Xishi Liu

Patterns of and risk factors for recurrence in women with ovarian endometriomas.

OBJECTIVE: To identify risk factors for and the patterns of recurrence of endometrioma and of dysmenorrhea in women with ovarian endometrioma. METHODS: We evaluated 710 consecutive patients operated on for ovarian endometriomas who were followed up for an average of 22.4 months. Twenty factors were examined to assess their effect on risk of recurrence of endometrioma and of dysmenorrhea using survival analysis. Hazard rate also was estimated to examine recurrence patterns. RESULTS: For recurrence of endometrioma, the revised American Fertility Society (rAFS) score, younger age at surgery, and previous medical treatment of endometriosis were identified to be risk factors. For recurrence of dysmenorrhea, rAFS score was the only risk factor. For both recurrences, there was a constant hazard rate in the first 28–30 months after surgery, indicating that the recurrence in that period is completely random. After that period, the hazard rate increased dramatically. CONCLUSION: The total rAFS score, but not rAFS stage, is a risk factor for recurrence of both endometrioma and dysmenorrhea, indicating that the rAFS stage has little prognostic value. The existence of a completely random recurrence period may be a universal phenomenon, with its duration and the magnitude of recurrence risk determined by patient characteristics and quality of care. The second phase of much higher recurrence risk may reflect successful reseeding, reimplantation, and regrowth of ectopic endometrium. Therefore, the identification of risk factors as well as patterns of recurrence should shed better light on possible causes for recurrence, which is now poorly understood. LEVEL OF EVIDENCE: II

Trichostatin A, a histone deacetylase inhibitor, reduces lesion growth and hyperalgesia in experimentally induced endometriosis in mice

BACKGROUND The aim of this study was to evaluate the effect of trichostatin A (TSA) in a mouse model of endometriosis on serum tumour necrosis factor alpha (TNFalpha) levels, hotplate latency, lesion size and immunoreactivity to Trpv1, Pkcepsilon and Pgp9.5. METHODS We used 30 adult female mice, and endometriosis was induced by auto-transplanting pieces of uterus (ENDO) or fat (SHAM) to peritoneum in lower parts of the abdominal and pelvic cavity. Two weeks later, the ENDO group was further divided into two groups randomly: one received TSA treatments and the other received injections of dimethyl sulfoxide, as did the SHAM mice. Four weeks later, all mice were sacrificed. Response latency in hotplate test and serum TNFalpha levels were measured before the surgery, and before and after the treatment, along with the average lesion size and the immunoreactivity to Trpv1, Pkcepsilon and Pgp9.5, in both eutopic and ectopic endometrium and vaginal tissue. RESULTS We found that mice receiving TSA had a significantly reduced average lesion size as compared with untreated mice, as well as a significant improvement in response to a noxious thermal stimulus. They also had a significantly lower immunoreactivity to Trpv1 in eutopic endometrium, to Pkcepsilon in ectopic endometrium and to Pgp9.5 in vagina. CONCLUSIONS Endometriosis causes increased central sensitivity to noxious stimuli. Treatment with TSA significantly reduces lesion growth and may relieve pain symptoms in women with endometriosis, indicating that histone deacetylase inhibitors may be a promising therapeutic agent.

Promoter Hypermethylation of Progesterone Receptor Isoform B (PR-B) in Adenomyosis and Its Rectification by a Histone Deacetylase Inhibitor and a Demethylation Agent

Adenomyosis is a fairly common gynecologic disease with unknown pathogenesis. We sought to investigate as to whether the promoter of progesterone receptor isoform B (PR-B) is hypermethylated in adenomyosis and to investigate the treatment of ectopic endometrial stromal cells with trichostatin A (TSA), a histone deacetylase inhibitor (HDI), and 5-aza-2-deoxycytidine (ADC), a demethylation agent, on PR-B gene and protein expression, and on cell viability. Ectopic endometrial tissue specimens were obtained from 9 women with adenomyosis whereas control endometrial tissue samples were obtained from 8 women with surgically diagnosed benign ovarian cysts but without any clinical history of endometriosis/adenomyosis/ myoma. Endometrial stromal cells were isolated, purified, cultured, and analyzed by methylation-specific polymerase chain reaction (PCR), real-time reverse transcriptase PCR (RT-PCR), and Western blot analysis, cell viability assays, and fluorescence-activated cell sorting. We found that none of the normal endometrial stromal cells had PR-B promoter methylation. In contrast, 2 out of 3 ectopic endometrial stromall cells had PR-B hypermethylation (P < .05). The treatment with both TSA and ADC elevated PR-B gene and protein expression in ectopic, but not in normal, endometrial stromal cells. Both TSA and ADC treatment dose-dependently reduced cell viability of ectopic endometrial stromal cells. Trichostatin A and ADC treatment also suppressed the cell cycle progression in ectopic endometrial stromal cells. Thus, this study provides the first piece of evidence that adenomyosis has epigenetic aberration and may also be an epigenetic disease amenable to rectification by pharmacological means. This perspective may shed new light onto the pathogenesis of adenomyosis and lead to novel ways to treat the disease.

Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis

OBJECTIVE To evaluate uterine contractility, oxytocin receptor (OTR) expression in myometrial smooth muscle cells (MSMCs) derived from uterine tissues from women with and without adenomyosis correlate OTR expression with uterine contractility and dysmenorrhea severity, and see whether trichostatin A (TSA) and andrographolide inhibit OTR expression. DESIGN Laboratory study using human tissues. SETTING Academic hospital. PATIENT(S) Twenty patients (cases) with histologically confirmed adenomyosis and 10 (controls) with leiomyomas, cervical dysplasia, and cancer but no adenomyosis or endometriosis. INTERVENTION(S) Dysmenorrhea severity was scored by Visual Analog Scale. Uterine tissue samples were collected during hysterectomy. Myometrial smooth muscle cells derived from tissue samples were cultured and OTR protein levels were measured. The effect of TSA (0.5 or 1 μM) and andrographolide (15 or 30 μM) on OTR expression was evaluated. MAIN OUTCOME MEASURE(S) Visual Analog Scale scores, and contractile amplitude and frequency. The OTR protein levels in MSMCs were quantified by Western blot analysis. RESULT(S) The contractile amplitude and OTR expression levels were significantly higher in cases than in controls. Dysmenorrhea Visual Analog Scale scores correlated positively with contractile amplitude and OTR expression level. Both TSA and andrographolide dose-dependently inhibit OTR expression in MSMC. CONCLUSION(S) Oxytocin receptor overexpression in MSMCs may be responsible for increased uterine contractility and adenomyosis-associated dysmenorrhea. Both histone deacetylase inhibitors and andrographolide are therapeutically promising.

Immunoreactivity of oxytocin receptor and transient receptor potential vanilloid type 1 and its correlation with dysmenorrhea in adenomyosis

OBJECTIVE We sought to investigate the expression and localization of oxytocin receptor (OTR) and transient receptor potential vanilloid type 1 (TRPV1) in women with and without adenomyosis. STUDY DESIGN Ectopic and homologous eutopic endometrium from 50 women with adenomyosis and endometrium from 18 women without adenomyosis were used for immunohistochemical analysis of OTR and TRPV1. Microscopic evaluation assessed the presence and localization of OTR and TRPV1 throughout the menstrual cycle in both eutopic endometrial and endometriotic tissues of women with adenomyosis and compared them with normal endometrium. RESULTS Compared with normal endometrium, immunoreactivity of OTR and TRPV1 were significantly increased in ectopic endometrium. Both OTR and TRPV1 immunoreactivity were positively correlated with the severity of dysmenorrhea and found to be significant predicators for dysmenorrhea severity. CONCLUSION These findings suggest that OTR and TRPV1 may be involved in dysmenorrhea and its severity in adenomyosis and may be potential therapeutic targets.

Increased Immunoreactivity to SLIT/ROBO1 in Ovarian Endometriomas A Likely Constituent Biomarker for Recurrence

While surgery is currently the treatment of choice for endometriosis, recurrence remains a serious problem, and its prevention is an unmet clinical need. SLIT, a secreted protein that functions through the Roundabout (ROBO) receptor as a repellent for axon guidance and neuronal migration, has been recently found to induce tumor angiogenesis. We investigated the potential role of SLIT/ROBO1 in ovarian endometriomas and examined their predictive value in recurrence based on tissue samples from 43 patients with recurrence and 45 without recurrence. Microvascular density counts were evaluated by CD34 immunohistochemistry, and statistical analyses were performed to evaluate the effect of SLIT/Robo1 on recurrence risk after adjustment for other risk factors. We found that SLIT expression was positively correlated with microvascular density in ectopic endometrium and that its expression was higher in ectopic endometrium than control endometrium. Both SLIT and Robo1 expression were higher in recurrent cases than in non-recurrent cases. Higher immunoreactivity to SLIT, along with the presence of adhesion, PR-B, and nuclear factor-kappaB, was identified to be a risk factor for recurrence, with a sensitivity of 86% and a specificity of 87%. Therefore, increased SLIT immunoreactivity is likely an important constituent factor for recurrence of ovarian endometriomas, possibly through promoting angiogenesis in ectopic endometrium. Thus, the SLIT/ROBO1 system may be a potential target for reducing the risk of recurrence.

Platelets are an unindicted culprit in the development of endometriosis: clinical and experimental evidence

STUDY QUESTION Do platelets play any role in the development of endometriosis? SUMMARY ANSWER Activated platelets aggregate in endometriotic lesions and play important roles in the development of endometriosis. WHAT IS KNOWN ALREADY Platelets play important roles in cancer development and metastasis but there is no published study on their role in the development of endometriosis, even though endometriotic lesions undergo repeated cycles of tissue injury and repair, which characteristically involve platelets. STUDY DESIGN, SIZE, DURATION Cross-sectional clinical studies of women with and without endometriosis, in vitro experimentation, and animal studies using platelet and/or macrophage depletion. PARTICIPANTS/MATERIALS, SETTING, METHODS Immunohistochemistry analysis of ectopic/eutopic endometrial tissues from 58 women with and 47 without endometriosis. Proliferation assay, cell cycle analysis by flow cytometry, gene expression and protein analysis for COX-2, VEGF, MMP-9, and Bcl-2 using primary cell culture, and evaluation of the rate of platelet activation induced by peritoneal fluid from women with and without endometriosis. Two mouse experiments, one that evaluated the effect of platelet depletion on lesion development and its associated phenotypic changes, and the other, the effect of platelet and/or macrophage depletion. MAIN RESULTS AND THE ROLE OF CHANCE We found that platelets aggregated in endometriotic lesions, concomitant with elevated VEGF expression and microvessel density. Co-culture of endometriotic stromal cells with platelets enhanced cellular proliferation, and increased the expression of COX-2, MMP-9, VEGF, and Bcl-2. IL-1β-induced COX-2 up-regulation and increased production of the coagulant TXA(2) in endometriotic stromal cells. Tissue factor (TF) expression was elevated in endometriosis and TF concentrations were significantly elevated both in the supernatant of cultured primary endometriotic stromal cells and in peritoneal fluid from women with endometriosis. Platelet depletion resulted in significantly reduced lesion size and improved hyperalgesia in mice with induced endometriosis. LIMITATIONS, REASONS FOR CAUTION This study is limited by its cross-sectional design and by its focus on ovarian endometriomas. WIDER IMPLICATIONS OF THE FINDINGS The demonstration that platelets are involved in the development of endometriosis provides a rationale for the use of anti-coagulants to treat endometriosis, and opens prospects for developing novel biomarkers for diagnostic or prognostic purposes. STUDY FUNDING/COMPETING INTERESTS Financial support for this study was provided by grants from the National Science Foundation of China, a grant from the Shanghai Science and Technology Commission, support from the Key Specialty Project of the Ministry of Health, Peoples Republic of China. None of the authors has any conflict of interest to disclose.

Immunoreactivity of progesterone receptor isoform B, nuclear factor κB, and IκBα in adenomyosis

Compared with normal endometrium, progesterone receptor isoform B (PR-B) and IkappaBalpha immunoreactivity were statistically significantly reduced in ectopic as well as eutopic endometrium from women with adenomyosis while nuclear p65, p50, and p52 immunoreactivity were statistically significantly increased in ectopic and eutopic endometrium. Nuclear p65 immunoreactivity was positively associated with heavier menses, and decreased PR-B and increased nuclear p65 immunoreactivity in ectopic endometrium were statistically significantly associated with the severity of dysmenorrhea in women with adenomyosis.

EndometriosisImmunoreactivity of progesterone receptor isoform B, nuclear factor κB, and IκBα in adenomyosis

Compared with normal endometrium, progesterone receptor isoform B (PR-B) and IkappaBalpha immunoreactivity were statistically significantly reduced in ectopic as well as eutopic endometrium from women with adenomyosis while nuclear p65, p50, and p52 immunoreactivity were statistically significantly increased in ectopic and eutopic endometrium. Nuclear p65 immunoreactivity was positively associated with heavier menses, and decreased PR-B and increased nuclear p65 immunoreactivity in ectopic endometrium were statistically significantly associated with the severity of dysmenorrhea in women with adenomyosis.

Valproic acid as a therapy for adenomyosis: a comparative case series.

Adenomyosis is a difficult disease to manage and currently there is no investigative drug for adenomyosis on the horizon. We have previously reported in a pilot study that valproic acid (VPA) appears to be effective in treating adenomyosis. In this case series, we further evaluated the efficacy of VPA, with or without a progestin-containing intrauterine device, in the treatment of patients with adenomyosis. We recruited 12 patients with confirmed adenomyosis who complained of dysmenorrehea and had enlarged uterus. All patients took VPA for 3 months, then randomly assigned to 2 groups, 1 receiving no further treatment and the other were inserted with a levonorgestrel-releasing intrauterine system (Mirena) and were followed up for an additional 3 months. The primary outcome measures were the severity of dysmenorrhea and uterine size. Both measures were evaluated prior to the drug treatment and 3 and 6 months after the drug treatment, respectively. We found that VPA treatment resulted in complete resolution of dysmenorrhea and an average reduction in uterine size by 26% 6 months after the treatment, regardless of whether Mirena was used or not. Moreover, the amount of menses decreased significantly. Thus, VPA appears to be well tolerated and a promising drug for treating adenomyosis.