Aberrant expression of erythropoietin in uterine leiomyoma: implications in tumor growth

A rare case of venous sinus thrombosis and pulmonary embolisms secondary to myomatous erythrocytosis syndrome

Myomatous erythrocytosis syndrome is a rare phenomenon of secondary polycythemia evolving from uterine leiomyoma. Although the underlying pathology is still unknown, patients have an increased risk of venous thrombosis. A 44-year-old GO (gravida zero) presented with an incidental finding of secondary polycythemia, and a diagnosis of myomatous erythrocytosis syndrome was made because of her large uterine fibroids. She was placed on therapeutic anticoagulation after developing pulmonary embolisms and a dural sinus venous thrombosis. Subsequently, she underwent uterine artery embolization, which resulted in a substantial decrease in her erythropoietin (8.1 mU/mL) along with hemoglobin (15.1 g/dL) and hematocrit (4 5g/dL). Myomatous erythrocytosis syndrome can cause venous thrombosis, leading to neurologic complications. In patients with increased risk for surgery, uterine artery embolization is an effective option for treatment.

Pathways of Hypoxia-Inducible Factor (HIF) in the Orchestration of Uterine Fibroids Development

Uterine fibroids (UF) are common benign tumors in women. The course of UF is associated with troubling symptoms and the development of infertility and pregnancy pathology. Surgical treatment even implies hysterectomy, while pharmacological interventions are modestly effective. Classically, hypoxic metabolism is considered a hallmark of malignant tumor. However, the role of hypoxia-induced factor (HIF) is significant in benign tumors as well. Herein, we briefly review the basic biology of HIF-family proteins, outlining their possible roles in UF. Apart from theoretical justifications, we summarized 15 studies reporting increased expression of HIFs and downstream factors in UF samples. Altogether, data suggest that increased expression of the HIF-protein and altered expression of its dependent genes are presumed to be the factors leading to UF development. Thus, even without being a malignant tumor, UF is characterized by the strong involvement of HIF. This novel insight may give rise to further research in the direction of finding new prognostic markers and effective medicines against UF.

Secondary Erythrocytosis Associated with Uterine Myoma Is Rare but Should Be of Concern

Myomatous erythrocytosis syndrome (MES) is a rare gynecological condition, defined by the presence of the clinical triad of erythrocytosis, uterine fibroids, and normalization of red blood cell counts after the surgical removal of uterine fibroids. Herein, we report the case of a woman, in the postmenopausal stage, with the clinical triad of MES. She had a history of erythrocytosis of unknown etiology and underwent phlebotomy for a year prior to visiting our hospital. Pre-operative hemoglobin (Hb) level, hematocrit (Hct) level, and red blood cell (RBC) count were 18.1 g/dL, 56.1%, and 6.52 million cells/μL, respectively. She underwent exploratory laparotomy, transabdominal hysterectomy, and bilateral salpingo-oophorectomy. The operative findings revealed a large uterine myoma, and the pathology result was compatible with uterine leiomyoma. All hematologic parameters returned to the normal range on post-operative day 1. Her hematologic parameters returned to normal values 4 weeks after surgery with a Hb level of 13.5 g/dL, Hct level of 41.2%, and RBC count of 4.92 million cells/μL. The exact pathophysiology of this condition remains unknown. However, surgical removal of uterine myoma is the mainstay of treatment. Despite the rarity of this condition, its diagnosis should be considered in patients presenting with erythrocytosis and uterine masses.

MED12 mutations in uterine leiomyomas: prediction of volume reduction by gonadotropin-releasing hormone agonists

BACKGROUND

Gonadotropin-releasing hormone agonists are used to treat premenopausal uterine leiomyomas; however, leiomyoma volume reduction is not always achieved. The reduction rate after this treatment varies for each leiomyoma, even in the same patient. Therefore, an effective method for predicting uterine leiomyoma volume reduction is required to reduce the adverse hypoestrogenic effects and drug-related economic burden related to gonadotropin-releasing hormone agonists.

OBJECTIVE

This study aimed to determine the predictive use of MED12 mutations for evaluating the effect of gonadotropin-releasing hormone agonist treatment concerning reducing uterine leiomyoma volume and to predict the MED12 mutation status based on the findings of magnetic resonance imaging performed before treatment.

STUDY DESIGN

MED12 exon 2 mutation and erythropoietin expression in uterine leiomyomas were evaluated concerning volume reduction, as measured using magnetic resonance imaging. We developed a system for classifying leiomyomas according to T2-weighted magnetic resonance imaging signals to noninvasively predict the presence or absence of MED12 mutations in leiomyomas. Leiomyoma samples (>5 cm) were obtained from 168 patients during surgery (hysterectomy or myomectomy) between 2005 and 2021 at Yokohama City University Hospital. To analyze the rate of leiomyoma volume reduction, 41 patients had been preoperatively administered the gonadotropin-releasing hormone agonist (leuprorelin acetate 3.75 mg, monthly subcutaneous injection) for 3 months; magnetic resonance imaging was performed before and after treatment without contrast material.

RESULTS

Patients with MED12 exon 2 mutations had smaller volume reduction after treatment with the gonadotropin-releasing hormone agonist (P<.001, Mann-Whitney U test) and displayed lower signal intensity on T2-weighted images than those with leiomyomas expressing wild-type MED12 exon 2. The newly proposed magnetic resonance imaging-based classification system showed that MED12 exon 2 mutations were more frequent in the low-signal group than in the high-signal group, with nearly equal proportions of mutated and wild-type MED12 exon 2 leiomyomas noted in the intermediate group. The low-signal group had significantly lower erythropoietin expression levels than the high-signal group (P<.001, Kruskal-Wallis test with the Dunn posthoc analysis).

CONCLUSION

MED12 mutation status can be a candidate marker for predicting the effect of gonadotropin-releasing hormone agonists on uterine leiomyoma reduction. Magnetic resonance imaging findings can be used to determine MED12 mutation status as a noninvasive strategy to select patients who will most likely benefit from gonadotropin-releasing hormone agonist treatment.

Case Report: Myomatous erythrocytosis syndrome presenting as rapid growth of an extra-uterine mass

Objective

To report a case of myomatous erythrocytosis syndrome (MES) with an extra-uterine manifestation.

Case report

A 43-year-old woman presented with progressive abdominal distension and rapid enlargement of a pelvic mass. Upon survey, a high-level of hemoglobin (19.0 g/dl) was documented. The initial impression was an ovarian malignancy, but uterine sarcoma could not be ruled out because of its rapid growth. However, during exploratory laparotomy, the pelvic mass was found to be a 31 cm broad ligament leiomyoma; which is extremely rare for its size and location. The specimen was further studied immunohistochemically, which revealed excessive expressions of erythropoietin and erythropoietin receptors in addition to the diffusely matured blood vessels in the myoma tissue. The patient’s hemoglobin level resumed to normal three months post-surgery. The diagnosis of MES was confirmed both clinically and histologically.

Conclusion

A correct preoperative diagnosis is challenging when MES manifests as an extrauterine mass. The coexistence of MES should be considered in the management of all leiomyoma with polycythemia, regardless of locations.

Different DNA methylome, transcriptome and histological features in uterine fibroids with and without MED12 mutations

Somatic mutations in Mediator complex subunit 12 (MED12m) have been reported as a biomarker of uterine fibroids (UFs). However, the role of MED12m is still unclear in the pathogenesis of UFs. Therefore, we investigated the differences in DNA methylome, transcriptome, and histological features between MED12m-positive and -negative UFs. DNA methylomes and transcriptomes were obtained from MED12m-positive and -negative UFs and myometrium, and hierarchically clustered. Differentially expressed genes in comparison with the myometrium and co-expressed genes detected by weighted gene co-expression network analysis were subjected to gene ontology enrichment analyses. The amounts of collagen fibers and the number of blood vessels and smooth muscle cells were histologically evaluated. Hierarchical clustering based on DNA methylation clearly separated the myometrium, MED12m-positive, and MED12m-negative UFs. MED12m-positive UFs had the increased activities of extracellular matrix formation, whereas MED12m-negative UFs had the increased angiogenic activities and smooth muscle cell proliferation. The MED12m-positive and -negative UFs had different DNA methylation, gene expression, and histological features. The MED12m-positive UFs form the tumor with a rich extracellular matrix and poor blood vessels and smooth muscle cells compared to the MED12m-negative UFs, suggesting MED12 mutations affect the tissue composition of UFs.

Treating Myomatous Erythrocytosis Syndrome With Uterine Artery Embolization

BACKGROUND

Myomatous erythrocytosis syndrome, a form of secondary polycythemia associated with uterine leiomyomas, increases the risk of thrombosis and traditionally has been treated with hysterectomy.

CASE

The patient is a 68-year-old woman with 7-year history of polycythemia initially thought to be secondary to a gastrointestinal stromal tumor that persisted after resection. A subsequent search for an alternative etiology led to the discovery of an 11.2-cm submucosal leiomyoma and likelihood of myomatous erythrocytosis syndrome. The patient declined surgical management and continued to undergo recurrent phlebotomy to maintain a hematocrit of less than 45% until consultation with an interventional radiology specialist. She underwent uterine artery embolization in July 2017, and her hematocrit has remained within normal limits through 17 months of follow-up.

CONCLUSION

Uterine artery embolization is an effective alternative treatment modality for myomatous erythrocytosis syndrome.

More Than a Myoma: A Review of Myomatous Erythrocytosis Syndrome

Myomatous erythrocytosis syndrome (MES) is gynaecological condition marked by isolated erythrocytosis and a fibroid uterus. This report presents a case of MES and reviews common clinical presentations, hematological trends, and patient outcomes. This study was a combined case report and review of published cases of MES. Cases were identified using Medline and EMBASE databases. Binomial statistics were used to compare clinical characteristics among patients with MES. Kruskal-Wallis one-way analysis of variance was used to compare hematological values across time points (Canadian Task Force Classification III). A total of 57 cases of MES were reviewed. The mean age at presentation was 48.7 years. Commonly reported signs or symptoms at presentation include abdominopelvic distension or mass (93%), skin discolouration (33%), and menstrual irregularities (25%). There was no difference in parity (P = 0.42), menopausal status (P = 0.87), or hydronephrosis on imaging (P = 0.48) among patients. Preoperative phlebotomy to reduce the risk of thromboembolic complications was performed in half of all cases. On average, a 51% reduction in serum erythropoietin levels was observed following surgical resection (P = 0.004). In conclusion, patients with MES present with signs and symptoms attributed to either an abdominopelvic mass or erythrocytosis. Preoperative phlebotomy to decrease the severity of erythrocytosis has been used to mitigate the risk of thrombotic complications. Surgical resection of the offending leiomyoma is a valid approach for the treatment of MES.

Expression of platelet-derived growth factor BB, erythropoietin and erythropoietin receptor in canine and feline osteosarcoma

The discovery of expression of the erythropoietin receptor (EPO-R) on neoplastic cells has led to concerns about the safety of treating anaemic cancer patients with EPO. In addition to its endocrine function, the receptor may play a role in tumour progression through an autocrine mechanism. In this study, the expression of EPO, EPO-R and platelet-derived growth factor BB (PDGF-BB) was analysed in five feline and 13 canine osteosarcomas using immunohistochemistry (IHC) and reverse transcription polymerase chain reaction (RT-PCR).

EPO expression was positive in all tumours by IHC, but EPO mRNA was only detected in 38% of the canine and 40% of the feline samples. EPO-R was expressed in all samples by quantitative RT-PCR (RT-qPCR) and IHC. EPO-R mRNA was expressed at higher levels in all feline tumours, tumour cell lines, and kidney when compared to canine tissues. PDGF-BB expression was variable by IHC, but mRNA was detected in all samples. To assess the functionality of the EPO-R on tumour cells, the proliferation of canine and feline osteosarcoma cell lines was evaluated after EPO administration using an alamarBlue assay and Ki67 immunostaining. All primary cell lines responded to EPO treatment in at least one of the performed assays, but the effect on proliferation was very low indicating only a weak responsiveness of EPO-R. In conclusion, since EPO and its receptor are expressed by canine and feline osteosarcomas, an autocrine or paracrine tumour progression mechanism cannot be excluded, although in vitro data suggest a minimal role of EPO-R in osteosarcoma cell proliferation.