Clinical characteristics of endometrioma with and without dysmenorrhea diagnosed by laparoscopy: A retrospective cohort study in a tertiary center

OBJECTIVE

Clinical characteristics of patients with endometrioma without dysmenorrhea have not been well delineated; our goal was to remedy this issue by performing a retrospective cohort study.

METHODS

A total of 379 patients who underwent laparoscopic surgery for endometrioma ≥4 cm at a tertiary hospital were included in this retrospective study. Patients were divided into two groups based on the presence of dysmenorrhea at the time of hospital visit; with dysmenorrhea group and without dysmenorrhea group.

RESULTS

Patients without dysmenorrhea comprised 9.5% of all surgically confirmed endometriomas. Significant differences were found in the revised American Society for Reproductive Medicine (rASRM) stage, age at surgery, and bilaterality. Patients with rASRM stage IV were more likely to have dysmenorrhea than were subjects with rASRM stage III (odds ratio (OR), 10.58; 95% confidence interval (CI), 4.63-24.21; P < 0.001). Older patients were less likely to have dysmenorrhea (OR, 0.94; 95% CI, 0.88-1.00; P = 0.045), as were patients with bilateral rather than unilateral endometrioma (OR, 0.36; 95% CI, 0.15-0.82; P = 0.015). No significant differences in cyst size, age at menarche, body mass index (BMI), parity, or history of previous ovarian surgery were found between the two groups.

CONCLUSION

Patients without dysmenorrhea comprised 9.5% of endometrioma cases and had less advanced rASRM stage, were older at surgery, and had a higher probability of bilateral than unilateral endometrioma than patients with dysmenorrhea.

Dienogest attenuates STAT3 activation in ovarian endometriotic cysts

OBJECTIVE

Recent studies have suggested that endometriosis could be the result of excessive activation of signal transducer and activator of transcription 3 (STAT3), which is associated with the regulation of essential cellular mechanisms such as proliferation, invasion, and apoptosis. That finding implies that regulating STAT3 activation could play a key role in treating endometriosis. In the present study, we aimed to evaluate whether the anti-endometriotic effects of dienogest is mediated by the regulation of STAT3 activation.

STUDY DESIGN

STAT3 activation was evaluated in normal endometrial and ovarian endometriotic tissues obtained from patients with/without preoperative dienogest treatment. A subsequent in vitro analysis with endometriotic cyst stromal cells (ECSCs) was used to confirm the direct influence of dienogest in STAT3 activation.

RESULT

STAT3 activation is significantly higher in endometriotic tissues from non-treated patients than in normal endometrial tissues, and that difference is reversed by preoperative administration of dienogest. Similarly, the inhibitory effects of dienogest on STAT3 activation are demonstrated by in vitro results showing that dienogest treatment significantly inhibits IL-6-stimulated STAT3 activation in cultured ECSCs. That inhibition was accompanied by decreased expression of proliferative (PCNA), invasive (MMP-2), and anti-apoptotic (BCL-2) proteins. Furthermore, downregulating STAT3 activity with siRNA decreased PCNA, MMP-2, and BCL-2 expression in IL-6-treated ECSCs.

CONCLUSION

Dienogest inhibits STAT3 activation in ECSCs, which affects their proliferation, invasiveness, and apoptosis.

Different effects of menopausal hormone therapy on non-alcoholic fatty liver disease based on the route of estrogen administration

The effects of menopausal hormone therapy (MHT) on non-alcoholic fatty liver disease (NAFLD) were compared based on the route of estrogen administration. The study included 368 postmenopausal women who received MHT for 12 months. Patients were divided into transdermal (n = 75) and oral (n = 293) groups based on the estrogen route. Changes in the prevalence of NAFLD were compared between the two groups before and after 12 months of MHT. In addition, differences in the progression of NAFLD after MHT based on the dose of estrogen and type of progestogen were evaluated in the oral group. After MHT, the prevalence of NAFLD decreased from 24 to 17.3% in the transdermal group but increased from 25.3 to 29.4% in the oral group. Little or no change was found in clinical characteristics and laboratory tests in the transdermal group during MHT. However, serum levels of total cholesterol and low-density lipoprotein cholesterol decreased and triglycerides and high-density lipoprotein cholesterol increased significantly in the oral group. Furthermore, changes in the prevalence of NAFLD were not significantly different based on the dose of estrogen or type of progestogen. Our findings indicate that transdermal estrogen can be beneficial in terms of NAFLD progression.

Clinical Characteristics of Gynecologic Problems During Childhood in the Korean Population

BACKGROUND

This study analyzed common gynecologic problems among Korean patients younger than ten years.

METHODS

We performed a retrospective analysis of medical records of patients younger than ten years who visited the Pediatric and Adolescent Gynecology Clinic at Samsung Medical Center between 1995 and 2020.

RESULTS

Among the 6,605 patients who visited the Pediatric and Adolescent Gynecology Clinic, data from 642 patients younger than ten years were analyzed in this study. The most common chief complaint was genital anomalies, followed by increased vaginal discharge and abnormal findings on clinical examinations. The most common disease entity was agglutination of the labia minora, which was commonly discovered incidentally during routine screenings. Vulvovaginitis, the second most common disease, was identified by symptoms of vaginal discharge, pruritus, and vaginal spotting. Neoplasm, issues with vaginal bleeding, and "other causes" were additional categories of gynecologic problems. 245 patients (38.2%) were referred from primary care sources, 175 patients (27.4%) sought care directly at the clinic, 169 patients (26.3%) were referrals from the institution's pediatric department, and the remainder were referrals from other departments.

CONCLUSION

This study provides information about the gynecologic problems most frequently encountered in pediatric patients. The study provides helpful insight for primary care physicians into the proper management and timing of referrals for these gynecologic problems of pediatric patients.

The current status of emergency contraception use in reproductive-aged Korean women: a population-based internet survey

Objective

This study was conducted to assess the current status of emergency contraception (EC) use in reproductive-aged Korean women.

Materials and methods

This study utilized a population-based, cross-sectional online survey using a self-completed questionnaire in women aged 20-44 years who had visited a clinic in the previous six months for contraception counseling. Reason for use, anxiety, and counseling for further contraception at EC use were analyzed according to age, history of childbirth, and contraceptive failure in EC users.

Results

Among 1,011 respondents, 461 (45.6%) had experience with EC use. Younger age, need for EC due to inadequate contraception, and high anxiety were highly prevalent among EC users. However, women in the 20s were less likely to get counseling for further contraception at EC use. Additionally, the proportions of women who used EC due to inadequate contraception during sexual intercourse and who experienced high anxiety were lower among women who had a history of childbirth. Women who had a history of contraceptive failure worried less about EC use.

Conclusion

Our findings offer insight for developing and improving individualized strategies for appropriate contraception, especially in young Korean EC users.

Comparison of goserelin and leuprorelin for ovarian protection during chemotherapy in young patients with breast cancer

PURPOSE

Although different gonadotropin-releasing hormone (GnRH) agonists may have different effects, their effect of ovarian protection during chemotherapy for breast cancer has not been compared. This study aimed to compare the effects of goserelin and leuprorelin for ovarian protection during chemotherapy in young patients with breast cancer.

METHODS

This prospective study analyzed 193 patients with breast cancer aged ≤ 40 years who had regular menstruation and serum anti-Müllerian hormone (AMH) levels ≥ 1 ng/mL before treatment. Patients received either goserelin or leuprorelin for ovarian protection during doxorubicin/cyclophosphamide-based chemotherapy. Resumption of menstruation and changes in serum levels of AMH were compared between the two groups at 12 months after completion of chemotherapy.

RESULTS

The mean age and the pretreatment serum AMH level were 33.2 years and 4.4 ng/mL in goserelin group and 34.2 years and 4.0 ng/mL in leuprorelin group. The proportion of patients who resumed menstruation was not different between the goserelin (94.4%) and leuprorelin (95.3%) groups at 12 months after chemotherapy completion. Serum AMH levels decreased significantly in both the goserelin (from 4.4 to 1.2 ng/mL) and leuprorelin (from 4.0 to 1.2 ng/mL) groups, with no statistical significance. In addition, no difference was found in the proportion of patients with serum AMH levels ≥ 1 ng/mL between the goserelin (49.5%) and leuprorelin (44.2%) groups at 12 months after chemotherapy.

CONCLUSION

Goserelin and leuprorelin were comparable in terms of ovarian protection during doxorubicin/cyclophosphamide-based chemotherapy in young patients with breast cancer.

Risk factors for the development of idiopathic macular hole: a nationwide population-based cohort study

This nationwide population-based cohort study searched for demographic, comorbid, behavioral, and reproductive risk factors for idiopathic macular hole (MH) development using data provided by the Korean National Health Insurance Service. A total of 4,496,867 individuals aged 50-79 years who participated in the Korean National Health Screening Program in 2013 or 2014 were included. Participants were followed up until December 2018, and incident cases of idiopathic MH were identified. Prospective associations between incident idiopathic MH and various covariates were investigated using multivariable-adjusted Cox proportional hazard models. During an average follow-up period of 4.91 years, 3054 patients were newly diagnosed with idiopathic MHs. Women showed greater risk (hazard ratio of 1.71) and earlier presentation of idiopathic MH than men. Compared to the normal body mass index group, the obese group (≥ 25 kg/m²) showed a significantly lower risk of idiopathic MH. Among postmenopausal women, those with two or more children showed a greater risk of idiopathic MH than those who had not been pregnant, with a hazard ratio of 1.80. In conclusion, idiopathic MH occurred earlier and greater in women. Childbirth were associated with an increased risk of MH development, and obesity was associated with a lower risk of MH.

Perceptions and Knowledge of Women Regarding Contraception and Current Trends in Contraceptive Use in Korea

PURPOSE

This study aimed to investigate the perceptions and behaviors of Korean women of reproductive age in regards to contraception counseling.

MATERIALS AND METHODS

The study sample was collected in Korea and comprised 1011 women aged 20-44 years and 150 obstetrics and gynecology (OB/GYN) doctors. Participants completed online questionnaires assessing their current methods of contraception, knowledge of and satisfaction with contraceptive methods, and willingness to learn about and use other contraceptive methods.

RESULTS

Women used condoms (74.2%), natural methods (cycle control or withdrawal, 52.4%), and combined oral contraceptives (COCs) (36.9%) more frequently than long-acting reversible contraception (LARC) methods, such as hormone-releasing intrauterine system (IUS) (4.5%), copper-intrauterine devices (3.3%), and subdermal implants (1.4%). Although the proportion of women who used LARC was low, those who used hormone-releasing IUS or subdermal implants reported high levels of satisfaction. The findings revealed discordant results between women and OB/GYN doctors regarding the initiation and quality of information provided by doctors about contraception and overall satisfaction with counseling. Most women (83.1%) expressed a desire to have more information about various contraceptive methods. More than 60% of women reported a willingness to use LARC, such as hormone-releasing IUS or subdermal implants, when provided with detailed information in counseling.

CONCLUSION

The majority of Korean women are familiar with condoms and natural methods, but lack knowledge about alternative contraceptive methods, including LARC. Women who used LARC reported higher levels of satisfaction than those who used other methods.

Efficacy of Post-Operative Medication to Prevent Recurrence of Endometrioma: Cyclic Oral Contraceptive (OC) After Gonadotropin-Releasing Hormone (GnRH) Agonist Versus Dienogest

BACKGROUND

There are several medical treatment options for endometrioma. Progestin, especially dienogest, is an effective drug for preventing recurrence of endometrioma after surgery. Additionally, oral contraceptive (OC) use after conservative surgery has been reported to reduce significantly the risk of endometrioma recurrence. The aim of this study was to compare the long-term effects of gonadotropin-releasing hormone (GnRH) agonist followed by OC to those of dienogest alone to prevent recurrence of endometrioma after laparoscopic surgery.

METHODS

A retrospective cohort study was performed on patients who underwent conservative laparoscopic surgery for endometrioma between January 2000 and December 2020, in the Endometriosis Clinic, Department of Gynecology, Samsung Medical Center. A total of 624 patients who received medical treatment at least six months after laparoscopic conservative surgery for endometrioma was included. Among them, 372 patients used OC after GnRH agonist therapy, and 252 patients used dienogest. Within the OC group, 148 used a 21/7 regiment and 224 used a 24/4 regimen. A cumulative endometrioma recurrence curve was presented using the Kaplan-Meier method to compare the recurrence of those groups.

RESULTS

The cumulative recurrence rate of endometrioma for 60 months was 2.08% (n = 4) in the OC after GnRH agonist group and 0.40% (n = 1) in the dienogest group. There was no statistical difference in cumulative recurrence of endometrioma between the two groups. In subgroup analysis, the cumulative recurrence rate of endometrioma over 60 months was 4.21% (n = 2) in the 21/7 OC group and 1.09% (n = 2) in the 24/4 OC group and showed no significant difference.

CONCLUSION

Long-term use of OC after GnRH agonist as well as that of dienogest treatment are effective postoperative medical therapies for preventing endometrioma recurrence. Thus, the choice of regimen can be individualized or used interchangeably depending on patient condition, need for contraception, and compliance with drug therapy.

Inhibition of the NLRP3 inflammasome by progesterone is attenuated by abnormal autophagy induction in endometriotic cyst stromal cells: implications for endometriosis

The NOD-like receptor pyrin domain containing 3 (NLRP3) inflammasome is a cytosolic multi-protein complex that induces inflammation and is known to be regulated negatively by autophagy. Previous studies reported an abnormal induction of autophagy linked to progesterone resistance in human endometriotic cells. Therefore, an aberrant autophagy induction response to progesterone might contribute to the altered inflammatory response observed in endometriotic tissues. To evaluate this hypothesis, we elucidate whether regulation of the NLRP3 inflammasome by ovarian steroids is mediated by autophagy in human endometrial stromal cells (NESCs) from patients with uterine leiomyoma (presumed normal) and whether abnormal autophagy induction in endometriotic cyst stromal cells (ECSCs) affects NLRP3 inflammasome-induced interleukin-1β (IL-1β) production. Our results show that estrogen enhanced NLRP3 inflammasome activation in NESCs, resulting in increased IL-1β production. Progesterone decreased NLRP3 inflammasome activity with an increase in autophagy induction in estrogen-treated NESCs. Inhibition of NLRP3 inflammasome activity by progesterone was blocked by autophagy inhibition. However, progesterone failed to change NLRP3 inflammasome activity and autophagy induction in estrogen-treated ECSCs. By contrast, dienogest, a specific progesterone receptor agonist, reduced NLRP3 inflammasome-mediated IL-1β production through autophagy induction in ECSCs. Furthermore, autophagy induction was decreased and NLRP3 inflammasome activity was increased in endometriotic tissues, which was reversed by pre-operative administration of dienogest. In conclusion, our results suggest that progesterone inhibits NLRP3 inflammasome activation through autophagy in endometrial stromal cells. However, this inhibitory effect is attenuated in endometriotic stromal cells due to an aberrant autophagic response to progesterone, which could lead to an altered inflammatory response in endometriosis.

Nuclear factor-kappa B signaling in endometriotic stromal cells is not inhibited by progesterone owing to an aberrant endoplasmic reticulum stress response: a possible role for an altered inflammatory process in endometriosis

Endoplasmic reticulum (ER) stress serves as a key modulator of the inflammatory response by controlling nuclear factor-kappaB (NF-κB) signaling. Previous studies from our laboratory have reported an abnormal induction of ER stress linked to progesterone resistance in human endometriotic cells. Therefore, an aberrant ER stress response to progesterone might contribute to the altered inflammatory response observed in endometriotic tissues. To evaluate this hypothesis, we investigated whether ER stress is involved in regulation of NF-κB in endometrial stromal cells and whether induction of aberrant ER stress in endometriotic stromal cells affects pro-inflammatory cytokine production. We found that tunicamycin-induced ER stress inhibited NF-κB activation and pro-inflammatory cytokine (IL-6 and COX2) production in TNF-α- or IL-1β-treated normal endometrial stromal cells (NECSs). Tunicamycin increased the expression of A20 and C/EBPβ, which are negative regulators of NF-κB, and this increase inhibited NF-κB activity in NESCs incubated with TNF-α or IL-1β. Similarly, progesterone increased A20 and C/EBPβ expression through upregulation of ER stress in NESCs, resulting in inhibition of NF-κB activity and IL-6 and COX2 production. However, progesterone had no significant effects on induction of ER stress, A20 or C/EBPβ expression, NF-κB activity or IL-6 or COX2 production in ovarian endometriotic cyst stromal cells (ECSCs). In contrast, upregulation of ER stress by tunicamycin significantly reduced IL-6 and COX2 production by inhibiting NF-κB activity in ECSCs. In conclusion, our results suggest that NF-κB activity in endometriotic stromal cells was not inhibited because of an aberrant ER stress response to progesterone, resulting in an increase in pro-inflammatory cytokine production.

Dienogest regulates apoptosis, proliferation, and invasiveness of endometriotic cyst stromal cells via endoplasmic reticulum stress induction

Dienogest, a specific progesterone receptor agonist, is used in the treatment of endometriosis. However, it is still unclear as to the mechanisms of therapeutic effects on endometriosis. Our recent study showed that endometriosis may be the result of aberrant endoplasmic reticulum (ER) stress induction due to progesterone resistance. This finding suggests that the regulation of ER stress induction may play a key role in treatment of endometriosis. Therefore, the anti-endometriotic effects of dienogest may be mediated by regulation of ER stress. To test this hypothesis, we elucidate whether dienogest affects endometriotic stromal cell apoptosis, proliferation and invasiveness by modulating ER stress-induced CCAAT/enhancer-binding protein homologous protein (CHOP) expression. Specifically, PRKR-like ER kinase (PERK)/eukaryotic initiation factor 2α (eIF2α)/activating transcription factor 4 (ATF4), inositol-requiring kinase 1 (IRE1)/TNF receptor-associated factor 2 (TRAF2)/apoptosis signal-regulating kinase 1 (ASK1)/c-Jun N-terminal kinase (JNK) signaling, and downstream CHOP were evaluated to determine the involved ER stress-mediated regulation mechanism of CHOP expression. Our results show that progesterone treatment did not have any significant effects on ER stress, apoptosis, proliferation, and invasion in estrogen-treated endometriotic cyst stromal cells (ECSCs). However, dienogest treatment upregulated the induction of ER stress. It also led to increased apoptosis, and decreased proliferation and invasiveness. These dienogest-induced changes in apoptosis, proliferation and invasiveness were reversed by the ER stress inhibitor salubrinal. Furthermore, dienogest-induced ER stress increased CHOP expression through activation of both PERK/elf2α/ATF4 and IRE1/TRAF2/ASK1/JNK signaling. This upregulation was blocked by transfection with PERK and IRE1 siRNA, which decreased apoptosis and increased the proliferation and invasiveness of dienogest-treated ECSCs. Taken together, our findings indicate that dienogest enhances ER stress induction in endometriotic stromal cells, which affects apoptosis, proliferation and invasiveness via CHOP upregulation.

The Long-Term Effect of Dienogest on Bone Mineral Density After Surgical Treatment of Endometrioma

The aim of this study was to evaluate the changing pattern of bone mineral density (BMD) levels after 3 years of dienogest use post endometrioma surgery and investigate the possible predictive factors for BMD reduction. This retrospective study included 44 reproductive-aged women who took dienogest (2 mg/day) and followed up BMD for 3 years after laparoscopic endometrioma surgery from July 2013 to December 2018. In addition, to investigate the predictive factors in the group with decreased BMD, analysis was added for patients with decreased BMD after taking dienogest for 1 year post laparoscopic endometrioma surgery. After 3 years of treatment with dienogest, BMD of both the lumbar spine (- 4.4%) and femur neck (- 3.6%) decreased significantly compared to the baseline levels. Bone loss predominantly occurred during the first year of treatment in the lumbar spine (- 2.4%) and gradually decreased with time during the treatment period. The predictive factors for BMD reduction after dienogest use were evaluated based on a 1-year change in BMD levels of 160 women, but no associated factors were found. This study demonstrated that dienogest use for 3 years was associated with a significant and gradual decrease in BMD and no predictive factors for BMD reduction during the first year of treatment with dienogest were found. These results may be useful in counseling patients regarding long-term effects of dienogest use on reducing BMD levels so that appropriate preventive measures can be taken.

Effect of Tissue-Selective Estrogen Complex on Hip Structural Geometry in Postmenopausal Women: A 12-Month Study

BACKGROUND

Hip structural analysis (HSA) is a method for evaluating bone geometry reflecting bone structural and biomechanical properties. However, tissue-selective estrogen complex (TSEC) treatment effects on HSA have not been investigated.

OBJECTIVE

This study was performed to evaluate the effect of TSEC treatment on hip geometry in postmenopausal Korean women. The treatment was given for 12 months, and hip geometry was measured by HSA.

MATERIALS AND METHODS

A total of 40 postmenopausal women who received TSEC containing conjugated estrogen 0.45 mg and bazedoxifene 20 mg for treating vasomotor symptoms were included in this retrospective cohort study. The changes in bone mineral density and parameters of HSA including the outer diameter, cross-sectional area, cross-sectional moment of inertia, cortical thickness, section modulus, and buckling ratio as determined by dual-energy X-ray absorptiometry were compared before and after 12 months of TSEC treatment.

RESULTS

Mean age and years since menopause were 55.1 and 4.5 years, respectively. Total hip bone mineral density significantly increased by 0.74% after treatment (P=0.011). The changes in HSA were mainly demonstrated in the narrow femoral neck: cross-sectional area (P=0.003) and cortical thickness (P<0.001) increased significantly. For the shaft region, only SM decreased significantly after treatment (P=0.009). However, most parameters did not change significantly with TSEC treatment in the intertrochanteric and shaft regions.

CONCLUSIONS

Our findings demonstrate that 12 months of TSEC treatment could improve bone geometry as measured by HSA. The findings suggest that TSEC might be an interesting option for the prevention of fracture as well as osteoporosis in postmenopausal women.

Appropriate Age for Height Control Treatment in Patients With Marfan Syndrome

OBJECTIVE

This study aimed to determine the most appropriate age for height control treatment in patients with Marfan syndrome (MFS).

MATERIALS AND METHODS

This retrospective study included patients with MFS who underwent height control treatment with estradiol valerate. The estrogen dose was increased according to the height change. The cut-off age for the maximum difference between the expected height and actual final height was evaluated.

RESULTS

Seventeen patients were included in this study. The difference between the height predicted by the growth curve and the final height (gcHtD) and that predicted by the bone age and the final height (baHtD) was the largest in the 10.5 years age group (p=0.0045 and p=0.0237, respectively). The gcHtD was 10.6 (10.2, 13.5) cm for patients aged ≤10.5 years, whereas it was 0.6 (-3.65, 5.85) cm for patients aged >10.5 years. The baHtD was 10.1 (7.31, 11.42) cm for patients aged ≤10.5 years, while it was 3.83 (0.84, 6.4) cm for patients aged >10.5 years. When height change was observed for a minimum of 6 months after completion of estrogen treatment, the average growth was 0.6 (0.2, 2.1) cm.

CONCLUSION

Initiating height control treatment before the age of 10.5 years is effective in female patients with MFS.

Involvement of endoplasmic reticulum stress in regulation of endometrial stromal cell invasiveness: possible role in pathogenesis of endometriosis

Endoplasmic reticulum (ER) stress is known to reduce invasiveness in some cancer cells by inhibiting the AKT/mTOR pathway. A previous study from our laboratory suggested that ER stress is promoted by progesterone in human endometrial cells, which suggests that progesterone may inhibit endometrial cell invasiveness by up-regulating ER stress. Therefore, aberrant ER stress in response to progesterone may contribute to the altered invasiveness found in endometriotic tissues. To test this hypothesis, we elucidate whether ER stress is involved in regulation of human endometrial cell invasiveness through the AKT/mTOR pathway and if this involvement is associated with altered invasiveness in endometriotic cells. Specifically, we sought to determine the effects of ER stress on AKT/mTOR pathway by evaluating ER stress-mediated CHOP/TRIB3 signaling, a negative regulator of AKT. We found that ER stress marker GRP78 expression increased with CHOP and TRIB3 expression in normal endometrial stromal cells (NESCs) treated with tunicamycin, and this increase was accompanied by decreased AKT and mTOR activity and cellular invasiveness. Similarly, progesterone increased GRP78, CHOP and TRIB3 expression in NESCs. Subsequently, inhibition of AKT and mTOR activity decreased cellular invasiveness. This progesterone-induced decrease in cellular invasiveness was reversed by inhibition of ER stress. In contrast, progesterone did not change CHOP, TRIB3, AKT, mTOR or invasiveness in endometriotic cyst stromal cells. In contrast to normal endometrium, endometriotic tissues showed no changes in CHOP, TRIB3 and invasion-related proteins (MMP2 and MMP9) expression throughout the menstrual cycle. Taken together, our findings indicate that abnormal ER stress response to progesterone increased endometriotic stromal cell invasiveness via the AKT/mTOR pathway.

The Efficacy of Long-Term Estrogen Replacement Therapy in Turner Syndrome Women with Premature Ovarian Insufficiency

STUDY OBJECTIVE

To evaluate the efficacy of long-term estrogen replacement therapy (ERT) in uterine development and bone mineral density (BMD) of Turner syndrome (TS) women with premature ovarian insufficiency (POI).

DESIGN AND SETTING

Retrospective study.

PARTICIPANTS AND INTERVENTIONS

Thirty-seven TS women grouped according to ovarian function status: TS women with POI (n = 32), aged 11-26 years, and those with intact ovarian function (IOF; n = 5), aged 13-17 years. TS women with POI underwent ERT.

MAIN OUTCOME MEASURES

Changes in uterine length, anterior-posterior (AP) fundal diameter of the uterus, and BMD were assessed. Statistical methods included Mann-Whitney U test and paired t test.

RESULTS

In TS women with POI, uterine length, AP fundal diameter, and BMD significantly increased after ERT (P < .001). TS women with POI were subdivided into classic (n = 11) and variant (n = 21) types, and there were no significant differences in uterine development and BMD according to types of chromosome. After receiving ERT, AP fundal diameter was significantly longer in classic TS women (P = .034) compared with those with variant type.

CONCLUSION

Long-term ERT increased uterine length (before: 4.4 cm; after: 7.2 cm) and AP fundal diameter (before: 0.9 cm; after: 2.4 cm), and improved BMD in TS women with POI. After ERT, in TS women with POI, uterine length, BMD at lumbar 2-4 and femoral neck were similar to those of TS women with IOF. Therefore, TS women with POI can catch up to those with IOF by receiving ERT.

Clinical and design factors influence the survivorship of custom flange acetabular components

AIMS

Custom flange acetabular components (CFACs) are a patient-specific option for addressing large acetabular defects at revision total hip arthroplasty (THA), but patient and implant characteristics that affect survivorship remain unknown. This study aimed to identify patient and design factors related to survivorship.

PATIENTS AND METHODS

A retrospective review of 91 patients who underwent revision THA using 96 CFACs was undertaken, comparing features between radiologically failed and successful cases. Patient characteristics (demographic, clinical, and radiological) and implant features (design characteristics and intraoperative features) were collected. There were 74 women and 22 men; their mean age was 62 years (31 to 85). The mean follow-up was 24.9 months (sd 27.6; 0 to 116). Two sets of statistical analyses were performed: 1) univariate analyses (Pearson's chi-squared and independent-samples Student's t-tests) for each feature; and 2) bivariable logistic regressions using features identified from a random forest analysis.

RESULTS

Radiological failure and revision rates were 23% and 12.5%, respectively. Revisions were undertaken at a mean of 25.1 months (sd 26.4) postoperatively. Patients with radiological failure were younger at the time of the initial procedure, were less likely to have a diagnosis of primary osteoarthritis (OA), were more likely to have had ischial screws in previous surgery, had fewer ischial screw holes in their CFAC design, and had more proximal ischial fixation. Random forest analysis identified the age of the patient and the number of locking and non-locking screws used for inclusion in subsequent bivariable logistic regression, but only age (odds ratio 0.93 per year) was found to be significant.

CONCLUSION

We identified both patient and design features predictive of CFAC survivorship. We found a higher rate of failure in younger patients, those whose primary diagnosis was not OA, and those with more proximal ischial fixation or fewer ischial fixation options. Cite this article: Bone Joint J 2019;101-B(6 Supple B):68-76.

The Effects of Menopausal Hormone Therapy on Serum Level of C-reactive Protein in Postmenopausal Korean Women

Objectives

Inflammation is a major mechanism underlying coronary heart disease (CHD) and C-reactive protein (CRP) is a marker of inflammation. When administered soon after menopause, menopausal hormone therapy (MHT) prevents CHD. This study was conducted to examine the impact of estrogen by administration route on CRP in postmenopausal Korean women using micronized progesterone (MP4) for endometrial protection.

Methods

This retrospective cohort study included 129 healthy women without CHD risk factors. Eighty-nine women took oral estrogen (conjugated equine estrogen, 0.625 mg/day or equivalent), and 40 women applied a 1.5-mg/day 0.1% percutaneous estradiol gel. MP4 was added in 82 women with an intact uterus. The CRP level was measured at baseline and three and six months after initiation of MHT.

Results

The baseline characteristics were comparable between the MHT groups except current age and age at menopause. After controlling for age, menopausal age, body mass index, and basal CRP, no significant change in CRP was observed in the oral estrogen group (n = 29). Follow-up CRP levels were also similar to the baseline in the percutaneous estrogen group (n = 18). However, three-month CRP was significantly lower than six-month CRP, and there was a significant time trend within the percutaneous estrogen group. However, the group difference did not reach statistical significance. CRP also did not differ by addition of MP4 in either group.

Conclusions

In postmenopausal Korean women, no change in CRP was observed with oral estrogen, while percutaneous estrogen might decrease CRP. The estrogenic impacts were not influenced by adding MP4.

Comparison of long-term use of combined oral contraceptive after gonadotropin-releasing hormone agonist plus add-back therapy versus dienogest to prevent recurrence of ovarian endometrioma after surgery

OBJECTIVE

The aim of this study was to compare long-term use of combined oral contraceptive (COC) after gonadotropin-releasing hormone (GnRH) agonist plus add-back therapy with dienogest (DNG) treatment as medical treatments after surgery for ovarian endometrioma.

METHODS

This prospective cohort study analyzed 52 reproductive-aged women who underwent surgery for ovarian endometrioma and received postoperative medical treatment with either COC after GnRH agonist (n = 20) or DNG (n = 32) for 24 months. Changes in quality-of-life (QOL) and bone mineral density (BMD) were compared according to treatment. In addition, recurrence of pain and lesions were compared.

RESULTS

Baseline characteristics did not differ in demographic profiles and factors associated with endometriosis or QOL. During 24 months of treatment, no differences in any component of QOL were found between the two groups. BMD at the lumbar spine significantly decreased after the first 6 months of treatment in both COC after GnRH agonist (-3.5%) and DNG (-2.3%) groups, but the groups did not differ statistically. After 6 months, further decrease in BMD was not observed until 24 months in both groups. In addition, no cases of pain or endometrioma recurrence were found.

CONCLUSION

Our results suggest that long-term use of COC after GnRH agonist plus add-back therapy is comparable to dienogest as a long-term postoperative medical treatment for endometriosis.

Association of BRCA Mutations and Anti-müllerian Hormone Level in Young Breast Cancer Patients

Background: Several preclinical and clinical studies have suggested that BRCA-mutation carriers may have decreased ovarian reserve. However, data in this area are limited and inconsistent, especially in young breast cancer patients. Objective: This study evaluated the association between BRCA mutation status and serum anti-Müllerian hormone (AMH) level in young, reproductive-aged patients with breast cancer. Materials and Methods: Patients ≤ 40 years of age with breast cancer and who had known BRCA status and baseline serum AMH level at Samsung Medical Center, Seoul, Korea, were considered for inclusion. A total of 52 BRCA mutation carriers (27 BRCA1 and 25 BRCA2) and 264 non-carriers were selected for analyses. The serum level of AMH was compared according to presence of a BRCA mutation, and linear and logistic regression analyses were performed to evaluate the association between BRCA mutation and serum AMH level. Results: No difference was found in clinical characteristics between BRCA-mutation carriers and non-carriers. Subjects with any BRCA mutation had a significantly lower median AMH than those without a mutation (2.60 vs. 3.85 ng/mL, 32% reduction, P = 0.004). Linear regression analysis showed a significant negative association between BRCA mutation and AMH level. In addition, logistic regression demonstrated non-significantly increased odds of mutation carriers having AMH < 1.2 ng/mL. However, no difference was found between BRCA1/2 mutations. Conclusions: Breast cancer patients with BRCA mutation have significantly lower serum AMH level. Fertility preservation should be considered more aggressively in young breast cancer patients with BRCA mutation.

Usefulness of repeat pelvic ultrasonography before surgery for benign ovarian mass

OBJECTIVE

To evaluate the results of repeat pelvic ultrasonography before surgery in patients with suspicion of benign ovarian tumor.

METHODS

A retrospective study included premenopausal women who were scheduled to undergo surgery for a benign-appearing ovarian mass and who had repeat ultrasonography on the day before surgery at Samsung Medical Center, Seoul, South Korea, between January 1, 2007, and December 31, 2011, to check for any change in the mass. Ultrasonography findings and final histology were evaluated by medical record review.

RESULTS

Of 1854 women studied, regression of mass was detected before surgery for 27 patients, and 105 patients had histologically proven functional cysts; considered together, 132 patients had functional cysts, and the remaining 1722 women had benign ovarian tumors. Evaluation of the findings of initial ultrasonography revealed that mean size (P=0.008) and proportion of bilateral cysts (P<0.001) were lower in the presence of functional cysts than benign tumors. Additionally, an anechoic pattern was more common among regressed functional cysts than among histologically proven functional cysts (P<0.001). In total, 105 (5.7%) patients required surgery for a functional cyst despite repeat ultrasonography.

CONCLUSION

Repeating ultrasonography prior to surgery may have only a limited ability to prevent unnecessary surgeries for functional cysts.

Prediction of ovarian function recovery in young breast cancer patients after protection with gonadotropin-releasing hormone agonist during chemotherapy

PURPOSE

This study evaluated predictive factors for recovery of ovarian function after ovarian protection by GnRH agonist during chemotherapy in young breast cancer patients.

METHODS

This prospective cohort study analyzed 105 young breast cancer patients who were studied longitudinally after receiving GnRH agonist during cyclophosphamide-based chemotherapy for ovarian protection. Associations between pretreatment hormones, clinical factors, and recovery of ovarian function (resumption of menstruation or anti-Müllerian hormone (AMH) ≥ 1 ng/ml) were evaluated at 12 months and long-term follow-up after completion of chemotherapy.

RESULTS

Mean age was 32 years (range 23-42 years). In multivariate analyses, tamoxifen use (P = 0.035) and pretreatment follicle-stimulating hormone (FSH) (P = 0.032) were predictive of resumption of menstruation, and age (P = 0.019), tamoxifen use (P = 0.022), pretreatment FSH (P < 0.001), and AMH (P = 0.040) were predictors for AMH ≥ 1 ng/ml at 12 months. In addition, pretreatment AMH was a predictor for AMH ≥ 1 ng/ml after long-term follow-up. Receiver operating characteristic curve analyses gave area under the curve of 0.805 for resumption of menstruation and 0.903 for serum AMH concentration ≥ 1 ng/ml at 12 months, when age, tamoxifen use, pretreatment FSH, and AMH were combined.

CONCLUSION

Pretreatment AMH (3.26 ng/ml), age (33.9 years), pretreatment FSH (5.5 IU/l), and tamoxifen use are useful predictors for AMH ≥ 1 ng/ml at 12 months after GnRH agonist. This finding will support patient and clinician decision-making regarding fertility preservation.

Abstract P6-07-10: The ERβ4 variant induce transformation of the normal breast mammary epithelial cell line MCF-10A; the ERβ variants ERβ2, ERβ4 and ERβ5 increase aggressiveness of TNBC by regulation of hypoxic signaling

Triple negative breast cancer (TNBC) still remains a challenge to treat in the clinic due to a lack of good targets for treatment. Although TNBC lacks expression of ERα, the expression of ERβ and its variants are detected quite frequently in this cancer type and can represent an avenue for treatment. We show that the variants of ERβ, namely ERβ1, ERβ2, ERβ4, and ERβ5, regulate aggressiveness of TNBC by regulating hypoxic signaling. RNA-seq of patient derived xenografts (PDX) from TNBC show expression of ERβ4 and ERβ5 variants in more than half of the samples. Furthermore, expression of ERβ4 in the immortalized, normal mammary epithelial cell line MCF-10A that is resistant to mammosphere formation caused transformation and development of mammospheres. By contrast, ERβ1, ERβ2 or ERβ5 were unable to support mammosphere formation. We have previously shown that all variants except ERβ1 stabilizes HIF-1α but only ERβ4 appear to have the ability to transform normal mammary epithelial cells, pointing towards a unique property of ERβ4. We propose that ERβ variants may be good diagnostic tools and also serve as novel targets for treatment of breast cancer.

Citation Format: Faria M, Karami S, Granados-Principal S, Dey P, Verma A, Choi DS, Elemento O, Bawa-Khalfe1 T, Chang JC, Gustafsson J-A, Strom AM. The ERβ4 variant induce transformation of the normal breast mammary epithelial cell line MCF-10A; the ERβ variants ERβ2, ERβ4 and ERβ5 increase aggressiveness of TNBC by regulation of hypoxic signaling [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-07-10.

LPS-induced cortical kynurenic acid and neurogranin-NFAT signaling is associated with deficits in stimulus processing during Pavlovian conditioning

The N-Methyl-d-Aspartate receptor (NMDAR) antagonist kynurenic acid (KYNA) and the post-synaptic calmodulin binding protein neurogranin (Nrgn) have been implicated in neurological and neuropsychiatric conditions including Alzheimer's disease and schizophrenia. This study indicates that systemic dual-lipopolysaccharide (LPS) injections increases KYNA in the medial prefrontal cortex (mPFC), which is accompanied with increased phosphorylation of nuclear factor kappa chain of activated B cells (NFκB) and activation of the nuclear factor of activated T- cells (NFAT). Our results also indicate that dual-LPS increases Nrgn phosphorylation and concomitantly reduces phosphorylation of calmodulin kinase-II (CaMKII). We confirmed that systemic blockade of kynurenine-3 monooxygenase in conjunction with kynurenine administration results in significant increases in Nrgn phosphorylation and a significant reduction of CaMKII phosphorylation in the mPFC. Consequently, dual-LPS administration induced significant impairments in stimulus processing during Pavlovian conditioning. Taken together, our study indicates that elevations in KYNA in the mPFC can directly regulate NMDA-Nrgn-CaMKII signaling, suggesting that neuroinflammatory conditions affecting this pathway may be associated with cognitive dysfunction.

Effects of long-term postoperative dienogest use for treatment of endometriosis on bone mineral density

OBJECTIVE

This study was conducted to evaluate the effects of long-term postoperative dienogest (DNG) use for the treatment of endometriosis on bone mineral density (BMD).

STUDY DESIGN

Sixty reproductive-aged women who underwent conservative surgery for endometriomas and received postoperative DNG (2mg/day) for at least 12 months to prevent recurrence were analyzed. BMD was measured before and after DNG treatment by using dual energy X-ray absorptiometry, and changes in BMD were evaluated.

RESULTS

Mean patient age was 30.5 years, and mean duration of DNG treatment was 18.6 months. BMD at the lumbar spine significantly decreased after the first 6 months (-2.2%), and 1year (-2.7%) of DNG treatment, compared to baseline. The proportion of women who had significantly decreased BMD at the lumbar spine after 1year was 75% (45/60). In addition, BMD at the femur neck also decreased significantly after 1year (-2.8%). BMDs after 2 years were not different from those after 1year at both sites in 24 women who received DNG for ≥2years. In addition, there were no differences in baseline characteristics between women who had significantly reduced BMD at the lumbar spine after 1year (N=45) and women who did not (N=15).

CONCLUSION

This study suggests that long-term postoperative DNG treatment might have an adverse effect on BMD in reproductive-aged women. Bone loss mostly occurs during the first 6 months of treatment with DNG. A clinical trial is warranted to establish the effects of long-term DNG treatment on bone mass.

Abstract P6-14-02: An anti-PD1 antibody-based therapy results in dramatic reduction of TNBC PDX tumors in humanized mice models

Recently, the field of cancer immunotherapy has seen a rapid growth based on a better understanding of the complex interplay between the tumor and the immune system. Although for long time breast cancer has been considered non-immunogenic and patients have seen limited options to immunotherapies, new strategies have changed this paradigm. In the present study, we aimed to test the in vivo activity of a human anti-PD1 antibody against the TNBC tumor line MC1. One of the main limitations of performing laboratory-based in vivo studies resides in the availability of the appropriate animal models. To circumvent these obstacles, we used patient-derived breast cancer tumor lines xenografts (PDX) from our existing collection previously established in immuno-compromised SCID/beige mice. Low-passage fresh xenograft tumor fragments of the TNBC tumor lines MC1 and HM#2147 were transplanted into the cleared fat pad of recipient non-humanized (non-hNSG) and humanized NSG (hNSG) mice. Humanized mice were obtained by i.v. injecting 3-4 weeks old NSG mice with CD34+ hematopoietic stem cells (HSC) following whole body radiation. Flow cytometry and immuno-histochemistry analyses of hNSG blood, spleen and bone marrow showed the presence of human CD45+ (15.1% ± 10.3; 61.5% ± 19.1; 71.9% ± 17.9; respectively), CD20+, CD3+, CD8+, CD68+, and CD33+ cells. BC tumor engraftment was then evaluated by comparing the growth of the MC1 tumor line in non- and hNSG mice, showing a slower growth in the corresponding humanized mice. Importantly, the presence of hCD45+ cells was readily detectable in all the hNSG-derived tumors, localizing both toward the periphery of the tumors and inside them. Analysis of hCD45+ subpopulation cells showed also the tumor presence of hCD20+ cells (B cells), hCD8+ T-cells and CD68+ (macrophages) cells. To determine whether BC PDX may have conserved the capability to metastasize to the lung, hNSG mice were engrafted with the tumor line HM#2147. Once the primary tumor reached the maximum volume allowed by humane standards, mice humanization levels, tumor engraftment and lung metastasis were evaluated. Humanized engrafted mice showed same levels of human cells and primary tumor engraftment as those harboring MC1 PDXs. Macroscopically, lungs displayed clear evidence of metastases. IHC assays using Ki67 and CK19 identified the microscopic region corresponding to its localization. Importantly, as described in the primary breast tumor, the presence of hCD45+ was also observed infiltrating the lung metastatic tumor. The efficacy of an anti-PD1 therapy was then evaluated. Levels of tumor PD-L1 were determined by western blot showing high levels of expression. Animals were weekly i.p.-administered either the human anti-PD1 antibody or vehicle. Evaluation of tumor volumes showed a significant reduction in anti-PD1- vs. vehicle-treated animals at day 18 of treatment (i.e. 457.8 mm3 vs. 1074.24 mm3, respectively; P= 0.001). The present study show encouraging results associated with anti-PD1 immunotherapy to treat TNBC tumors. In addition, our results provide evidence supporting the use of humanized mice as key animal model that may allow to overcome some of the technical difficulties associated with the investigation of immune-based therapies.

Citation Format: Rosato RR, Davila-Gonzalez D, Choi DS, Dave B, Chang JC. An anti-PD1 antibody-based therapy results in dramatic reduction of TNBC PDX tumors in humanized mice models [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-14-02.

Abstract P3-03-02: Inhibition of NOS promotes ER stress response and augments docetaxel-mediated apoptosis in TNBC

Introduction: Chemoresistance in triple negative breast cancer (TNBC) is related to an activation of a survival response orchestrated by endoplasmic reticulum (ER) stress. We hypothesize that attenuation of nitric oxide (NO) signaling pathway can overcome treatment resistance, preventing relapse, ultimately improving survival of TNBC patients. Here, we aimed to investigate the effects of pharmacological iNOS (inducible nitric oxide synthase) inhibition by L-NMMA on docetaxel-meditated ER stress response and to determine whether the therapeutic NOS inhibition may improve chemotherapy-based response.

Methods: BT-549, SUM-149, MDA-MB-436, and MDA-MD-468 TNBC cell lines were treated with docetaxel (D; 5 nm)/ L-NMMA (L; 4mM)/ amlodipine (A; 5 µm) daily for 48 and 72 hours. Cell death and proliferation were assayed by Annexin V and ATP quantification, respectively. Western Blot (WB) was used to measure ER stress markers. In vivo regimen treatment followed three 2-weekscycles of D (20 mg/kg intraperitoneal [IP] on day 1) and L (200 mg/kg oral gavage on day 2-6); A (10 mg/kg IP on day 2-6) A was administered together with L to counteract the well-known effects of L on blood pressure (hypertension). TNBC Patient derived xenograft (PDX) models #2147, #5998, #3107 and #4664 were transplanted into the mammary fat pad of SCID Beige mice. PDX #2147 received either, single drug (vehicle, L, A, D), double (L+A, D+L, D+A), or triple drug combination (L+A+D). Models #4664, #3107 and #5998 received only vehicle, D or D+ L+A. Mice weight and tumor volumes were recorded twice weekly. D concentration was measured by mass spectrometry.

Results: Studies on SUM-159 cell line showed that, when compared to the docetaxel-treated group, D+L+A increased cell death significantly, as indicated by a rise in annexin V/propidium iodide-positive cells. Increase in cell death by D+L+A was further demonstrated by accumulation of mitochondrial cleaved BAX. The enhanced apoptotic effects of D+L+A in MDA MD 468, BT 549 and MDA MD TNBC cell lines were confirmed by a decrease in ATP levels compared to D alone. WB revealed a survival stress response activated by docetaxel. When it was coupled with NOS inhibition, ER stress response showed higher expression of ATF4 and CHOP, triggering a proapoptotic response by pASK1/JNK pathway and cleaved caspases (CC3 and CC9). PDX #2147 showed that L, A and L+A treatment groups had similar tumor volume growth as the untreated group. However, combination therapy, D+L+A, significantly reduced the tumor volume and increased survival proportions compared with vehicle and docetaxel. Combination therapy also dramatically reduced tumor size on TNBC #4664 and #3107, and significantly improved response on #5998 compared with docetaxel alone. Intratumoral docetaxel concentration was 5.3-fold higher in mice receiving D+L+A than in those receiving docetaxel alone (#5998). In both groups, docetaxel was not detected in the plasma one week after injection.

Conclusion: The present data suggest that iNOS may be a critical target for docetaxel resistance in TNBC. iNOS inhibition enhanced chemotherapy response in TNBC PDX models indicating that addition of iNOS inhibitor may improve prognosis and prevent relapse in TNBC patients who have failed conventional chemotherapy.

Citation Format: Davila-Gonzalez D, Choi DS, Kuhn J, Granados SM, Rosato RR, Dave B, Chang JC. Inhibition of NOS promotes ER stress response and augments docetaxel-mediated apoptosis in TNBC [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-03-02.

Abstract P5-05-01: Physico-biochemical regulation of EMT by microtubule associated protein 7 (MAP7)

Background: We previously reported about 500 cancer stem cell (CSC) specific gene signatures from patient tumor samples. After screening with shRNAs for the 500 genes affecting mammosphere forming ability, we identified microtubule-assoicated protein 7 (MAP7) as one of the top candidate genes, which may serve as a target for breast CSCs. Although MAP7 is a predominant epithelial microtubule binding protein, only limited number of reports suggests that MAP7 may be a regulator of microtubule dynamics during cell division and a cofactor of Kinesin-1 in compartment transport in cells. However, little is known about how MAP7 supports epithelial cancers, especially breast cancer. Previously, we have reported that the mammosphere forming cells exhibit treatment resistance and high metastatic potential, which are intrinsic characters for CSCs displaying epithelial mesenchymal transition (EMT). We hypothesize that MAP7 supports breast cancer progression by promoting CSC self-renewal and survival through regulation of EMT.

Objectives: Here, we aim to show that MAP7 is an essential regulator of breast CSCs and to elucidate mechanism behind EMT regulation by MAP7 in breast CSCs.

Methods and Results: On Oncomine database analysis, MAP7 was up-regulated in most epithelial cancers, when compared to the corresponding normal tissues. Similarly, its expression in breast cancer was 2-fold higher than in the normal breast tissue (p&lt;0.05), but without significant variances in the expression across the breast cancer subtypes. Gene silencing of MAP7 significantly reduced CD44+/CD24- breast CSC populations and mammosphere forming efficiencies of MDA-MB-231, HCC1937, and MDA-MB-468 breast cancer cells. Furthermore, the silencing of MAP7 expression compromised invasive potential of MDA-MB-231 cells by 50% and significantly altered the cell membrane mechanics of MDA-MB-468 cells, as indicated by a high-content image analysis for cell shapes and cell adhesion efficiency. More importantly, delivery of siRNA in vivo inhibited the growth of BCM2147 patient-derived tumor, and limiting dilution assay demonstrated that the tumor initiation potential of BCM2147 can be eliminated by MAP7 silencing. Through confocal microscope analysis of images of fluorescent immunostaining and co-immunoprecipatation assays, MAP7 showed polarized-expressions in spindle-shaped cancer cells and was co-localized with Focal Adhesion Kinase (FAK). Moreover, MAP7 silencing inhibited the phosphorylation of FAK by inactivating p130CAS and JSAP1, the upper stream and the down-stream regulators of FAK.

Conclusion: We have showed the ectopic expression of MAP7 in breast tumors and other epithelial tumors, suggesting MAP7 may be involved in tumorigenesis and critical for the survival of tumor cells. Moreover, our results suggest that MAP7 is a key element for survival and self-renewal of breast CSCs through polarization of cells and activation of FAK, required for the initiation of EMT. To that end, here we report that MAP7 is essential for breast cancer growth by supporting CSC survival and self-renewal.

Citation Format: Choi DS, Dave B, Rosato RR, Chang JC. Physico-biochemical regulation of EMT by microtubule associated protein 7 (MAP7) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-05-01.

Aberrant PTEN expression in response to progesterone reduces endometriotic stromal cell apoptosis

In some human cancer cells, PTEN (phosphatase and tensin homolog deleted on chromosome 10) is known to regulate autophagy induction positively through the inhibition of PI3K/AKT pathway, leading to the activation of mTOR, a major negative regulator of autophagy. Recent studies reported that PTEN expression is abnormally decreased in endometriotic lesions. In endometriosis, abnormal PTEN expression may contribute to the alteration of endometrial cell autophagy, which may affect apoptosis because endometrial cell autophagy is directly involved in the regulation of apoptosis. To test this hypothesis, we evaluated the involvement of PTEN in the regulation of autophagy induction in human normal endometrial stromal cells (NESCs). In addition, we sought to determine whether aberrant PTEN expression in endometriotic cyst stromal cells (ECSCs) is associated with autophagy dysregulation, and a subsequent decrease in apoptosis. Our results show that PTEN expression was enhanced by progesterone treatment in NESCs. Subsequently, autophagy and apoptosis induction increased through the inhibition of AKT and mTOR activity. This progesterone-induced increase in apoptosis was reversed by the inhibition of autophagy induction using either mifepristone (progesterone receptor modulator) or PTEN inhibitor. In contrast, progesterone had no significant effects on PTEN expression, AKT, mTOR activity, autophagy or apoptosis in ECSCs. Furthermore, in contrast to normal eutopic endometrium, endometriotic tissues have constant PTEN expression, autophagy and apoptosis throughout the menstrual cycle. In conclusion, our results suggest abnormal PTEN expression in response to progesterone was observed in ECSCs, which led to the dysregulation of autophagy induction via AKT/mTOR signalling and a subsequent decrease in apoptosis.

The age-related recurrence of endometrioma after conservative surgery

OBJECTIVE

As endometrioma frequently recurs after conservative surgery, long-term postoperative medical treatment for the prevention of recurrence is necessary. However, it has not been elucidated whether long-term postoperative medical treatment is crucial to all patients until menopause. Thereupon, this study was conducted to evaluate the age-related recurrence patterns after conservative surgery for endometrioma.

STUDY DESIGN

A retrospective cohort study was performed on a total of 420 reproductive-aged women who underwent conservative surgery for endometrioma between January 2000 and December 2010. Ultrasonography was used during the follow-up period to detect endometrioma recurrence. Patients were classified into two groups according to the use of postoperative medications. The first group was observation only, while the second received gonadotropin releasing hormone agonists followed by cyclic oral contraceptives. The cumulative recurrence rate of endometrioma was compared according to the age at surgery (20-29 years, 30-39 years, 40-45 years) within each group. Subgroup analysis was performed according to the age between the two groups.

RESULTS

The median follow-up duration after surgery was 29.0 months (range 6-159 months) for all patients. After adjusting for parity, size and bilaterality of cyst, and stage with American Society for Reproductive Medicine classification of endometriosis which was statistically different, within the group of no treatment, the cumulative recurrence rate in 40-45 years (10.2%) was significantly lower compared with those in 20-29 years (43.3%; hazard ratio (HR)=0.04; 95% confidence interval (CI)=0.01-0.52) and 30-39 years (22.5%; HR=0.19; 95% CI=0.04-0.92). However, there were no differences within the group of postoperative medical treatment. When we compared between the two groups, the cumulative recurrence rate was significantly different in 20-29 years (8.1 vs 43.3%; p<0.001) and 30-39 years (5.4 vs 22.5%; p=0.007), but there was no difference in 40-45 years (4.5 vs 10.2%; p=0.901).

CONCLUSIONS

Our preliminary results demonstrate that the risk of endometrioma recurrence decreases with age. After the age of forty, the recurrence rate does not differ according to the use of postoperative medication. Based on our results, postoperative medical treatment may be individualized according to the patient's age at the time of surgery. Further studies are needed to identify patients who may benefit from postoperative medication.

Gonadotropin-releasing hormone agonist with add-back treatment is as effective and tolerable as dienogest in preventing pain recurrence after laparoscopic surgery for endometriosis

PURPOSE

This study was performed to compare the efficacy and tolerability of GnRH agonist with add-back therapy versus dienogest treatment for preventing pelvic pain recurrence after laparoscopic surgery for endometriosis.

METHODS

Sixty-four reproductive-aged women who underwent laparoscopic surgery for endometriosis received post-operative medical treatment with either GnRH agonist plus 17β-estradiol and norethisterone acetate (n = 28) or dienogest (n = 36) for 6 months. The pre- to post-treatment changes in pain were assessed using a visual analogue scale, and changes in quality-of-life and menopausal symptoms were measured by questionnaire.

RESULTS

Visual analogue scale pain score decreased significantly for both treatments with no significant differences between groups. Neither physical, psychological, social, and environmental components of quality-of-life nor menopausal rating scale score were significantly different between the two groups. Bone mineral density at the lumbar spine declined significantly in both treatment groups (-2.5 % for GnRH agonist plus add-back and -2.3 % for dienogest), with no significant difference between the two groups.

CONCLUSION

GnRH agonist and add-back therapy using 17β-estradiol and norethisterone acetate are as effective and tolerable as dienogest for the prevention of pelvic pain recurrence after laparoscopic surgery for endometriosis.

Uterine Development After Estrogen Replacement Therapy in Women with Different Etiologies of Primary Hypogonadism

STUDY OBJECTIVE

To evaluate uterine development with estrogen replacement therapy in patients with primary amenorrhea due to hypogonadism.

DESIGN AND SETTING

Retrospective study.

PARTICIPANTS

Thirty-five women.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Women who were younger than 20 years of age and who had primary amenorrhea and an immaturely shaped uterus were included. Changes in uterine cross-sectional area (UXA) and uterine maturity in pelvic ultrasound after 2 year of estrogen replacement therapy were assessed on the basis of the etiology of primary hypogonadism.

RESULTS

Patients were classified into three groups according to the etiology of primary hypogonadism: Turner syndrome (n = 19), hypogonadotropic hypogonadism after brain surgery (n = 10), and premature ovarian insufficiency after cancer treatment (n = 6). Overall, the mean UXA significantly increased (from 3.1 ± 1.8 to 11.6 ± 4.9 cm(2)) after estrogen replacement therapy (P < .001), but the final UXA was significantly smaller in patients with premature ovarian insufficiency compared with other etiologies. In logistic regression analysis, etiology and the cumulative dose of estrogen were associated with uterine maturation (P = .011 and .004, respectively).

CONCLUSION

Estrogen replacement therapy induced growth of the uterus in patients with primary hypogonadism. However, the response to estrogen replacement therapy varied on the basis of the total cumulative dose of estrogen and etiology of primary hypogonadism.

Repeated LPS Injection Induces Distinct Changes in the Kynurenine Pathway in Mice

The immune system has been recognized as a potential contributor to psychiatric disorders. In animals, lipopolysaccharide (LPS) is used to induce inflammation and behaviors analogous to some of the symptoms in these disorders. Recent data indicate that the kynurenine pathway contributes to LPS-induced aberrant behaviors. However, data are inconclusive regarding optimal LPS dose and treatment strategy. Here, we therefore aimed to evaluate the effects of single versus repeated administration of LPS on the kynurenine pathway. Adult C57BL6 mice were given 0.83 mg/kg LPS as a single or a repeated injection (LPS + LPS) and sacrificed after 24, 48, 72, or 120 h. Mice receiving LPS + LPS had significantly elevated brain kynurenine levels at 24 and 48 h, and elevated serum kynurenine at 24, 48 and 72 h. Brain kynurenic acid and quinolinic acid were significantly increased at 24 and 48 h in mice receiving LPS + LPS, whereas serum kynurenic acid levels were significantly decreased at 24 h. The increase of brain kynurenic acid by LPS + LPS was likely unrelated to the higher total dose as a separate group of mice receiving 1.66 mg/kg LPS as single injection 24 h prior to sacrifice did not show increased brain kynurenic acid. Serum quinolinic acid levels were not affected by LPS + LPS compared to vehicle. Animals given repeated injections of LPS showed a more robust induction of the kynurenine pathway in contrast to animals receiving a single injection. These results may be valuable in light of data showing the importance of the kynurenine pathway in psychiatric disorders.

Associations of Health-Risk Behaviors and Health Cognition With Sexual Orientation Among Adolescents in School: Analysis of Pooled Data From Korean Nationwide Survey From 2008 to 2012

Homosexual adolescents may face significant health disparities. We examined health-risk behaviors and health cognition related to homosexual behavior in a representative sample of adolescents.Data were obtained from 129,900 adolescents between 2008 and 2012 over 5 cycles of the Korean Youth Risk Behavior Survey, a national survey of students in grades 7 to 12. Various health-risk behaviors and aspects of health cognition were compared between homosexual and heterosexual adolescents and analyzed with multiple logistic regression models.Compared with heterosexual adolescents (n = 127,594), homosexual adolescents (n = 2306) were more likely to engage in various health-risk behaviors and to have poor health cognition. In multiple logistic regression analysis, not living with parents, alcohol experience (adjusted odds ratio, 1.50; 95% confidence interval, 1.26-1.78 for males and 1.66; 1.33-2.07 for females), smoking experience (1.80; 1.54-2.10 for males and 3.15; 2.61-3.79 for females), and drug experience (3.65; 2.81-4.80 for males and 3.23; 2.35-4.46 for females) were associated with homosexual behavior. Homosexual adolescents were more likely to use adult internet content (2.82; 2.27-3.50 for males and 7.42; 4.19-13.15 for females), and to be depressed (1.21; 1.03-1.43 for males and 1.32; 1.06-1.64 for females). In addition, suicide ideation (1.51; 1.26-1.81 for males and 1.47; 1.16-1.86 for females) and attempts (1.67; 1.37-2.05 for males and 1.65; 1.34-2.03 for females) were significantly more prevalent among homosexual adolescents.Homosexual adolescents report disparities in various aspects of health-risk behavior and health cognition, including use of multiple substances, adult internet content and inappropriate weight loss methods, suicide ideation and attempts, and depressive mood. These factors should be addressed relevantly to develop specific interventions regarding sexual minorities.

Abstract P6-15-01: Triple negative breast cancer is vulnerable to Pan-HER, an antibody mixture simultaneously targeting EGFR, HER2 and HER3

Background: Triple negative breast cancer (TNBC) is a highly heterogeneous and aggressive subtype of cancer, lacking expression of estrogen and progesterone receptors as well as human epidermal growth factor receptor (HER) 2 protein. Limited standard therapeutic options, absence of effective targeted therapies, and early metastatic spread have contributed to poor prognosis and outcomes associated with this disease. Although overexpression of EGFR has been reported in nearly 80% TNBC, EGFR-targeted therapy has yielded little clinical benefit, and the outcome is still under debate. In conjunction, we also found mixed effects of EGFR-targeted therapy on TNBC xenograft tumors despite significant target engagement, suggesting that tumor heterogeneity and compensating mechanisms may contribute to the variable drug responses to the EGFR-targeted therapy. Recently, we reported superior anti-cancer effects of Pan-HER, a mixture of antibodies targeting the HER family members EGFR, HER2 and HER3 on various types of cancer by overcoming drug resistance and tumor heterogeneity. To this end, we hypothesized that Pan-HER can effectively inhibit tumor growth in TNBC by inhibiting tumor heterogeneity and drug resistance.

Objective: The goal of this study is to test the effect of Pan-HER antibody mixture (Sym013) on tumor growth and recurrence of 14 patient-derived (PDX) TNBC orthotopic xenograft tumor models and to investigate molecular biomarkers which can predict drug response to Pan-HER.

Methods: We evaluated in-vivo anti-tumor effects of Pan-HER (50 mg/kg, i.p. three times/week, 10 doses in total for 3 weeks) over vehicle on tumor growth and tumor recurrence on 14 PDX TNBC models with known expression levels of EGFR and HER3 (n=3/group). HER family proteins and related downstream molecules (Akt, Erk, Stat3, FAK) in the tumor tissues were evaluated by Western blot assay and immunohistochemistry analysis. Additionally, using dCHIP and ingenuity pathway analysis, we compared microarray data from the tested cohorts and other TNBC PDX models with known HER family receptor status.

Results: We found that Pan-HER alone effectively inhibited tumor growth in all 14 PDX models and showed statistical significance (p=0.0103) when compared to the vehicle groups. Among these, one PDX model, BCM-3186, showed substantial tumor reduction and additional two (MC1 and BCM-4913) showed complete response with no recurrence after the last treatment of Pan-HER. The significant anti-tumor effects of Pan-HER were positively correlated with inhibition of phosphorylation and expression of EGFR, HER3, Akt, Erk, and FAK, but not Stat3, and this was consistent in all PDX models tested. Additionally, the microarray and the pathway enrichment analyses suggest that loss of PTEN expression and up-regulation of FAK and RAS pathways may be the predictive markers for the Pan-HER drug response in TNBC.

Conclusion: Our in-vivo data suggest that simultaneous targeting of the three HER family receptors is a potential new approach for treatment of TNBC. Further confirmation of our in-vivo results will warrant a phase I clinical trial and lend support to single agent Pan-HER as a viable treatment strategy for TNBC patients in the clinic.

Citation Format: Choi DS, Qian W, Davila-Gonzalez D, Ensor JE, Lantto J, Kragh M, Horak ID, Chang JC. Triple negative breast cancer is vulnerable to Pan-HER, an antibody mixture simultaneously targeting EGFR, HER2 and HER3. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-15-01.

Estrogen-mediated Height Control in Girls with Marfan Syndrome

This study evaluated the efficacy of a stepwise regimen of estradiol valerate for height control in girls with Marfan syndrome. Eight girls with Marfan syndrome who had completed estrogen treatment for height control were included. Estradiol valerate was started at a dose of 2 mg/day, and then was increased. The projected final height was estimated using the initial height percentile (on a disease-specific growth curve for Korean Marfan syndrome [gcPFHt]), and the initial bone age (baPFHt). After the estrogen treatment, the projected final height was compared to the actual final height (FHt). The median baseline chronological and bone age were 10.0 and 10.5 years, respectively. After a median of 36.5 months of treatment, the median FHt (172.6 cm) was shorter than the median gcPFHt (181.0 cm) and baPFHt (175.9 cm). In the six patients who started treatment before the age of 11 years, the median FHt (171.8 cm) was shorter than the median gcPFHt (181.5 cm) and baPFHt (177.4 cm) after treatment. The median differences between the FHt and gcPFHt and baPFHt were 9.2 and 8.3 cm, respectively. In two patients started treatment after the age of 11, the differences between FHt and gcPFHt, and baPFHt after treatment were -4 and 1.4 cm, and -1.2 and 0 cm for each case, respectively. A stepwise increasing regimen of estradiol valerate may be an effective treatment for height control in girls with Marfan syndrome, especially when started under 11 years old.

Feasibility of investigating differential proteomic expression in depression: implications for biomarker development in mood disorders

The objective of this study was to determine whether proteomic profiling in serum samples can be utilized in identifying and differentiating mood disorders. A consecutive sample of patients with a confirmed diagnosis of unipolar (UP n=52) or bipolar depression (BP-I n=46, BP-II n=49) and controls (n=141) were recruited. A 7.5-ml blood sample was drawn for proteomic multiplex profiling of 320 proteins utilizing the Myriad RBM Discovery Multi-Analyte Profiling platform. After correcting for multiple testing and adjusting for covariates, growth differentiation factor 15 (GDF-15), hemopexin (HPX), hepsin (HPN), matrix metalloproteinase-7 (MMP-7), retinol-binding protein 4 (RBP-4) and transthyretin (TTR) all showed statistically significant differences among groups. In a series of three post hoc analyses correcting for multiple testing, MMP-7 was significantly different in mood disorder (BP-I+BP-II+UP) vs controls, MMP-7, GDF-15, HPN were significantly different in bipolar cases (BP-I+BP-II) vs controls, and GDF-15, HPX, HPN, RBP-4 and TTR proteins were all significantly different in BP-I vs controls. Good diagnostic accuracy (ROC-AUC⩾0.8) was obtained most notably for GDF-15, RBP-4 and TTR when comparing BP-I vs controls. While based on a small sample not adjusted for medication state, this discovery sample with a conservative method of correction suggests feasibility in using proteomic panels to assist in identifying and distinguishing mood disorders, in particular bipolar I disorder. Replication studies for confirmation, consideration of state vs trait serial assays to delineate proteomic expression of bipolar depression vs previous mania, and utility studies to assess proteomic expression profiling as an advanced decision making tool or companion diagnostic are encouraged.

A FRAX Experience in Korea: Fracture Risk Probabilities with a Country-specific Versus a Surrogate Model

Background

Recently, a Korean fracture-risk assessment tool (FRAX) model has become available, but large prospective cohort studies, which are needed to validate the model, are still lacking, and there has been little effort to evaluate its usefulness. This study evaluated the clinical usefulness of the FRAX model, a FRAX developed by the World Health Organization, in Korea.

Methods

In 405 postmenopausal women and 139 men with a proximal femoral fracture, 10-year predicted fracture probabilities calculated by the Korean FRAX model (a country-specific model) were compared with the probabilities calculated with a FRAX model for Japan, which has a similar ethnic background (surrogate model).

Results

The 10-year probabilities of major osteoporotic and hip fractures calculated by the Korean model were significantly lower than those calculated by the Japanese model in women and men. The fracture probabilities calculated by each model increased significantly with age in both sexes. In patients aged 70 or older, however, there was a significant difference between the two models. In addition, the Korean model led to lower probabilities for major osteoporotic fracture and hip fracture in women when BMD was excluded from the model than when it was included.

Conclusions

The 10-year fracture probabilities calculated with FRAX models might differ between country-specific and surrogate models, and caution is needed when applying a surrogate model to a new population. A large prospective study is warranted to validate the country-specific Korean model in the general population.

A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea

OBJECTIVE

To evaluate practice patterns of gynecologists in the management of abnormal uterine bleeding (AUB) in South Korea.

METHODS

Between February 24 and March 12, 2014, a cross-sectional survey was performed through face-to-face interviews with 100 gynecologists selected through quota sampling reflecting regions and hospital types. Through the use of a questionnaire, the level of awareness and practice patterns regarding diagnosis and management of AUB were evaluated.

RESULTS

Among 100 respondents, 60 reported that they had not previously heard of the International Federation of Gynecology and Obstetrics (FIGO) classification system. The standardization of AUB terminology was reported to be necessary or very necessary by 70 respondents. Pelvic ultrasonography would be used for diagnosis by 99 physicians. The most common first-line AUB treatment was combined oral contraceptives: 55 respondents would use them for heavy menstrual bleeding, 56 for intermenstrual bleeding, and 56 for polycystic ovary syndrome. Combined oral contraceptives were the preferred follow-up medication: 30 would use them for heavy menstrual bleeding, 24 for intermenstrual bleeding, and 52 for polycystic ovary syndrome.

CONCLUSION

Despite implementation of the FIGO AUB classification system and guidelines, awareness and use among gynecologists in South Korea remains low.

Disease-specific Growth Charts of Marfan Syndrome Patients in Korea

Patients with Marfan syndrome (MFS) presents with primary skeletal manifestations such as tall stature, chest wall abnormality, and scoliosis. These primary skeletal manifestations affect the growth pattern in MFS. Therefore, it is not appropriate to use normal growth charts to evaluate the growth status of MFS. We aimed to develop disease-specific growth charts for Korean MFS patients and to use these growth charts for understanding the growth patterns in MFS and managing of patients with MFS. Anthropometric data were available from 187 males and 152 females with MFS through a retrospective review of medical records. Disease-specific growth charts were generated and 3, 25, 50, 75, and 97 percentiles were calculated using the LMS (refers to λ, μ, and σ, respectively) smoothing procedure for height and weight. Comparisons between MFS patients and the general population were performed using a one-sample t-test. With regard to the height, the 50th percentile of MFS is above the normative 97th percentile in both genders. With regard to the weight, the 50 percentile of MFS is above the normative 75th percentile in male and between the normative 50th percentile and the 75th percentile in female. The disease-specific growth charts for Korean patients with MFS can be useful for monitoring growth patterns, planning the timing of growth-reductive therapy, predicting adult height and recording responses to growth-reductive therapy.