Endometriosis and cancer

Association Between Endometriosis and Prognosis of Ovarian Cancer: An Updated Meta-Analysis

Objective

Increased risk of ovarian cancer (OC) among endometriosis patients has been proposed. However, the association between endometriosis and prognosis of OC remains controversial. This study evaluated whether endometriosis had influence on the survival outcomes of OC through a meta-analysis.

Methods

Relevant studies were retrieved from PubMed, Embase, and Web of Science databases and were evaluated using the Newcastle-Ottawa Quality Assessment Scale. Effect size was presented as hazard ratio (HR) and 95% confidence interval (CI). Heterogeneity test evaluation was performed using Cochran’s Q test and I2 statistics. Publication bias was determined using Egger’s test. Statistical analysis was performed using Stata 12.0 software.

Results

Twenty-one studies involving 38641 patients were included. For the total OC, there were significant differences in overall survival (OS) [HR (95% CI)=0.67 (0.55, 0.80), P<0.001] and progression-free survival (PFS) [HR (95% CI)=0.58 (0.42, 0.81), P=0.001] between endometriosis-associated ovarian cancer (EAOC) and non-EAOC patients in the random-effects models (P<0.05). For ovarian clear cell cancer, there were significant differences in terms of OS [HR (95% CI)=0.63 (0.48, 0.83), P=0.001] and PFS [HR (95% CI)=0.67 (0.52, 0.87), P=0.002] between EAOC and non-EAOC patients in the fixed-effects models (P>0.05). Subgroup analysis suggested no significant differences between EAOC and non-EAOC in OS and PFS in the univariate analysis per subgroup, and PFS in the American subgroup (P>0.05).

Conclusion

EAOC patients tended to have better OS and PFS than non-EAOC patients. Conducting higher quality prospective cohort studies with large sample sizes is recommended to confirm the authenticity of the current study’s results.

Systematic Review Registration

https://inplasy.com/inplasy-2022-3-0109/.

Increased expression of IL-37 correlates with TNF-α levels and disease stage in endometriosis patients

Background

IL-37 is an anti-inflammatory cytokine that increases in several inflammatory diseases with the main inducing signal for its production being pro-inflammatory cytokines like TNF-α. We aimed to assess the correlation between peritoneal fluid levels of IL-37 and TNF-α in endometriosis patients and investigate their association with disease stage. Levels of IL-37 and TNF-α were assessed in peritoneal fluid of 50 patients with endometriosis and 23 endometriosis-free females using enzyme-linked immunosorbent assay. We also assessed serum levels of IL-37 using enzyme-linked immunosorbent assay and expression of IL-37 mRNA in peritoneal fluid cells using polymerase chain reaction.

Results

Peritoneal fluid levels of IL-37 and TNF-α were higher in endometriosis patients than in control females. Also, levels were higher in patients with late endometriosis than patients with early endometriosis. In addition, serum levels of IL-37, as well as IL-37 mRNA expression in peritoneal fluid cells, were higher in patients than controls. In endometriosis patients, peritoneal fluid levels of IL-37 positively correlated with levels of TNF-α.

Conclusion

Collectively, our results show increased levels of the anti-inflammatory cytokine IL-37 in endometriosis patients that correlate with levels of the pro-inflammatory cytokine TNF-α, one of the main signals for IL-37 production.

Upregulation of h-TERT and Ki-67 in ectopic endometrium is associated with recurrence of endometriosis

At present, endometriosis remains a worldwide health burden, with the main symptoms of dysmenorrhea, chronic pelvic pain, and infertility, markedly reducing the quality of life (de Ziegler et al., 2010). Although there is no proof that the disease is associated with high mortality, this disorder can significantly contribute to the deterioration of women's general well-being (McPeak et al., 2018). The main current treatment for endometriosis is surgery to remove endometriotic lesions; however, the recurrence rate following surgical treatment is as high as 21.5% at two years and 40.0%‍-‍50.0% at five years post-surgery (Koga et al., 2015). To prevent recurrence, adjuvant treatment with drugs after surgery is recommended to prolong relapse-free intervals. However, it is inconvenient for patients to continuously use such medications in terms of adverse effects and cost (Turk, 2002).

APOBEC mediated mutagenesis drives genomic heterogeneity in endometriosis

Endometriosis is a benign gynecologic condition, acting as a precursor of certain histological subtypes of ovarian cancers. The epithelial cells of endometriotic tissues and normal uterine endometrium accumulated somatic mutations in cancer-associated genes such as phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) and Kirsten rat sarcoma (KRAS) proto-oncogene. To determine the genomic characteristic of endometriotic epithelial cells and normal uterine endometrium and to identify the predominant mutational process acting on them, we studied the somatic mutation profiles obtained from whole exome sequencing of 14 endometriotic epithelium and 11 normal uterine endometrium tissues and classified them into mutational signatures. We observed that single base substitutions 2/13 (SBS), attributed to Apolipoprotein B mRNA Editing Enzyme Catalytic Subunit (APOBEC) induced mutagenesis, were significant in endometriotic tissues, but not in the normal uterine endometrium. Additionally, the larger number and wider allele frequency distribution of APOBEC signature mutations, compared to cancer-associated driver mutations in endometriotic epithelium suggested APOBEC mutagenesis as an important source of mutational burden and heterogeneity in endometriosis. Further, the relative risk of enriched APOBEC signature mutations was higher in endometriosis patients who were carriers of APOBEC3A/3B germline deletion, a common polymorphism in East Asians which involves the complete loss of APOBEC3B coding region. Our results illustrate the significance of APOBEC induced mutagenesis in driving the genomic heterogeneity of endometriosis.

Double-edged Sword Role of Iron-loaded Ferritin in Extracellular Vesicles

Human epidemiological and animal studies have demonstrated that excess iron is a risk for cancer. The responsible mechanisms are: 1) increased intracellular iron catalyzes the Fenton reaction to generate hydroxyl radicals, leading to mutagenic oxidative DNA lesions; 2) iron is necessary for cellular proliferation as cofactors of many enzymes. Thus, iron-excess milieu promotes selecting cellular evolution to ferroptosis-resistance, a major basis for carcinogenesis. Ferritin is a 24-subunit nanocage protein required for iron storage under the regulation of the iron-regulatory protein (IRP)/iron-responsive element (IRE) system. Ferritin is a serum marker, representing total body iron storage. However, how ferritin is secreted extracellularly has been unelucidated. We recently discovered that an exosomal marker CD63 is regulated by the IRP/IRE system and that iron-loaded ferritin is secreted as extracellular vesicles under the guidance of nuclear receptor coactivator 4 (NCOA4). On the other hand, we found that macrophages under asbestos-induced ferroptosis emit ferroptosis-dependent extracellular vesicles (FedEVs), which are received by nearby mesothelial cells, resulting in significant mutagenic DNA damage. Therefore, cells, including macrophages, can share excess iron with other cells, via iron-loaded ferritin packaged in extracellular vesicles as safe non-catalytic iron. However, similar process, such as one involving FedEVs, may cause accumulation of excess iron in other specific cells, which may eventually promote carcinogenesis.

Genetics of endometriosis and its association with ovarian cancer

Endometriosis is a chronic and destructive developmental gynecologic condition that affects approximately 10% percent of females worldwide, and is one of the most frequent causes of extreme pelvic pain. The endometrium-like tissue, glands, and stroma outside the uterine cavity are often affected by endometriosis. It is estrogen-dependent and frequently affects the ovaries, fallopian tubes, and pelvic peritoneum. Symptoms such as chronic pelvic pain, infertility, dyspareunia, as well as digestive and urinary symptoms often accompany endometriosis. The overall condition shares characteristics with ovarian carcinoma such as enhanced vascular activation of the endothelial growth factor, local invasion, lymph angiogenesis, neoangiogenic, mechanism tolerance to apoptosis, and genome instability. Genetic studies have shown that endometriotic lesions contain gene mutations related directly to malignancies, particularly theARID1A, p53, KRAS, andPTENgenes. However, women with endometriosis have a lower risk of ovarian cancer than the general population, where endometriosis was seen in only 1.3%, and did not diagnose ovarian cancer progression among them. We need to look into the connection between endometriosis and uterine carcinomas, as well as the common lesions and correlations in the uterine microenvironment, which may play a role in mutations and malignant exchanges. Although endometriosis is a risk factor of ovarian cancer, malignant cells from the uterus can migrate to the ovary and cause endometriosis-related ovarian cancer. The purpose of this article is to examine current data on genetic phenomena and molecular changes for endometriosis associated with ovarian cancer, focusing primarily on the proliferation of uterine and precise cell biomarkers.

The Role of Peritoneal Macrophages in Endometriosis

Endometriosis is an estrogen-dependent gynecological disorder, defined as the growth of endometrial stromal cells and glands at extrauterine sites. Endometriotic lesions are more frequently located into the abdominal cavity, although they can also be implanted in distant places. Among its etiological factors, the presence of immune dysregulation occupies a prominent place, pointing out the beneficial and harmful outcomes of macrophages in the pathogenesis of this disease. Macrophages are tissue-resident cells that connect innate and adaptive immunity, playing a key role in maintaining local homeostasis in healthy conditions and being critical in the development and sustainment of many inflammatory diseases. Macrophages accumulate in the peritoneal cavity of women with endometriosis, but their ability to clear migrated endometrial fragments seems to be inefficient. Hence, the characteristics of the peritoneal immune system in endometriosis must be further studied to facilitate the search for new diagnostic and therapeutic tools. In this review, we summarize recent relevant advances obtained in both mouse, as the main animal model used to study endometriosis, and human, focusing on peritoneal macrophages obtained from endometriotic patients and healthy donors, under the perspective of its future clinical translation to the role that these cells play on this pathology.

Endometriosis stem cell sources and potential therapeutic targets: literature review and bioinformatics analysis

The stem cell origin theory of endometriosis (EMS) is a significant area of new research but the sources of this have yet to be adequately summarized. Existing treatments for EMS are commonly associated with a high recurrence rate; consequently, there is an urgent need to develop new therapeutic measures for the future treatment of this disease from the view of stem cells and gene therapy. Recently, we described the evidence for the potential sources of EMS stem cells and other key molecules participating in the establishment of lesions, and predict the miRNAs that target these key genes via bioinformatics analysis for further research. This review highlights the origin of EMS stem cells and potential therapy targets.

Sanhuang Decoction Controls Tumor Microenvironment by Ameliorating Chronic Stress in Breast Cancer: A Report of Ninety Cases

Long-term endocrine treatment which results in estrogen deprivation causes chronic stress associated with a series of uncomfortable symptoms leading not only to a decrease in quality of life but also to cancer recurrence, which may be mediated primarily through the enhanced expression of angiogenic factors, as well as a series of inflammatory microenvironmental changes that favor tumor progression. In this study, we designed a clinical trial and aimed to explore the effects of Sanhuang Decoction (SHD) treatment on chronic stress, inflammatory factors, and breast cancer recovery. A total of 90 patients with breast cancer who met the inclusion/exclusion criteria were randomly allocated to a treatment or control group. The treatment group received the standard endocrine treatment and the traditional Chinese medicine decoction known as SHD. The control group received the standard endocrine treatment only. The treatment period was 6 months. The modified Kupperman Menopausal Index, the self-rating anxiety scale, and the self-rating depression scale were evaluated once per month. The body microenvironment plasma indices related to chronic stress, such as oxidative and antioxidative stress markers, inflammatory factors, hemorheology, coagulation, lipid and D-dimer, immunologic functions, tumor biomarkers, and angiogenic factors of the vascular endothelial growth factor (VEGF) were measured before and after 6 months of treatment. After treatment for 5 months, the scores in the treatment group decreased to nearly normal levels and the control group showed no significant improvement. After treatment for 6 months, all indices related to the body microenvironment, as well as the tumor biomarkers and carcinoembryonic antigen, carbohydrate antigen 153, and angiogenic factor VEGF levels improved significantly to normal levels in the treatment group. Our primary research showed that treatment with SHD effectively improved the quality of life of breast cancer patients by facilitating a change in the body microenvironment that controlled tumor growth and prevented drug resistance.

Molecular Basis of Endometriosis and Endometrial Cancer: Current Knowledge and Future Perspectives

The human endometrium is a unique tissue undergoing important changes through the menstrual cycle. Under the exposure of different risk factors in a woman's lifetime, normal endometrial tissue can give rise to multiple pathologic conditions, including endometriosis and endometrial cancer. Etiology and pathophysiologic changes behind such conditions remain largely unclear. This review summarizes the current knowledge of the pathophysiology of endometriosis and its potential role in the development of endometrial cancer from a molecular perspective. A better understanding of the molecular basis of endometriosis and its role in the development of endometrial pathology will improve the approach to clinical management.

Estrogen- and Progesterone (P4)-Mediated Epigenetic Modifications of Endometrial Stromal Cells (EnSCs) and/or Mesenchymal Stem/Stromal Cells (MSCs) in the Etiopathogenesis of Endometriosis

Endometriosis is a common chronic inflammatory condition in which endometrial tissue appears outside the uterine cavity. Because ectopic endometriosis cells express both estrogen and progesterone (P4) receptors, they grow and undergo cyclic proliferation and breakdown similar to the endometrium. This debilitating gynecological disease affects up to 15% of reproductive aged women. Despite many years of research, the etiopathogenesis of endometrial lesions remains unclear. Retrograde transport of the viable menstrual endometrial cells with retained ability for attachment within the pelvic cavity, proliferation, differentiation and subsequent invasion into the surrounding tissue constitutes the rationale for widely accepted implantation theory. Accordingly, the most abundant cells in the endometrium are endometrial stromal cells (EnSCs). These cells constitute a particular population with clonogenic activity that resembles properties of mesenchymal stem/stromal cells (MSCs). Thus, a significant role of stem cell-based dysfunction in formation of the initial endometrial lesions is suspected. There is increasing evidence that the role of epigenetic mechanisms and processes in endometriosis have been underestimated. The importance of excess estrogen exposure and P4 resistance in epigenetic homeostasis failure in the endometrial/endometriotic tissue are crucial. Epigenetic alterations regarding transcription factors of estrogen and P4 signaling pathways in MSCs are robust in endometriotic tissue. Thus, perspectives for the future may include MSCs and EnSCs as the targets of epigenetic therapies in the prevention and treatment of endometriosis. Here, we reviewed the current known changes in the epigenetic background of EnSCs and MSCs due to estrogen/P4 imbalances in the context of etiopathogenesis of endometriosis. Graphical Abstract.

Overexpressed MPS-1 contributes to endometrioma development through the NF-κB signaling pathway

BACKGROUND

Endometriosis is a benign gynecological disease that shares some characteristics with malignant tumors and affects approximately 10% of women of reproductive age. Endometrioma refers to endometriosis that appears in the ovary. Metallopanstimulin-1 (MPS-1) is a component of the 40S subunit of ribosomes that has extra-ribosomal functions that contribute to the development of diseases. This study aimed to explore the expression pattern and role of MPS-1 in endometrioma development.

METHODS

Quantitative real time polymerase chain reaction, western blotting, immunohistochemistry, and enzyme-linked immunosorbent assay were used to determine the expression of MPS-1 in patients with endometrioma. Following the successful knockdown of MPS-1 by siRNA, CCK-8 assays, flow cytometry, and transwell assays were performed to detect ectopic endometrial stromal cells (EcESCs) proliferation, the rate of apoptosis, and cell cycle, migration, and invasion, respectively. Western blotting was used to explore the effect of MPS-1 knockdown on protein levels in the NF-κB signaling pathway.

RESULTS

The expression of MPS-1 was significantly higher in endometrioma and the serum of endometrioma patients than in the patients without endometriosis. In addition, the downregulation of MPS-1 expression inhibited EcESCs proliferation, migration, and invasion. This downregulation led to the arrest of the EcESCs cycle in the G0/G1 phase and apoptosis and depressed the NF-κB signaling pathway.

CONCLUSION

MPS-1 can regulate EcESCs proliferation, motility, invasion, apoptosis, and cell cycle via the NF-κB signaling pathway in endometrioma. This may contribute to the formation or development of endometriotic foci. This study suggests the potential role of MPS-1 in the pathogenesis of endometriosis and enabled further research into the use of MPS-1 in the clinical diagnosis of endometrioma.

Phytoestrogens for the Management of Endometriosis: Findings and Issues

Endometriosis, a chronic disease characterized by recurrent pelvic pain and infertility, severely impacts the health and life quality of many women worldwide. Since phytoestrogens are commonly found in a variety of foods, and estrogen is a major pathological factor for the pathogenesis of endometriosis, their possible involvement cannot be ignored. This review summarizes data on the relationship between phytoestrogen intake and endometriosis risk, and analyzes the findings from in vitro experiments, rodent endometriotic models, and human intervention trials. While favorable results were often obtained from endometrial primary cultures and animal models for resveratrol, isoflavones and puerarin, only resveratrol showed promising results in human intervention trials. Critical issues concerning the current study efforts are discussed: the possible reasons beneath the discrepant observations of estrogenic/anti-estrogenic effects by phytoestrogens; the complicated interplays between phytoestrogens and endogenous estrogens; the shortage of currently used animal models; the necessity to apply reasonable doses of phytoestrogens in experiments. It is expected that the analyses would help to more properly assess the phytoestrogens' effects on the endometriosis pathogenesis and their potential values for preventive or therapeutic applications.

Current Knowledge on Endometriosis Etiology: A Systematic Review of Literature

Objective

To review the mechanisms of endometriosis development, including those related to epigenetic mutations, cellular dysregulation, inflammatory processes, and oxidative stress.

Methods

A systematic literature review regarding current aspects of endometriosis etiology, genesis and development was performed using the PubMed, Google Scholar, and eLibrary databases. Keywords included endometriosis, etiology, development, genesis, associations and mechanisms. A multilingual search was performed.

Results

Several mechanisms underline the pathophysiological pathways for endometriosis development. Epigenetic mutations, external and internal influences, and chronic conditions have a significant impact on endometriosis development, survival and regulation. Several historically valid theories on endometriosis development were discussed, as well as updated findings.

Conclusion

Despite recent advances, fundamental problems in understanding endometriosis remain unresolved. The identification of unknown circulating epithelial progenitors or stem cells that are responsible for epithelial growth in both the endometrium and endometriotic foci seems to be the next step in solving these questions.

Inhibition of p22phox Suppresses Epithelial Ovarian Cancer Cell Proliferation and Tumorigenesis

The aim of this study was to investigate the biological role and molecular mechanism of p22^phox in epithelial ovarian cancer. Immunohistochemistry was employed to determine the p22^phox expression level in epithelial ovarian cancer tissues. The effects of p22^phox on epithelial ovarian cancer cell proliferation, tumorigenesis, and chemosensitivity were evaluated by CCK-8, EdU assay, colony formation and apoptosis assays in vitro and by mouse experiments in vivo. Immunoprecipitation analyses were utilized to explore the potential mechanisms of p22^phox mediated downstream signaling, and RT-PCR and western blot were used to confirm the relevance. P22^phox expression could be detected in epithelial ovarian cancer tissues and normal fallopian epithelial cells. Silencing p22^phox suppressed epithelial ovarian cancer cell proliferation and colony formation capacity in vitro, and inhibited the tumor growth in nude mice bearing the A2780 xenograft in vivo. Mechanistic investigations showed that p22^phox regulated proteasome ubiquitination and subsequent proteasome-dependent degradation of p53 in A2780 and U87 cells in vitro. Furthermore, knockdown of p22^phox significantly increased the chemosensitivity of A2780 cells to cisplatin or paclitaxel. These results suggested that p22^phox as a pivotal oncogene during epithelial ovarian cancer carcinogenesis and p22^phox inhibition might be a potential therapeutic strategy for epithelial ovarian cancer.

MicroRNA-342 Promotes the Malignant-Like Phenotype of Endometrial Stromal Cells via Regulation of Annexin A2

The relevance of miRNA- (miR-) 342 to endometriosis has been highlighted, while its function in regulating the malignant-like phenotype of endometrial stromal cells which demonstrate epigenetic abnormalities that alter expression of transcription factors, remains unclear. Therefore, we sought to characterize the effects of miR-342 in endometrial stromal cell proliferation by regulating Annexin A2 (ANXA2). We first characterized the levels of miR-342 and ANXA2 in 31 cases of normal endometrium from patients with grade II-III cervical intraepithelial neoplasia or patients with hysterectomy versus ectopic endometrial tissues of 42 patients with endometriosis. miR-342 was upregulated, while ANXA2 was downregulated in ectopic endometrial tissues. Bioinformatics website and dual-luciferase reporter assay revealed that miR-342 negatively modulated ANXA2 expression. Following loss- and gain-of-function approaches, CCK-8, Transwell, and flow cytometry demonstrated that overexpression of miR-342 markedly increased cell proliferation, migration, and invasion but inhibited cell apoptotic ratio of endometrial stromal cells, which was reversed by ANXA2 elevation. Further, overexpressed miR-342 activated the PI3K/AKT/mTOR signaling pathway, as evidenced by upregulated levels of p-PI3K/PI3K, p-AKT/AKT, and p-mTOR/mTOR. Taken together, miR-342 targets ANXA2 to activate the PI3K/AKT/mTOR signaling pathway, thereby promoting the malignant-like phenotype of endometrial stromal cells, highlighting miR-342 inhibition as a promising approach for the treatment of endometriosis.

Endometriosis, infertility and MicroRNA's: A review

The review aims to explore circulating small non- coding regulatory Ribonucleic Acids (miRNA) as biomarkers of endometriosis; a reproductive age group disorder. miRNA are linked with genetic, epigenetic and angiogenic factors, hormones, cytokines, chemokines, oxidative stress (OS) markers, mediators of inflammation, hypoxia, angiogenesis and altered immune system contributing to the pathogenesis of endometriosis. Hormonal imbalance occurs by decreased levels of miRNAs -23a and miRNAs -23b and increase in miRNAs -:135a, 135b, 29c and 194-3p. Angiogenesis by vascular endothelial growth factor is attributed to increased miRNAs -126, miRNAs -210, miRNAs -21, miRNAs -199a-5p and miRNAs 20A. OS upregulates miRNAs -302a by increased levels of Tumor Necrosis factor (TNF)-α, TNF- β and Interleukin -1β. Upregulation of miRNAs -199a and miRNAs -16 promotes inflammation and cell proliferation in the endometriotic lesions. The gold standard to diagnose endometriosis is laparoscopy, yet miRNA can be validated as diagnostic tool for detection, progression and prevention of endometriosis in large, independent cohorts of women, with and without endometriosis.

Differentiation between endometriosis-associated ovarian cancers and non- endometriosis-associated ovarian cancers based on magnetic resonance imaging

OBJECTIVES

Endometriosis-associated ovarian cancer (EAOC) patients show different clinical characteristics compared with non-EAOC patients. However, a few studies are focused on the imaging characteristics of EAOC until now. We assessed MRI characteristics in differentiating EAOC and non-EAOC.

METHODS

We retrospectively analyzed clinical and MRI characteristics from 54 patients with 67 lesions diagnosed with primary epithelial ovarian carcinoma at the Third Affiliated Hospital of Guangzhou Medical University between January 2012 and October 2020. We studied MRI findings such as maximum diameter, morphology, configuration, locularity, features of mural nodules, lymphadenopathy, peritoneal implants, the presence of hyperintensity on T1WI, and hypointensity on T2WI. We also studied the clinical characteristics. Significant MRI variables in univariate analysis were selected for subsequent multivariate regression analysis. This study evaluated the diagnostic performance of the significant MRI variables in univariate analysis.

RESULTS

We found that the patients with EAOC, compared with those with non-EAOC, were younger, more unilateral, and had earlier FIGO stage. Univariate analysis revealed that morphology, locularity, growth pattern of mural nodules, and hypointensity on T2WI were factors that significantly differed between EAOC and non-EAOC. In the multivariate logistic regression analysis, locularity and hypointensity on T2WI were independent predictors to distinguish EAOC from non-EAOC.

CONCLUSIONS

EAOC typically presented as a unilocular mass with hypointensity on T2WI in cystic components. MRI could help distinguish EAOC from non-EAOC.

ADVANCES IN KNOWLEDGE

MRI is a promising tool for preoperative diagnosis of EAOC.

Berberine inhibits the proliferation, invasion and migration of endometrial stromal cells by downregulating miR‑429

Endometriosis (EM) is a common gynecological disease, and its pathological process is accompanied by the migration and proliferation of uterine cells. Berberine (BBR) has been shown to exhibit antitumor activity; however, the effects of BBR on EM have seldom been reported to date. The expression of microRNA (miR)-429 is upregulated in EM and miR-429 can be used as a target for drug regulation of cancer cells. Whether BBR plays a regulatory role in EM by targeting miR-429 has not been reported. Thus, the aim of the present study was to determine the effects of BBR on EM cells. The survival rate of immortalized human endometrial stromal cells (HESCs) was determined using a Cell Counting Kit-8 assay. A colony formation assay was used to detect the rate of cell proliferation. The expression levels of proliferation-related proteins, including proliferation marker protein Ki-67 (Ki-67) and proliferating cell nuclear antigen (PCNA), were detected by reverse transcription-quantitative PCR (RT-qPCR) and western blotting. Wound healing and Transwell assays were performed to detect cell migration and invasion, and western blotting was used to detect the expression of the migration- and invasion-related proteins, including matrix metalloproteinase (MMP)2, MMP4 and MMP9. The expression of miR-429 was detected by RT-qPCR following its overexpression via cell transfection. The results revealed that treatment with 80 µM BBR significantly inhibited cell proliferation and colony formation, and inhibited the expression of Ki-67 and PCNA proteins in HESCs. BBR inhibited cell invasion and migration, as well as the expression of MMP2, MMP4 and MMP9. In this process, it was found that the expression of miR-429 decreased following treatment of the cells with BBR, whereas the inhibitory effects of BBR on cell proliferation, invasion and migration were suppressed following the overexpression of miR-429. Overall, the findings of the present study indicated that BBR inhibited the proliferation, invasion and migration of HESCs by downregulating the expression of miR-429.

The Role of Myeloid-Derived Suppressor Cells (MDSCs) in the Development and/or Progression of Endometriosis-State of the Art

Endometriosis (EMS) is a common gynecological disease characterized by the presence of endometrial tissue outside the uterus. Approximately 10% of women around the world suffer from this disease. Recent studies suggest that endometriosis has potential to transform into endometriosis-associated ovarian cancer (EAOC). Endometriosis is connected with chronic inflammation and changes in the phenotype, activity, and function of immune cells. The underlying mechanisms include quantitative and functional disturbances of neutrophils, monocytes/macrophages (MO/MA), natural killer cells (NK), and T cells. A few reports have shown that immunosuppressive cells such as regulatory T cells (Tregs) and myeloid-derived suppressor cells (MDSCs) may promote the progression of endometriosis. MDSCs are a heterogeneous population of immature myeloid cells (dendritic cells, granulocytes, and MO/MA precursors), which play an important role in the development of immunological diseases such as chronic inflammation and cancer. The presence of MDSCs in pathological conditions correlates with immunosuppression, angiogenesis, or release of growth factors and cytokines, which promote progression of these diseases. In this paper, we review the impact of MDSCs on different populations of immune cells, focusing on their immunosuppressive role in the immune system, which may be related with the pathogenesis and/or progression of endometriosis and its transformation into ovarian cancer.

Impact of endometriosis on reproductive health: an integrative review

Endometriosis is a debilitating chronic disease that affects 10% of the general female population, with a frequency of 38% in infertile women. This review aims to provide an overview of the impact of endometriosis on different aspects of reproductive health. A literature search was performed in four international databases, including PubMed, Science Direct, Scopus, and Google scholar, from January 1995 to December 2019 to identify the potentially relevant articles. We included all relevant articles published in English and identified 46 studies on health issues in women with endometriosis. The research suggests that women with endometriosis are at risk for physical, psychosocial, social, and sexual disturbances and obstetrical complications. More research is needed to clarify better understanding of endometriosis complications specifically obstetrical consequences.

Risk factors for endometriotic-cyst associated ovarian cancer: A case controlled study

OBJECTIVE

Primary objective is to identify risk factors of endometriotic-cyst associated ovarian cancer (EAOC). Secondary objective is to evaluate the clinical characteristics of EAOC patients.

MATERIALS AND METHODS

A retrospective case-control study was conducted by analyzing data of patients from 1999 to 2014. Cases were endometriotic-cyst associated ovarian cancer with pathologically confirmed diagnosis. Controls were randomly selected with year-matched patients with benign ovarian endometriotic cyst. Univariate and multivariate with logistic regression analyses were used to identify patients' characteristics that were risk factors for endometriotic-cyst associated ovarian cancer.

RESULTS

Altogether, 158 controls and 79 EAOC cases were recruited. Mean age of the EAOC group was 13 years older than that of the control group (49 vs. 36 years). The most common stage of EAOC was stage I (59.74%). Clear cell subtype is the most commonly found in this population (60.76%). Univariate analysis showed that age ≥42 years, menopause, weight loss, cyst diameter ≥8.33 cm, presence of solid area, bilaterality and CA 125 higher than 117.6 units/ml were significant. Multivariate analysis showed that patients with age ≥42 years (OR 7.69, 95%CI: 2.47, 23.87), menopause (OR 33.19, 95%CI: 2.37, 465.12), weight loss (OR 11.94, 95%CI: 1.52, 94.08), cyst diameter ≥ 8.3 cm (OR 10.56, 95%CI: 4.39, 25.35) and presence of solid area by ultrasonography (OR 6.70, 95%CI: 2.19, 22.35) were significant risk factors for EAOC.

CONCLUSION

Advanced age, menopause, weight loss, cyst diameter ≥ 8.33 cm and presence of solid area from ultrasonography were important risk factors for EAOC.

Endometriosis and ovarian cancer risk, an epigenetic connection

Endometriosis is a gynecological disorder that affects 176 million women worldwide and 1 in 10 females in the United States. Endometriosis most often affects women of child-bearing age, with most going undiagnosed. Endometriosis also shares many characteristics common to invasive cancer and has been known to be associated with epithelial ovarian cancer. Ovarian cancer is the 11^th most common cancer among women and over 22,000 new cases will be diagnosed within the next year. Women most commonly diagnosed with this cancer are between the ages of 55–64 years, outside the range of the age of women affected with endometriosis. While no known cause of either disease has been established, epigenetic regulation is thought to play a major role in both. This review focuses on epigenetic changes that occur within each individual disease as well as those that are similar in both, suggesting a possible etiological link between the two diseases.

Detection of a novel glycodelin biomarker using electrochemical immunosensor for endometriosis

Endometriosis is one of the important issues in women worldwide, which decreases the quality of women's lives in their reproductive age. The diagnosis of endometriosis is carried out by the invasive procedure, which is expensive and painful. In the last few decades, researchers have given more attention to constructing a suitable biomarker-based biosensor for semi/non-invasive diagnosis of endometriosis. As a result, glycodelin (GLY) was found as a promising biomarker because of its selectivity and sensitivity. To the best of our knowledge, it was the first study that reported the detection of GLY biomarker using an electrochemical immunosensor. Briefly, a label-free electrochemical immunosensing platform was constructed through in-situ surface modification of cysteamine layer and immobilisation of antibody (anti-GLY) with help of glutaraldehyde. The interaction between antigen and antibody was measured using square wave voltammetry (SWV). The SWV signal could decrease proportionally with the increasing GLY concentration ranging from 1 to 1000 ng mL^-1 (R² = 0.9981) and a detection limit (LOD) of 0.43 ng mL^-1. Moreover, an immunosensor could exhibit high sensitivity, selectivity, long-term stability, reproducibility and regeneration. Accuracy of the immunosensor was compared with enzyme-linked immunosorbent assay (ELISA), and satisfying results were obtained. The detection of GLY biomarker may be a new possibility for endometriosis diagnosis.

Carcinogenesis as Side Effects of Iron and Oxygen Utilization: From the Unveiled Truth toward Ultimate Bioengineering

Simple Summary

Cancer is a major cause of human mortality worldwide. No life on earth can live without iron. Persistent oxidative stress resulting from continuous use of iron and oxygen may be a fundamental cause of carcinogenesis. Many animal models demonstrated that excess iron may lead to carcinogenesis. This is supported by a variety of human epidemiological data on cancer risk and prognosis. Cancer is basically a disease of the genome with persistently activated oncogenes and inactivated tumor suppressor genes through which iron addiction with ferroptosis-resistance is established. We predict that fine use of nanomaterials and non-thermal plasma may be able to reverse this situation.

Abstract

Evolution from the first life on earth to humans took ~3.8 billion years. During the time there have been countless struggles among the species. Mycobacterium tuberculosis was the last major uncontrollable species against the human public health worldwide. After the victory with antibiotics, cancer has become the leading cause of death since 1981 in Japan. Considering that life inevitably depends on ceaseless electron transfers through iron and oxygen, we believe that carcinogenesis is intrinsically unavoidable side effects of using iron and oxygen. Many animal models unequivocally revealed that excess iron is a risk for carcinogenesis. This is supported by a variety of human epidemiological data on cancer risk and prognosis. Cancer is basically a disease of the genome with persistently activated oncogenes and inactivated tumor suppressor genes through which iron addiction with ferroptosis-resistance is maintained. Engineering has made a great advance in the past 50 years. In particular, nanotechnology is distinct in that the size of the engineered molecules is similar to that of our biomolecules. While some nano-molecules are found carcinogenic, there are principles to avoid such carcinogenicity with a smart possibility to use nano-molecules to specifically kill cancer cells. Non-thermal plasma is another modality to fight against cancer.

Novel ovarian endometriosis model causes infertility via iron-mediated oxidative stress in mice

Ovarian endometriosis (OE) provides women of reproductive age with not only severe menstrual pain but also infertility and an increased risk for ovarian carcinogenesis. Whereas peritoneal endometriosis models have been developed with syngeneic implantation of minced uterine tissue and oncogenic K-ras allele with conditional Pten deletion within ovarian surface epithelium generated preneoplastic endometrial glandular morphology, followed by endometrioid adenocarcinoma, there has been no mouse model of OE similar to human counterparts, applicable to preclinical studies. Here we for the first time established a murine OE model that reveals infertility, and evaluated the involvement of iron catalyzed oxidative stress in the pathogenesis. Minced uterine tissue from female mice was implanted on ovarian surface of syngeneic mice after bursectomy to induce OE. Ectopic growth of endometrium was observed in association with ovary 4 weeks after implantation in 85.7% (12/14) of the operated mice with our protocol. Endometriotic lesions involved intestine, pancreas and peritoneal wall. Fibrosis around the ovary was prominent and increased time-dependently in the OE group. Iron accumulation was significantly increased in the OE group, leading to oxidative stress in each stage of the follicles as evaluated by 4-hydroxy-2-nonenal-modified proteins and 8-hydroxy-2′-deoxyguanosine. Expression of follicle stimulating hormone receptor in the follicles revealed a significant decrease during pre-antral, antral and pre-ovulatory phases in the OE group. Finally, the number of pups was significantly reduced in the OE group in comparison to the controls. This model affords an opportunity to evaluate agents or procedures to counteract ovarian endometriosis in the preclinical settings.

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We for the first time established a murine ovarian endometriosis model via bursectomy.

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Ovarian endometriosis induced iron catalyzed oxidative stress in ovarian follicles.

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This ovarian endometriosis model reveals infertility and is applicable to preclinical studies.

Inhibition of KIF20A by BKS0349 reduces endometriotic lesions in a xenograft mouse model

Several studies have suggested a possible etiological association between ovarian endometriosis and ovarian cancer. Evidence has shown that KIF20A overexpression might confer a malignant phenotype to ovarian tumors by promoting proliferation and inhibiting apoptosis. However, no data about the role of KIF20A in endometriosis have been described. In this study, the human endometrium (n = 4) was transfected by mCherry adenovirus and intraperitoneally implanted in mice. Subsequently, mice were divided in three groups (n = 8/group) that were treated with Vehicle, BKS0349 (KIF20A-antagonist) or cabergoline (dopamine receptor agonist) for 21 days. mCherry-labeled endometriotic lesions were monitored over time using the IVIS Imaging System. Mice were sacrificed 72 h after the last administration; proliferation was evaluated by immunohistochemistry and apoptosis by TUNEL. CCND1 gene expression (G1 phase-related gene) was measured by qRT-PCR. A significant reduction in mCherry-fluorescent signal was observed in the BKS0349 group after treatment ended (D24) compared with D0 (P-value = 0.0313). Moreover, the mCherry signal on D24 showed a significant decrease in the BKS0349 group compared with controls (P-value = 0.0303), along with significant size reduction of endometriotic lesions observed in the BKS0349 group compared with control on D24 (P-value = 0.0006). Functional studies showed a significant reduction in proliferating cells in the BKS0349-treated group compared with controls (P-value = 0.0082). In addition, CCND1 expression was decreased in the BKS0349 group compared with control (P-value = 0.049) at D24 and a significant increase in apoptotic cells among endometriotic lesions in BKS0349-treated mice was observed compared with control (P-value = 0.0317). Based on these findings, we concluded that BKS0349 induces apoptosis and inhibits cell proliferation, reducing endometriotic lesion size and suggesting KIF20A inhibition by BKS0349 as a novel therapeutic treatment for endometriosis.

The estrogen-regulated lncRNA H19/miR-216a-5p axis alters stromal cell invasion and migration via ACTA2 in endometriosis

Fibrotic tissue may contribute to the origin of some endometriosis-related symptoms, such as chronic pelvic pain and infertility. Alterations in the H19/miR-216a-5p/ACTA2 pathway may mediate the regulation of eutopic endometrial stromal cell (euESC) invasion and migration and may represent a potential mechanism underlying fibrous tissue formation or fibrosis in women with endometriosis. In this study, we aimed to determine the expression of H19 and ACTA2 in endometrial tissues of women with endometriosis. Two groups of 23 infertile women with endometriosis and 23 matched infertile women without endometriosis were investigated. Primary cultured cells of endometrial tissues were analyzed using RT-PCR and western blotting (WB) to determine expression of H19 and ACTA2. 5-Ethyl-2'-deoxyuridine, CCK8 and Transwell assays were used to study the functions of H19 and ACTA2. Human embryonic kidney 293 cells were used for luciferase assays to study miR-216a-5p binding sites with H19 and ACTA2. We found that H19 and ACTA2 levels were significantly higher in endometriosis euESCs than in control euESCs (P < 0.05) and were positively correlated in endometriosis euESCs. Luciferase assays indicated that H19 regulates ACTA2 expression via competition for inhibitory miR-216a-5p binding sites. Our results indicate that alterations in the estrogen/H19/miR-216a-5p/ACTA2 pathway regulated endometriosis euESC invasion and migration. Downregulation of H19 or ACTA2 inhibited endometriosis euESC invasion and migration; however, estrogen promoted endometriosis euESC invasion and migration via H19. The main limitation of our study was that experiments were conducted in vitro and further in vivo studies are required in the future. However, our study showed that primary cultured cells represented endometriosis cells more clearly than cell lines.

Is standard radical surgery necessary for elderly patients with early-stage epithelial ovarian carcinoma? ~Propensity score matched analysis~

OBJECTIVE

The impact of 'standard full-staged radical surgery (SRS)' on overall survival (OS) in elderly patients with early-stage epithelial ovarian cancer (EOC) remains unclear. In the current study, we investigated the impact of SRS on OS in elderly patients with early-stage EOC in a multicentric analysis using a propensity score (PS)-matching technique.

METHODS

Between 1986 and 2017, 3227 patients with EOC were registered and accumulated by the Tokai Ovarian Tumor Study Group, consisting of 14 collaborating institutions, after a central pathological review. Among them, 204 elderly patients aged older than or equal to 65 years who had a stage I EOC were analyzed, including 72 patients who had received SRS (Group I) and 132 who had undergone non-SRS limited surgery (Group II). Oncologic outcomes were compared between the two groups using a PS-matching technique to adjust for various clinicopathologic risk factors.

RESULTS

The median follow-up duration of all surviving patients was 55.9 months. Consequently, 54 patients (26.5%) developed recurrence. In addition, 33 patients (16.2%) died of the disease. In the original cohort, the 5-year OS rates of Groups I and II were 95.8 and 82.3%, respectively. We identified a marginally significant difference between the two groups (Log-rank: P = 0.086). In the PS-matched cohort after adjustment for multiple clinicopathologic factors, there was no significant difference in OS between the two groups [OS (Group I vs. II), HR: 0.766 (95% CI: 0.271-2.165), P = 0.615].

CONCLUSIONS

After adjustment for clinicopathologic factors, non-SRS limited surgery may not worsen the oncologic outcome in elderly women with early-stage EOC. A large-scale clinical study is necessary to validate the findings.

Decreased Expression of Peroxiredoxin in Patients with Ovarian Endometriosis Cysts

BACKGROUND

Endometriosis (EMT) is a common occurrence in women of reproductive age. Since oxidative stress has been associated with the development and/or progression of the disease, the present study was conducted to detect the expression of peroxiredoxin (PRX) isoforms, including PRX1, PRX2, and PRX3.

METHODS

Fifty-two patients with ovarian endometriosis cysts and 47 controls were included in the study. Serum levels of PRXs were detected by enzyme-linked immunosorbent assay, and the expression of PRX in the endometrium was examined by immunohistochemistry.

RESULTS

Serum PRX1, PRX2, and PRX3 were significantly lower in EMT patients than in controls. The expression of the three isoforms was significantly decreased in ectopic endometrium compared to that in eutopic or control endometrium. There was no difference in PRX expression between eutopic endometrium of EMT patients and control endometrium, and no association was found between serum PRX levels and immunostaining scores.

CONCLUSION

Our results are the first report that PRXs are downregulated in EMT patients, which suggests that PRXs are involved in the oxidative state of the disease.

Subsequent Development of Epithelial Ovarian Cancer After Ovarian Surgery for Benign Ovarian Tumor: A Population-Based Cohort Study

Purpose

The goal of the current study is to determine the risk of subsequent development of epithelial ovarian cancer (EOC) in women after ovarian surgery for benign ovarian tumors.

Patients and Methods

We conducted the nationwide population-based historic cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan. Eleven thousand six hundred twenty women who underwent ovarian surgery for ovarian benign diseases were analyzed. The collected data included age, types of ovarian surgery, medical history by Charlson comorbidity index (CCI), infertility (yes/no), pelvic inflammatory disease (PID) (yes/no), tubal ligation (yes/no), total/subtotal hysterectomy (TH/STH) (yes/no), and endometrioma (yes/no). We used the Kaplan-Meier method and the Log-rank test to evaluate the risk factors. Cox proportional hazard methods were used to evaluate risk factors for the subsequent development of EOC. Multivariate analysis using Cox stepwise forward regression was conducted for the covariate selected in univariate analysis. Hazard ratio (HR) and 95% confidence interval (CI) were calculated using the Wald test.

Results

Subsequent EOC incidence rate (IR, incidence per 10,000 person-years) of women after ovarian surgery for benign ovarian tumors was 2.98. Separating into four groups based on different age, IR of EOC was 1.57 (<30 years), 4.71 (30-39 years), 3.59 (40-49 years) and 0.94 (≥50 years), respectively. Univariate and multivariate analyses identified only high level of CCI (≥2 or more) as an independent risk factor for subsequent development of EOC in women after ovarian surgery for benign ovarian tumors (HR 59.17, 95% CI 7.50-466.80 in women with CCI level of 2 and HR 190.68, 95% CI 24.33-2494.19, in women with CCI level ≥3, respectively).

Conclusion

Our results, if confirmed, suggest that women with other comorbidities (CCI) should be well informed that they may have a higher risk of subsequent development of EOC when ovarian surgery is planned even though the final pathology showed a benign ovarian tumor.

Pathophysiological Basis of Endometriosis-Linked Stress Associated with Pain and Infertility: A Conceptual Review

Women with endometriosis are often under stress due to the associated pain, infertility, inflammation-related and other comorbidities including cancer. Additionally, these women are also under stress due to taboos, myths, inter-personal troubles surrounding infertility and pain of the disease as well as due to frequent incidences of missed diagnosis and treatment recurrence. Often these women suffer from frustration and loss of valuable time in the prime phase of life. All these complexities integral to endometriosis posit a hyperstructure of integrative stress physiology with overt differentials in effective allostatic state in women with disease compared with disease-free women. In the present review, we aim to critically examine various aspects of pathophysiological basis of stress surrounding endometriosis with special emphasis on pain and subfertility that are known to affect the overall health and quality of life of women with the disease and promising pathophysiological basis for its effective management.

Survival after Anticancer Treatment of Terminally Ill Patients with Ovarian Carcinoma

Background: It remains unclear whether the end-of-life (EOL) treatment/environment impacts on survival after anticancer treatment in terminally ill women with ovarian carcinoma (OC). Objective: The aim of this investigation was to clarify how long those women actually survived after their last anticancer treatments and their hallmarks. Setting, Design, and Measurements: Between 2003 and 2011, 79 terminally ill women with OC were retrospectively analyzed as a single institutional study. Postcancer treatment survival (PCS), defined as the duration between the last date of the abovementioned "cancer treatment" and that of death from any cause, was analyzed on stratification by type of supportive care or where patients spend their EOL. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox regression analyses were employed to compare PCS between the two groups. Results: The median PCS of patients was 10.8 weeks. In the multivariable analysis, the performance status and EOL place retained their significance as independent prognostic factors of poorer PCS (performance status [2-3/0-1]: hazard ratio [HR] = 3.279 [95% confidence interval; CI 1.967-5.586; p < 0.0001], EOL place [hospital/home hospice]: HR = 0.574 [95% CI 0.355-0.913; p = 0.0188]). In the IPTW-adjusted cohort, the median PCS rates were 15.0 and 9.7 weeks in patients of home/hospice and hospital groups, respectively (p = 0.04). Also in the IPTW cohort, the EOL place retained its significance (IPTW-adjusted: HR [95% CI]: 1.548 [1.009-2.374], p = 0.045, multivariable adjusted with IPTW: HR [95% CI]: 1.670 [1.077-2.588], p = 0.022). Conclusion: Our current data may be hypothesis generating; it is possible that the EOL environment is a crucial prognostic factor for survival after anticancer treatment.

Abdominal wall endometriosis (a narrative review)

One of the rarest forms of endometriosis is abdominal wall endometriosis (AWE), which includes caesarean scar endometriosis. AWE remains a challenging condition because some issues related to this topic are still under debate. The increasing number of caesarean sections and laparotomies will expect to increase the rate of AWE. The current incidence in obstetrical and gynaecological procedures is still unknown. The disease is probably underestimated. The pathogenic mechanism involves local environment at the implant site including local inflammation and metalloproteinases activation due to local growth factors, estrogen stimulation through estrogen receptors and potential epigenetic changes. However, the underlying mechanisms are not fully explained, and we need more experimental models to understand them. The clinical presentation is heterogeneous; the patient may be seen by a gynaecologist, an endocrinologist, a general surgeon, an imaging specialist, or even an oncologist. No particular constellation of clinical risk factors has been identified, and the histological report is the major diagnostic tool for confirmation. Surgery is the first line of therapy. Further on we need protocols for multidisciplinary investigations and approaches.

Molecular Imaging of Endometriosis Tissues using Desorption Electrospray Ionization Mass Spectrometry

Endometriosis is a pathologic condition affecting approximately 10% of women in their reproductive years. Characterized by abnormal growth of uterine endometrial tissue in other body areas, endometriosis can cause severe abdominal pain and/or infertility. Despite devastating consequences to patients' quality of life, the causes of endometriosis are not fully understood and validated diagnostic markers for endometriosis have not been identified. Molecular analyses of ectopic and eutopic endometrial tissues could lead to enhanced understanding of the disease. Here, we apply desorption electrospray ionization (DESI) mass spectrometry (MS) imaging to chemically and spatially characterize the molecular profiles of 231 eutopic and ectopic endometrial tissues from 89 endometriosis patients. DESI-MS imaging allowed clear visualization of endometrial glandular and stromal regions within tissue samples. Statistical models built from DESI-MS imaging data allowed classification of endometriosis lesions with overall accuracies of 89.4%, 98.4%, and 98.8% on training, validation, and test sample sets, respectively. Further, molecular markers that are significantly altered in ectopic endometrial tissues when compared to eutopic tissues were identified, including fatty acids and glycerophosphoserines. Our study showcases the value of MS imaging to investigate the molecular composition of endometriosis lesions and pinpoints metabolic markers that may provide new knowledge on disease pathogenesis.