Malignant Transformation and Associated Biomarkers of Ovarian Endometriosis: A Narrative Review

Prioritization of potential drug targets in ovarian-related diseases: Mendelian randomization and colocalization analyses

OBJECTIVE

To identify key genes and potential drug targets for ovarian-related diseases through genome-wide Mendelian randomization (MR) and colocalization analyses.

DESIGN

We conducted a comprehensive two-sample MR analysis to estimate the causal effects of blood expression quantitative trait loci (eQTLs) on ovarian-related diseases, followed by colocalization analyses to verify the robustness of the expression instrumental variables (IVs). Phenome-wide association studies (PheWAS) were also performed to evaluate the horizontal pleiotropy of potential drug targets and possible side effects.

SUBJECTS

Large cohorts of European ancestry.

EXPOSURE

The exposure in this study was the genetic variants (eQTLs) associated with gene expression levels, considered a form of lifelong exposure. Expression quantitative trait loci data were obtained from the eQTLGen Consortium, encompassing 16,987 genes and 31,684 cis-eQTLs derived from blood samples of healthy individuals of European ancestry.

MAIN OUTCOME MEASURES

The primary outcome measures were the identification of genes causally associated with ovarian-related diseases and the validation of these genes as potential therapeutic targets.

RESULTS

Our study revealed that specific genes such as CD163L1, PPP3CA, MTAP, F12, NRM, BANK1, ZNF66, GNA15, and SLC6A9 were associated with ovarian endometriosis, ovarian cysts, and polycystic ovarian syndrome. Through MR and colocalization analyses, we identified potential drug targets, including CTNNB1, PTPN7, and ABCB4, with strong evidence of colocalization with ovarian-related diseases. Sensitivity analyses confirmed the robustness of our findings, showing no evidence of horizontal pleiotropy or heterogeneity.

CONCLUSION

This research highlights the significance of precision medicine approaches in identifying genetic factors underlying ovarian-related diseases and provides a foundation for developing targeted therapies, enhancing diagnostic accuracy, and improving treatment strategies for ovarian-related diseases.

Overexpression of FOS enhances the malignant potential of eutopic endometrial stromal cells in patients with endometriosis‑associated ovarian cancer

Endometrial cysts of the ovary (EMC) may develop into endometriosis (EM)‑associated ovarian cancer over time (EAOC), but the pathogenesis of this disease has not been determined. In the present study, RNA sequencing was used to identify a feasible biomarker, and the molecular function of this biomarker in eutopic endometrial cells from EAOC and EMC patients was evaluated to explore the potential mechanism related to EAOC and orthotopic endometrial tissue. RNA sequencing was performed on 5 EAOC and 4 EMC tissue samples, and differential expression analysis was performed. To identify biomarkers, differentially expressed genes were subjected to protein‑protein interaction network design, Gene Ontology pathway enrichment, and Gene Set Enrichment Analysis pathway enrichment. The expression of FOS in the endometrium was detected via immunohistochemical staining. Lv‑FOS was utilized to upregulate FOS in human endometrial stromal cells (hEnSCs), and Cell Counting Kit‑8, colony formation and scratch assays were performed to assess cell viability, proliferation and migration, respectively. Western blotting was used to determine protein expression. In total, 249 genes, including FOS, were differentially expressed. Pathway enrichment analysis demonstrated that the MAPK, AP‑1, ERK and other signaling pathways were involved in the EMC‑to‑EAOC conversion. FOS upregulation in hEnSCs increased cell viability, proliferation and migration. Western blot results revealed that after FOS expression was inhibited, P21 expression was upregulated, and CDK4, Cyclin D1, p‑Stat3, MMP2 and MMP9 expression was downregulated. In conclusion, mitosis and the cell cycle were found to affect the progression of EMC to EAOC. The expression of FOS, a novel biomarker, was identified to enhance the malignant potential of eutopic endometrial stromal cells in patients with EM‑associated ovarian cancer.

Potential biomarkers and immune infiltration linking endometriosis with recurrent pregnancy loss based on bioinformatics and machine learning

Objective

Endometriosis (EMs) is a chronic inflammatory disease characterized by the presence of endometrial tissue in the non-uterine cavity, resulting in dysmenorrhea, pelvic pain, and infertility. Epidemiologic data have suggested the correlation between EMs and recurrent pregnancy loss (RPL), but the pathological mechanism is unclear. This study aims to investigate the potential biomarkers and immune infiltration in EMs and RPL, providing a basis for early detection and treatment of the two diseases.

Methods

Two RPL and six EMs transcriptomic datasets from the Gene Expression Omnibus (GEO) database were used for differential analysis via limma package, followed by weighted gene co-expression network analysis (WGCNA) for key modules screening. Protein-protein interaction (PPI) network and two machine learning algorithms were applied to identify the common core genes in both diseases. The diagnostic capabilities of the core genes were assessed by receiver operating characteristic (ROC) curves. Moreover, immune cell infiltration was estimated using CIBERSORTx, and the Cancer Genome Atlas (TCGA) database was employed to elucidate the role of key genes in endometrial carcinoma (EC).

Results

26 common differentially expressed genes (DEGs) were screened in both diseases, three of which were identified as common core genes (MAN2A1, PAPSS1, RIBC2) through the combination of WGCNA, PPI network, and machine learning-based feature selection. The area under the curve (AUC) values generated by the ROC indicates excellent diagnostic powers in both EMs and RPL. The key genes were found to be significantly associated with the infiltration of several immune cells. Interestingly, MAN2A1 and RIBC2 may play a predominant role in the development and prognostic stratification of EC.

Conclusion

We identified three key genes linking EMs and RPL, emphasizing the heterogeneity of immune infiltration in the occurrence of both diseases. These findings may provide new mechanistic insights or therapeutic targets for further research of EMs and RPL.

[Pathogenesis of fibrosis development in ovarian endometriosis]

Endometriosis-associated fibrosis is a complex phenomenon, and the underlying mechanisms are still not fully understood. Fibrosis is invariably present in all forms of the disease and contributes to the classic endometriosis-associated symptoms such as chronic pelvic pain and infertility. The purpose of this literature review was to study the role of various cell populations, biological mechanisms and signaling pathways in inducing fibrogenesis of endometriosis lesions. PubMed and MEDLINE searched for studies published in English over the past 5 years that studied fibrosis in ovarian endometriosis.

Causal Relationship Between Endometriosis, Female Infertility, and Primary Ovarian Failure Through Bidirectional Mendelian Randomization

Background

Endometriosis and its associated gynecological diseases such as female infertility and primary ovarian failure (POF), impose a long-term disease burden on women. This study aims to explore the causal relationships between these conditions through a two-sample bidirectional Mendelian randomization (MR) study.

Methods

We utilized large-scale GWAS data and conducted bidirectional MR analyses using methods such as Inverse Variance Weighted (IVW) and MR-Egger to assess the causal relationships between endometriosis and female infertility, POF, amenorrhoea, and oligomenorrhoea.

Results

MR analysis revealed significant causal relationships between endometriosis and female infertility (OR=1.430, 95% CI 1.306-1.567, P<0.01) as well as POF (OR=1.348, 95% CI 1.050-1.731, P=0.019). Reverse MR analysis indicated causal relationships between amenorrhoea (OR=1.076, 95% CI 1.009-1.148, P=0.026) and female infertility (OR=1.340, 95% CI 1.092-1.645, P<0.01) with endometriosis. Sensitivity analyses confirmed the robustness of these findings (heterogeneity: Q_pval>0.05, pleiotropy: pval>0.05).

Conclusion

This study suggested that managing endometriosis may help prevent conditions such as female infertility and POF, and vice versa. Future research is needed to confirm these findings in more diverse populations.

Postmenopausal Endometriosis: Clinical Insights and Imaging Considerations

Endometriosis is a chronic systemic condition characterized by the presence of ectopic endometrial-like tissue outside of the uterus. It occurs most often in reproductive-aged patients and less frequently in postmenopausal women. In postmenopausal patients, endometriosis is more common in those undergoing hormone replacement therapy or taking tamoxifen. The risk of malignant transformation of endometriosis is higher in this older population, especially in those undergoing estrogen-only hormone replacement therapy. Many theories on the postmenopausal pathogenesis of endometriosis have been proposed, ranging from reactivation of premenopausal disease to de novo manifestation. Compared with premenopausal disease, postmenopausal endometriosis is typically less active and extensive, with fewer hemorrhagic components. Patients may be symptomatic, with chronic pelvic pain, or may receive the diagnosis after imaging performed for other indications such as an incidental ovarian lesion. Treatment is typically surgical resection or estrogen-blocking medications. Although the diagnosis requires pathologic confirmation, radiologists play an important role in diagnosing both benign endometriosis and malignant transformation. Pelvic US following a dedicated protocol is an accessible screening tool, with high sensitivity for diagnosis of bowel-invasive disease. MRI has better anatomic resolution and allows simultaneous characterization of adnexal and extrapelvic lesions, thereby providing excellent assessment for malignant transformation.

Decreased expression of KLF6 in ectopic endometrial stromal cells contributes to endometriosis progression by targeting CTNNB1

Despite decades of research, endometriosis remains a mysterious gynecological disease with unknown etiology and pathogenesis. Krüppel-like Factor 6 (KLF6), a transcription factor, has a wide expression profile and regulates a variety of biological processes. Here, we investigated the expression and function of KLF6 and its possible regulatory mechanisms in endometriosis. To determine the function of KLF6, knockdown and overexpression experiments were performed in eutopic endometrial stromal cells (EU-ESCs) and ectopic endometrial stromal cells (EC-ESCs), respectively. Cell viability, apoptosis, migration, invasion, and angiogenesis assays were conducted in ESCs. ChIP-sequencing and mRNA-sequencing were performed to investigate the functional mechanism of KLF6 in regulating ESCs. We found that KLF6 was highly expressed in eutopic endometrium of endometriosis patients, compared with ectopic endometrium. Similarly, the same was true in EU-ESCs, which was compared with EC-ESCs. Overexpression of KLF6 significantly suppressed EC-ESC proliferation, migration and invasion and induced cell apoptosis, while knockdown of KLF6 resulted in the opposite effects on EU-ESCs. Overexpression of KLF6 significantly inhibited EC-ESC angiogenesis. Mechanistically, the results of ChIP sequencing and mRNA sequencing revealed that CTNNB1 may be a transcriptional target regulated by KLF6. Reintroduction of KLF6 reversed the effects of KLF6 knockdown on EU-ESCs. KLF6 inhibited the proliferation, migration and angiogenesis of EC-ESCs by inhibiting the expression of CTNNB1. Our findings provided a new perspective on the role of KLF6 in endometriosis progression and inspire potential targeted therapeutic strategies.

Mass spectrum oriented metabolomics for evaluating the efficacy and discovering the mechanism of Shaofuzhuyu Decoction for endometriosis of cold coagulation and blood stasis

Shaofuzhuyu Decoction (SFZYD) is a classical formula for treating endometriosis of cold coagulation and blood stasis (ECB). The clinical efficacy is definite, but the potential mechanisms require further exploration. The study aimed to reveal the metabolic mechanisms of SFZYD for treating ECB using mass spectrum oriented metabolomics. Firstly, the study has used metabolomics data to identify biomarkers and to investigate metabolic pathways. Then, the targets of SFZYD for treating ECB were dug by building and analyzing a biological network of biomarkers. Finally, the obtained targets were validated by molecular docking. This study found that SFZYD could significantly improve the biochemical indicators and metabolic abnormalities of ECB. A total of 18 ECB-related biomarkers in 7 pathways were identified. SFZYD was able to regulate the levels of 14 biomarkers that were involved in 5 metabolic pathways. Furthermore, the study yielded 119 SFZYD active ingredients, 1119 target proteins associated with endometriosis, 610 targets associated with biomarkers, 727 GO functions, and 159 KEGG pathways. Biological network analysis constructed a network diagram of herbs-ingredients-targets-biomarkers, and found 6 key active ingredients and 9 core targets. Molecular docking showed high affinities between key ingredients and core targets. This study elucidated that SFZYD plays a role in treating ECB through multi-component, multi-target, and multi-pathway.

Follicular Fluid and Blood Monitorization of Infertility Biomarkers in Women with Endometriosis

Infertility is recognized globally as a social disease and a growing medical condition, posing a significant challenge to modern reproductive health. Endometriosis, the third-most frequent gynecologic disorder, is one of the most common and intricate conditions that can lead to female infertility. Despite extensive research, the etiology, malignant transformation, and biological therapy of endometriosis remain unknown. Blood and follicular fluid are two matrices that have been carefully studied and can provide insights into women's health. These matrices are clinically significant because they contain metabolites closely associated with women's illness stage and reproductive outcomes. Nowadays, the application of metabolomic analysis in biological matrices may be able to predict the outcome of assisted reproductive technologies with greater precision. From a molecular viewpoint on reproductive health, we evaluate and compare the utilization of human follicular fluid and blood as matrices in analysis for diagnostic and assisted reproductive technology (ART) predictors of success for endometriosis patients. In the follicular fluid (FF), plasma, and serum of endometriosis-affected women, researchers identified dysregulations of oxidative stress, upregulation of several immune factors, and aberrations in energy metabolic pathways. The altered signatures negatively correlate with the overall oocyte and embryo quality and fertilization rate.

The "Road" to Malignant Transformation from Endometriosis to Endometriosis-Associated Ovarian Cancers (EAOCs): An mTOR-Centred Review

Ovarian cancer is an umbrella term covering a number of distinct subtypes. Endometrioid and clear-cell ovarian carcinoma are endometriosis-associated ovarian cancers (EAOCs) frequently arising from ectopic endometrium in the ovary. The mechanistic target of rapamycin (mTOR) is a crucial regulator of cellular homeostasis and is dysregulated in both endometriosis and endometriosis-associated ovarian cancer, potentially favouring carcinogenesis across a spectrum from benign disease with cancer-like characteristics, through an atypical phase, to frank malignancy. In this review, we focus on mTOR dysregulation in endometriosis and EAOCs, investigating cancer driver gene mutations and their potential interaction with the mTOR pathway. Additionally, we explore the complex pathogenesis of transformation, considering environmental, hormonal, and epigenetic factors. We then discuss postmenopausal endometriosis pathogenesis and propensity for malignant transformation. Finally, we summarize the current advancements in mTOR-targeted therapeutics for endometriosis and EAOCs.

Immune pathway through endometriosis to ovarian cancer

Endometriosis is an estrogen-dependent inflammatory disease, defined by the presence of functional endometrial tissue outside of the uterine cavity. This disease is one of the main gynecological diseases, affecting around 10%-15% women and girls of reproductive age, being a common gynecologic disorder. Although endometriosis is a benign disease, it shares several characteristics with invasive cancer. Studies support that it has been linked with an increased chance of developing endometrial ovarian cancer, representing an earlier stage of neoplastic processes. This is particularly true for women with clear cell carcinoma, low-grade serous carcinoma and endometrioid. However, the carcinogenic pathways between both pathologies remain poorly understood. Current studies suggest a connection between endometriosis and endometriosis-associated ovarian cancers (EAOCs) via pathways associated with oxidative stress, inflammation, and hyperestrogenism. This article aims to review current data on the molecular events linked to the development of EAOCs from endometriosis, specifically focusing on the complex relationship between the immune response to endometriosis and cancer, including the molecular mechanisms and their ramifications. Examining recent developments in immunotherapy and their potential to boost the effectiveness of future treatments.

Endometriosis-Related Ovarian Cancer: Where Are We Now? A Narrative Review towards a Pragmatic Approach

BACKGROUND

Endometriosis affects more than 10% of reproductive-aged women, causing pelvic pain and infertility. Despite the benign nature of endometriosis, ovarian endometriomas carry a higher risk of developing endometrioid carcinomas (EnOCs) and clear cell ovarian carcinomas (CCCs). Atypical endometriosis, defined as cytological atypia resembling intraepithelial cancer, is considered the precursor of endometriosis-associated ovarian cancer (EAOC). This narrative review aims to provide an overview of EAOC, proposing a practical approach to clinical and therapeutic decision making.

METHODS

An electronic literature search was conducted from inception up to January 2023, using the MEDLINE database via PubMed to evaluate the existing literature on EAOC, including its pathogenesis, the diagnostic process, and the therapeutic possibilities, with articles not relevant to the topic or lacking scientific merit being excluded.

RESULTS

Eighty-one articles were included in the review to present the current state of the art regarding EAOC. A pragmatic clinical flowchart is proposed to guide therapeutic decisions and improve patient outcomes.

CONCLUSIONS

Endometriosis patients may have an increased risk of developing EAOC (either EnOC or CCC). Despite not being fully accepted, the concept of AE may reshape the endometriosis-ovarian cancer relationship. Further research is needed to understand the unaddressed issues.

Expression of high-mobility group box-1 in eutopic/ectopic endometrium and correlations with inflammation-related factors in adenomyosis

OBJECTIVE

To investigate the expression of HMGB1 and toll-like receptor 4 (TLR4) in adenomyosis eutopic/ectopic endometrium.

METHODS

Twenty patients with adenomyosis and 20 controls, all undergoing laparoscopy, were recruited from September 2015 to July 2016. Samples were collected from the endometrium without adenomyosis (CE), the eutopic endometrium with adenomyosis (EuE), and the ectopic endometrium with adenomyosis (EE). The mRNA and protein expression of HMGB1 and TLR4, and interleukin-6 (IL-6) and interleukin-8 (IL-8) RNA expression levels were measured.

RESULTS

The average age of the adenomyosis women was 43.4 ± 5.3 years; their BMI was 23.3 ± 2.3 kg/m2. The control group included women aged 38.8 ± 9.8 years, with BMI 22.2 ± 3.4 kg/m2. The mRNA expression levels of HMGB1, TLR4, IL-6, and IL-8 in the EE and EuE groups were higher than those in the CE group (p < .01), and those in the EE group were higher than those in the EuE group (p < .01). The protein expression levels of HMGB1 and TLR4 in the EE and EuE groups were higher than those in the CE group (p < .01); they were higher in the EE group than the ones in the EuE group (p < .01). HMGB1 mRNA was significantly positively correlated with TLR4 in EuE and EC patients (r = 0.538 and r = 0.916, p < .01), as well as with IL-6 (r = 0.470 and r = 0.976, p < .01) and IL-8 (r = 0.574 and r = 0.650, p < .01).

CONCLUSIONS

The overexpression of HMGB1 and TLR4 in EuE and EE is positively correlated with IL-6 and IL-8 expression. The HMGB1 signaling-mediated immune-inflammatory system might be involved in the development of adenomyosis.

Case Series and a Literature Review: Two Ovarian Clear Cell Carcinoma Cases with Recurrent Endometriosis

Introduction

Endometriosis-associated ovarian cancer (EAOC) is rare, occurring approximately in 1% of women with ovarian endometriosis. The main histological types are endometrioid adenocarcinoma and clear cell carcinoma (CCC), with the latter being the least common.

Case Presentation

In our hospital, we recently summarized two patients with ovarian clear cell carcinoma with similar characteristics. They all had endometriosis for a long time and had undergone ovarian cyst removal due to a chocolate cyst. Unfortunately, the cyst recurred after surgery, and the histological diagnosis was clear cell carcinoma. In case 1, the expression of P53 was found in the tumor by regular examination, and the stage was IIB. In Case 2, we found it in intraoperative freezing; the stage was IA. Case 1 has been treated with the TP regimen six times, and the survival period has reached one year. Case 2 had a survival period of 6 years after completing six TP regimen treatments. Clinicians should pay attention to patients with a long history of endometriosis and postoperative recurrence of ovarian cysts accompanied by serum CA-125 of more than 200U/mL. Imaging examination has a good prospect in diagnosing malignant transformation of endometriosis, especially PET-CT.

Conclusion

This case report highlights the risk factors related to the formation of ovarian clear cell carcinoma and suggests that the follow-up of patients with ovarian endometriosis is essential because of its recurrence characteristics. Radical surgery and postoperative platinum-containing chemotherapy are the primary treatment methods at present.

Mast Cell Tryptase and Carboxypeptidase A3 in the Formation of Ovarian Endometrioid Cysts

The mechanisms of ovarian endometrioid cyst formation, or cystic ovarian endometriosis, still remain to be elucidated. To address this issue, we analyzed the involvement of mast cell (MC) tryptase and carboxypeptidase A3 (CPA3) in the development of endometriomas. It was found that the formation of endometrioid cysts was accompanied by an increased MC population in the ovarian medulla, as well as by an MC appearance in the cortical substance. The formation of MC subpopulations was associated with endometrioma wall structures. An active, targeted secretion of tryptase and CPA3 to the epithelium of endometrioid cysts, immunocompetent cells, and the cells of the cytogenic ovarian stroma was detected. The identification of specific proteases in the cell nuclei of the ovarian local tissue microenvironment suggests new mechanisms for the regulatory effects of MCs. The cytoplasmic outgrowths of MCs propagate in the structures of the stroma over a considerable distance; they offer new potentials for MC effects on the structures of the ovarian-specific tissue microenvironment under pathological conditions. Our findings indicate the potential roles of MC tryptase and CPA3 in the development of ovarian endometriomas and infer new perspectives on their uses as pharmacological targets in personalized medicine.

Impacts of endometrioma on ovarian aging from basic science to clinical management

Endometriosis is a common reproductive disorder characterized by the presence of endometrial implants outside of the uterus. It affects ~1 in 10 women of reproductive age. Endometriosis in the ovary, also known as endometrioma (OMA), is the most frequent implantation site and the leading cause of reproductive failure in affected women. Ovarian aging is one of the characteristic features of OMA, however its underlying mechanism yet to be determined. Accumulated evidence has shown that pelvic and local microenvironments in women with OMA are manifested, causing detrimental effects on ovarian development and functions. Whilst clinical associations of OMA with poor ovarian reserve, premature ovarian insufficiency, and early menopause have been reported. Moreover, surgical ablation, fenestration, and cystectomy of OMA can further damage the normal ovarian reservoir, and trigger hyperactivation of primordial follicles, subsequently resulting in the undesired deterioration of ovarian functions. Nevertheless, there is no effective treatment to delay or restore ovarian aging. This review comprehensively summarised the pathogenesis and study hypothesis of ovarian aging caused by OMA in order to propose potential therapeutic targets and interventions for future studies.

MicroRNA-149 Regulates Proliferation, Migration, and Invasion of Pituitary Adenoma Cells by Targeting ADAM12 and MMP14

OBJECTIVE

Pituitary adenomas (PAs) can adapt an aggressive phenotype by invading adjacent brain structures with rapid cellular proliferation. Previous studies demonstrated that excessive expression of metalloproteases ADAM12 and MMP-14 is instrumental for the active proliferation and invasiveness of PA cells in vitro and of tumors in vivo. However, the mechanisms regulating ADAM12 and MMP-14 expression in PAs remain unclear.

METHODS

Target gene prediction and transcriptomic profiling of invasive vs. noninvasive human PA samples were performed to identify miRNA species potentially involved in the regulation of ADAM12 and MMP14. For cellular analyses of miRNA functions, two mouse PA cell lines (AtT20 and TtT/GF) were transfected with miR-149-3p and miR-149-5p, respectively. The effects of miR-149 (3p and 5p) on expression levels of ADAM12 and MMP14 were determined by Western blotting followed by an analysis of proliferation and colony formation assays, scratch migration assays, and invasion assays.

RESULTS

A significant downregulation of miRNA-149 was observed in invasive vs. noninvasive PA (0.32 vs. 0.09, P<0.0001). In AtT-20 and TtT/GF mouse PAs cells, transfection of mimic miRNA-149 (3p and 5p) caused a significantly reduced cell proliferation and matrigel invasion, whilst the effect on cell migration was less pronounced. Both strands of miRNA-149 (3p and 5p) markedly reduced protein levels of ADAM12 and MMP-14 by at least 40% in both cell lines.

CONCLUSION

This study proved that the invasiveness of PA cells is, at least partly, regulated by miRNA-149-dependent expression of ADAM12 and MMP-14.

The association between endometriosis and risk of endometrial cancer and breast cancer: a meta-analysis

PURPOSE

Endometriosis (EMS) is confirmed pathophysiologically to be an estrogen-dependent disease, similar to endometrial hyperplasia/cancer and breast cancer. Epidemiological and biological data on endometriosis might explain links between endometriosis and these cancers. We sought to identify the differences in the risk of endometrial cancer and breast cancer between women with and women without endometriosis.

METHODS

We searched PubMed, EMBASE, the Cochrane Library, and four Chinese databases (CNKI, VIP, WanFang, CBM) to identify relevant studies published online between January 2011 and March 2021. In our meta-analysis, we used the Newcastle-Ottawa Scale (NOS) to evaluate the design and quality of all studies, and we calculated the pooled risk ratio (RR) using the random model. The Q test and I2 were used to evaluate the degree of heterogeneity of eligible studies. We used funnel plots and Begg's and Egger's tests to assess publication bias.

RESULTS

Of the 1369 articles, we finally included 14 cohort studies and seven case-control studies. Data from large cohort and case-control studies indicate that women with endometriosis had an increased risk of both endometrial cancer [RR, 1.662; 95% CI, (1.148-2.407)] and breast cancer [RR, 1.082; 95% CI, (1.001-1.169)].

CONCLUSION

Endometriosis can increase the risk of endometrial cancer and breast cancer, and women with endometriosis are recommended to receive routine screening in long-term management.

Volatilomics as an Emerging Strategy to Determine Potential Biomarkers of Female Infertility: A Pilot Study

Due to its high prevalence, infertility has become a prominent public health issue, posing a significant challenge to modern reproductive medicine. Some clinical conditions that lead to female infertility include polycystic ovary syndrome (PCOS), endometriosis, and premature ovarian failure (POF). Follicular fluid (FF) is the biological matrix that has the most contact with the oocyte and can, therefore, be used as a predictor of its quality. Volatilomics has emerged as a non-invasive, straightforward, affordable, and simple method for characterizing various diseases and determining the effectiveness of their current therapies. In order to find potential biomarkers of infertility, this study set out to determine the volatomic pattern of the follicular fluid from patients with PCOS, endometriosis, and POF. The chromatographic data integration was performed through solid-phase microextraction (SPME), followed by gas chromatography–mass spectrometry (GC-MS). The findings pointed to specific metabolite patterns as potential biomarkers for the studied diseases. These open the door for further research into the relevant metabolomic pathways to enhance infertility knowledge and diagnostic tools. An extended investigation may, however, produce a new mechanistic understanding of the pathophysiology of the diseases.

Mass-like extragonadal endometriosis associated malignant transformation in the pelvis: A rare case report

BACKGROUND

Endometriosis affects approximately 10% of reproductive-age women, however, endometriosis associated malignant transformation is rare and is often report as a rare case.

CASE SUMMARY

Herein, we report of a 49-year-old female patient who suffered from severe left lower abdominal pain and imaging examination revealed an irregular mass in the left iliac fossa. Histopathological examination revealed main undifferentiated adenocarcinoma with a few typical endometrial epithelial and stromal tissues in the adjacent area. Combined with the immunohistochemical staining and the negative intra- or postoperative results from exploratory laparotomy, gastroscopy, enteroscopy and positron emission tomography, the tumor was considered to be derived from endometriosis. The patient underwent hysterectomy, bilateral salpingectomy, bilateral ovariectomy, and multipoint biopsy of the pelvic peritoneum. Subsequent radiotherapy and chemotherapy were performed. The patient recovered well post-operation and there was no evidence of recurrence after 10 mo of follow-up via computed tomography and magnetic resonance imaging.

CONCLUSION

This case highlights a rare presentation of mass-like extragonadal endometriosis associated malignant transformation in the pelvis. Endometriosis associated malignant transformation is rare and difficult to diagnose in clinical settings, with diagnoses depending on pathological results and the exclusion of metastasis from other organs. Fortunately, patients are often diagnosed at younger ages, as well as at early stages; thus they generally have relatively favorable prognoses.

Primary high-grade serous cancer arising from uterosacral ligament endometriosis: two case reports

Although high-grade serous cancer (HGSC) accounts for >70% of ovarian epithelial cancers, it is rarely associated with endometriosis. No previous study has reported an association between the malignant transformation of uterine ligament endometriosis and HGSC. Here, we reported two cases of Chinese female patients with HGSC arising from endometriosis in the uterosacral ligament. They had a long-term history of endometriosis and dysmenorrhea. Both were diagnosed with HGSC at stage IIB. They underwent operations and six cycles of chemotherapy with paclitaxel and carboplatin and have remained disease-free to date. Genomic analysis showed no known/suspected pathogenic variations or somatic homologous recombination deficiency in the two cases. In conclusion, these rare cases of HGSC from endometriosis might indicate a new origin of ovarian type II carcinoma. Patients with a long-term history of endometriosis and sudden aggravation of dysmenorrhea or vaginal bleeding should be aware of the possibility of endometriotic malignant transformation.

Evaluation of Women's Age and Ultrasonographic Features to Choose Surgical Treatment for Endometriosis Associated with Ovarian Cancer

Adequate surgical management of malignant endometriosis remains a clinical challenge in gynecology. Age, sonography variables, and tumor biomarkers have been reported as candidates in the clinical decision. This study aims were to analyze the factors of women’s age, body mass index, ultrasound features, and tumor biomarkers to predict endometriosis-associated ovarian cancer in a large series of endometriomas and to study the surgical treatment performed in this cohort. In this retrospective study, we reviewed the medical records of patients with ultrasound diagnosis of ovarian cyst classified as endometrioma (benign as well as with risk of malignancy), surgically treated in the endometriosis unit of Hospital Universitario La Paz (Madrid, Spain) between January 2019 and July 2021. According to the final histology examination, the women were clustered as non-endometriosis-associated ovarian cancer (OE, benign endometriomas, n = 59) and endometriosis-associated ovarian cancer (EAOC) (n = 17). Demographic, clinical, and surgical data were collected from these women. International Ovarian Tumor Analysis (IOTA) criteria were assessed for the ultrasound examination. The age of the women in the EAOC group was 50.0 [43.0; 63.0] years, which was significantly higher than OE (39.0 [34.0; 46.0] years; p-value < 0.001). In addition, the body mass index for the OE group (24.9 ± 5.3 kg/m2) was significantly higher than for the EAOC group (23.3 ± 4.6 kg/m2; p-value < 0.001). However, the tumor biomarker levels (CA 125, CA 19.9 and He4) were not significantly different among the groups. We performed 51.4% cystectomies and 48.6% adnexectomies, with an association between the adnexectomy and EAOC group (p-value < 0.001). In addition, a significant association was found between ultrasound features suspicious for malignancy and the EAOC group. Conclusively, women’s age and ultrasound features, such as papillary projections, septa, and positive echo-Doppler, were the main factors to consider when evaluating the malignancy risk associated with endometriosis.

A Systematic Review of Atypical Endometriosis-Associated Biomarkers

Ovarian endometriosis may increase the risk of malignancy. Several studies have suggested atypical endometriosis as the direct precursor of endometriosis-associated ovarian cancer. We performed an advanced, systematic search of the online medical databases PubMed and Medline. The search revealed n = 40 studies eligible for inclusion in this systematic review. Of these, n = 39 were finally included. The results from included studies are characterized by high heterogeneity, but some consistency has been found for altered expression in phosphoinositide 3-kinase (PI3K)/AKT/mTOR pathway, ARID1a, estrogen and progesterone receptors, transcriptional, nuclear, and growth factors in atypical endometriosis. Although many targets have been proposed as biomarkers for the presence of atypical endometriosis, none of them has such strong evidence to justify their systematic use in clinical practice, and they all need expensive molecular analyses. Further well-designed studies are needed to validate the evidence on available biomarkers and to investigate novel serum markers for atypical endometriosis.

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.

Genetic determination of the ovarian reserve: a literature review

The ovarian reserve is one of the most important indicators of female fertility. It allows for the evaluation of the number of viable oocytes. This parameter is actively used in pregnancy planning and in assisted reproductive technology application, as it determines chances of successful fertilization and healthy pregnancy. Due to increased attention towards diagnostic tests evaluating the ovarian reserve, there has been a growing interest in factors that influence the state of the ovarian reserve. True reasons for pathological changes in the ovarian reserve and volume have not yet been explored in depth, and current diagnostic screening methods often fall short in efficacy. In the following review we analyze existing data relating to the study of the ovarian reserve through genetic testing, determining specific characteristics of the ovarian reserve through genetic profiling. We explore existing studies dedicated to finding specific genetic targets influencing the state of the ovarian reserve.

Oestrogen up-regulates DNMT1 and leads to the hypermethylation of RUNX3 in the malignant transformation of ovarian endometriosis

RESEARCH QUESTION

What is the mechanism of hypermethylation of runt-related transcription factor 3 (RUNX3) in the eutopic endometrium of endometriosis as biomarker in the malignant transformation of endometriosis?

DESIGN

Methylation-specific polymerase chain reaction was used to analyse the methylation status of RUNX3 in endometriosis-associated ovarian cancer (EAOC). Primary eutopic endometrial stromal cells (ESC) were isolated from the uteri of patients with ovarian endometriosis. After RUNX3 knockdown by RNA interference technology or ESC treated with oestradiol, the proliferation and invasion ability were evaluated in ESC by using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) and transwell assays.

RESULTS

The frequency of methylation of RUNX3 in neoplastic tissue in the EAOC group was significantly higher than that in the ectopic endometrium of the endometriosis group (P < 0.001), and the frequency of methylation of RUNX3 in the eutopic endometrium of the EAOC group was significantly higher than that in the endometriosis group (P < 0.001). However, there was no significant difference in the eutopic endometrium when compared between the endometriosis group and the control endometrium group (P = 0.233). Silencing RUNX3 promoted the proliferation and invasion of ESC (P < 0.001 and P < 0.001). Following intervention with oestrogen, it was observed that the oestradiol group showed higher levels of RUNX3 methylation (P < 0.001) and DNA methyltransferase 1 (DNMT1) mRNA and protein expression (P < 0.001 and P < 0.001), and lower RUNX3 mRNA and protein expression when compared with the ESC group (P < 0.001 and P < 0.001).

CONCLUSION

This study demonstrated that hypermethylation of the RUNX3 was related to the malignant transformation of endometriosis and that this process was related to corresponding changes in the eutopic endometrium. Furthermore, the 'oestrogen-DNMT1' signalling pathway may induce the hypermethylation of RUNX3 to promote the malignant transformation of endometriosis.

A Review of the Clinical Characteristics and Novel Molecular Subtypes of Endometrioid Ovarian Cancer

Ovarian cancer is one of the most common gynecologic cancers that has the highest mortality rate. Endometrioid ovarian cancer, a distinct subtype of epithelial ovarian cancer, is associated with endometriosis and Lynch syndrome, and is often accompanied by synchronous endometrial carcinoma. In recent years, dysbiosis of the microbiota within the female reproductive tract has been suggested to be involved in the pathogenesis of endometrial cancer and ovarian cancer, with some specific pathogens exhibiting oncogenic having been found to contribute to cancer development. It has been shown that dysregulation of the microenvironment and accumulation of mutations are stimulatory factors in the progression of endometrioid ovarian carcinoma. This would be a potential therapeutic target in the future. Simultaneously, multiple studies have demonstrated the role of four molecular subtypes of endometrioid ovarian cancer, which are of particular importance in the prediction of prognosis. This literature review aims to compile the potential mechanisms of endometrioid ovarian cancer, molecular characteristics, and molecular pathological types that could potentially play a role in the prediction of prognosis, and the novel therapeutic strategies, providing some guidance for the stratified management of ovarian cancer.

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.

Health Science Community Will Miss This Bright and Uniting Star: In Memory of Professor Gjumrakch Aliev, M.D, Ph.D

It is with deep sadness that we offer our memorial on the unexpected demise of our dear colleague, Professor Gjumrakch Aliev [...].

Dienogest as a Maintenance Treatment for Endometriosis Following Surgery: A Systematic Review and Meta-Analysis

This study aimed to comprehensively assess the value of Dienogest (DNG) as a maintenance treatment following conservative surgery for endometriosis in terms of the outcomes of disease and pregnancy. We searched for relevant studies and trials up to November 2020 from PubMed, Cochrane Library, Medline, and EMBASE databases as well as the Web of Science. Patients who received DNG maintenance treatment were compared to those who received other treatments (OT), including the levonorgestrel-releasing intrauterine system (LNG-IUS) and gonadotropin-releasing hormone analogs (GnRH-a), or non-treatment (NT). The primary outcomes were disease recurrence and pregnancy rates. Eleven studies were included in this meta-analysis. The pooled analysis indicated that DNG maintenance treatment was associated with a lower rate of disease recurrence. A significant difference was observed in DNG maintenance treatment compared with NT, but not with OT, in the pregnancy rates postoperatively. Moreover, DNG maintenance treatment was related to a significant increase in vaginal bleeding and weight gain. DNG can be recommended as a maintenance treatment for patients with endometriosis to decrease the rates of disease recurrence following conservative surgery. However, DNG maintenance treatment has no advantage in improving pregnancy rates compared to OT.

Histomorphological and Functional Features of the Eutopic Endometrium in Patients with Ovarian Endometriosis After Surgery-a Clinical Study

Endometriosis causes infertility and the alterations in endometrial receptivity. Pinopodia in eutopic endometrial epithelium may have significant implications in the endometriosis-associated infertility. The aim of this study is to ascertain whether the surgical interventions to remove endometrioid ovarian cysts (EOCs) can improve endometrial receptivity. The study included 172 patients of reproductive age with EOC, who underwent laparoscopic cystectomy. Aspiration endometrial biopsy was performed at 6 and 12 months after the surgery during the proliferation and secretion phases. Histopathology analysis included H&E staining and IHC. Morphometric studies were performed on endometrial biopsies collected during the proliferation phase of 28 patients, and the secretion phase of 12 patients. The expression of IHC markers for estrogen receptors (ER) and progesterone receptors (PR) and the percentage of cells containing pinopodia were determined. A significant increase in the ER and PR expression was observed in the epithelium during the "middle stage, proliferation phase" and in the stroma and glands during "middle stage, secretion phase". A delay in endometrial secretory transformation and statistically significant decrease in the number of pinopodia was observed on the apical surface of the cells. These structural and functional alterations were observed both at 6 and 12 months after cystectomy. The endometriosis-associated infertility after surgical intervention of EOC could be due to the extensive expression of ER and PR during the proliferation and secretion phases, as well as the delayed secretory transformation and impaired formation of pinopodia in the eutopic endometrium in the patients at 6 and 12 months after surgery.

MiRNAs as Noninvasive Biomarkers and Therapeutic Agents of Pituitary Adenomas

Pituitary adenoma (PA) accounts for 10-15% of all intracranial neoplasms. Even though most pituitary adenomas are benign, it is known that almost 35% of them exhibit an aggressive clinical course, including rapid proliferative activity and invasion of neighboring tissues. MicroRNAs (miRNAs) are short single-stranded RNA molecules that can influence post-transcriptional regulation by controlling target genes. Based on research data on miRNAs over the past 20 years, more than 60% of genes encoding human proteins are regulated by miRNAs, which ultimately control basic cellular mechanisms, including cell proliferation, differentiation, and apoptosis. Dysregulation of miRNAs has been observed in a number of diseases, especially tumors like PA. A majority of miRNAs are expressed within the cells themselves. However, the circulating miRNAs can be detected in several biological fluids of the human body. The identification of circulating miRNAs as new molecular markers may increase the ability to detect a tumor, predict the course of a disease, plan to choose suitable treatment, and diagnose at the earliest signs of impending neoplastic transformation. Therapy of PAs with aggressive behavior is a complex task. When surgery and chemotherapy fail, radiotherapy becomes the treatment of choice against PAs. Therefore, the possibility of implementing circulating miRNAs as innovative diagnostic and therapeutic agents for PA is one of the main exciting ideas.