogeneity may have on cancer therapy.

Abstract B084: EMT-inducing transcription factors Twist1 and Snail1 non-cell autonomously increase metastatic properties of non-Twist1 or Snail1 expressing cells via induction of Six1

Breast cancer is the second leading cause of cancer related deaths in women and more than 90% of these deaths result from metastatic disease rather than from the primary tumor burden. The primary tumor itself is a heterogeneous mass of cells. Thus a better understanding of metastasis and cancer cell dynamics within the primary tumor will aid in developing efficient strategies to increase patient survival. Twist1 and Snail1 are two epithelial to mesenchymal transition (EMT)-inducing transcription factors (TF) that are known to increase metastasis through mechanisms that are cell autonomous. Our data demonstrate that these TFs can also non-cell autonomously increase in-vitro invasion and migration, as well as alter the expression of numerous genes and proteins associated with EMT, when conditioned medium (CM) taken from cells expressing these TFs is placed on cells not expressing the TFs. We show that the non-cell autonomous effects of Twist1 and Snail1 are in part induced via the ability of these TFs to up-regulate another known EMT related transcription factor, Six1. Indeed, we show that loss of Six1 downstream of these TFs mitigates their ability to non-cell autonomously influence EMT related characteristics including invasion and migration of non-metastatic non-TF expressing cells in-vitro, indicating that Six1 is a key player downstream of these TFs. Overexpression and knockdown of Six1 itself, in multiple mouse and human breast carcinoma cell lines non-cell autonomously influences invasion, migration, anoikis resistance, and alters the expression of EMT-related genes in the non-metastatic non-Six1 expressing cells in-vitro. We also show that Six1 expression in metastatic cells is sufficient to non-cell autonomously increase the metastatic potential of weakly metastatic, non Six1-expressing cells, when these cells are fluorescently tagged and co-injected into mice. We have identified several pro-metastatic cytokines, including IL-6 and Osteopontin, that are not only increased in CM from cells expressing Six1, but also have increased expression in cells expressing Twist1 and Snail1, in a manner that is dependent on Six1. We are currently assessing whether these cytokines play a role in the ability of Twist1, Snail1 and Six1 to mediate invasion, migration as well as metastasis of neighboring cells that do not express these EMT-inducing TFs. Importantly, EMT related transcription factors such as Six1, Twist1 and Snail1 are associated with poor prognosis and increased metastasis in breast cancer as well as in other cancers. Therefore, it is critical that we understand not only how these TFs mediate aggressive phenotypes in cells expressing these factors, but also how they mediate non-cell autonomous effects that contribute to increased metastasis of the neighboring non-TF expressing cells within the heterogeneous tumor.

Citation Format: Deepika Neelakantan, Ritsuko Iwanaga, David J. Drasin, Heide L. Ford. EMT-inducing transcription factors Twist1 and Snail1 non-cell autonomously increase metastatic properties of non-Twist1 or Snail1 expressing cells via induction of Six1. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research: Genetics, Biology, and Clinical Applications; Oct 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Res 2013;11(10 Suppl):Abstract nr B084.

Quality of life instruments in studies of chronic pelvic pain: a systematic review

The use of quality of life (QoL) instruments in chronic pelvic pain (CPP) will allow a more objective assessment of patient-centred clinical outcomes. However, there is concern that not enough emphasis is placed on clinical face validity (i.e. issues which are of importance to patients and reflect their experiences and concerns). To explore this issue, we performed a systematic review of published research. Relevant papers were identified through electronic scanning of six electronic databases and by manual searching of bibliographies of known primary and review articles. Studies were selected if they assessed women with CPP for life quality, either developing QoL instruments or applying them as an outcome measure. Selected studies were assessed for the quality of their QoL instruments using a 17-item checklist, including 10 items for clinical face validity and seven items for measurement (psychometric) properties. A total of 19 articles were eligible for inclusion in the review. The generic Short Form 36 Health Survey Questionnaire (SF-36) was used most frequently, being employed in 10/19 (53%) of the studies. Three studies developed disease-specific QoL instruments for CPP complying with 59 - 77% of the quality criteria. Overall, quality assessment showed that only 4/18 (22.2%) studies complied with more than half the criteria for face validity, whereas 12/18 (66.6%) studies complied with more than half of the criteria for measurement properties (P = 0.0001). Among existing QoL instruments, compliance with the quality criteria for measurement properties is higher than for clinical face validity. There is a need to develop disease specific QoL instruments for CPP with face validity in addition to sound measurement properties.

Role of rescue IVF-ET treatment in the management of high response in stimulated IUI cycles

Rescue in-vitro fertilisation and embryo transfer (IVF-ET) has been used in high response gonadotrophin intrauterine insemination (IUI) cycles to minimise the risks of ovarian hyperstimulation and multiple gestation. Such unplanned IVF treatment increases the cost of treatment. But can this added cost and the risks associated with IVF be justified? We present our experience with this treatment using clinical pregnancy and live birth rates as the primary outcomes. Between 1998 to 2001, 40 women undergoing IUI cycles who over responded (>3 follicles measuring >15 mm in diameter on the planned day of hCG administration) to gonadotrophin were offered the choice of conversion to IVF-ET or cancel the cycle. 17/40 declined rescue IVF/ET and had their cycles cancelled. 23/40 converted to IVF/ET and underwent transvaginal oocyte retrieval. 21/23 had embryo transferred. The clinical pregnancy and live birth rates were 52% and 48%, respectively. Rescue IVF-ET offers excellent clinical pregnancy and live birth rates in high responders. However, affordability can be an obstacle in the utilization of this treatment option.

Are the anticipated benefits of myomectomy achieved in women of reproductive age? A 5-year review of the results at a UK tertiary hospital

Fibroids are the most common benign tumours of the pelvis in women, with a prevalence estimated at 20-50%. They are more common towards the end of the reproductive years. There is a racial preponderance, being more common in black than white women. This may relate to the aetiology, which is still poorly understood. Generally, fibroids do not cause symptoms but some sufferers do complain about pressure symptoms, abnormal vaginal bleeding and infertility. For these reasons, myomectomy is often resorted to after failure of medical interventions on the premise that it brings about improvement/cure of symptoms and enhancement of fertility. However, the evidence for these indications for surgery is hazy. An analysis of the 109 medical records of symptomatic patients who had myomectomy over a 5-year period at a tertiary centre revealed the following. Single-symptom presentation in 41 (38%), menorrhagia in 20 (18%) being the most common. Only 52 (48%) patients had medical treatment of one form or another before myomectomy. Additional operative findings included pelvic adhesions, evidence of PID and endometriosis. Thirty-four (31%) had an estimated blood loss 500 ml and 23 of these patients needed blood transfusion. There were four cases of unscheduled hysterectomies due to uncontrollable bleeding. Pyrexia was the most common (38%) postoperative complication followed by superficial wound infection in 5%. We observed improvement of symptoms, assessed over a range of 2-24 months, in 34 cases (68%) in patients without fertility symptoms who accounted for 50 of these women. The symptomatic benefit was less (36%) in the 'infertility group'. Following an observation period of over 12-36 months, 17 patients in the 'infertility group' were lost to follow-up. Two (14%) of the 14 patients who attempted in vitro fertilisation (IVF) were successful. In the non-IVF group, 13 (46%) of the 28 achieved natural conception. These results suggest that symptomatic improvement and fertility enhancement may be possible in some patients with fibroids. In view of the risks and potential failure of treatment associated with myomectomy these results, yet again, support the fact that patients should be properly counselled before embarking on myomectomy and we strongly advocate local data to form the basis of the advice given during the consultation rather than what obtains in the literature.