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Hamang M, Yaden B, Dai G. Gastrointestinal pharmacology activins in liver health and disease. Biochem Pharmacol 2023; 214:115668. [PMID: 37364623 PMCID: PMC11234865 DOI: 10.1016/j.bcp.2023.115668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/06/2023] [Accepted: 06/20/2023] [Indexed: 06/28/2023]
Abstract
Activins are a subgroup of the TGFβ superfamily of growth and differentiation factors, dimeric in nature and consisting of two inhibin beta subunits linked via a disulfide bridge. Canonical activin signaling occurs through Smad2/3, with negative feedback initiated by Smad6/7 following signal transduction, which binds activin type I receptor preventing phosphorylation of Smad2/3 and activation of downstream signaling. In addition to Smad6/7, other inhibitors of activin signaling have been identified as well, including inhibins (dimers of an inhibin alpha and beta subunit), BAMBI, Cripto, follistatin, and follistatin-like 3 (fstl3). To date, activins A, B, AB, C, and E have been identified and isolated in mammals, with activin A and B having the most characterization of biological activity. Activin A has been implicated as a regulator of several important functions of liver biology, including hepatocyte proliferation and apoptosis, ECM production, and liver regeneration; the role of other subunits of activin in liver physiology are less understood. There is mounting data to suggest a link between dysregulation of activins contributing to various hepatic diseases such as inflammation, fibrosis, and hepatocellular carcinoma, and emerging studies demonstrating the protective and regenerative effects of inhibiting activins in mouse models of liver disease. Due to their importance in liver biology, activins demonstrate utility as a therapeutic target for the treatment of hepatic diseases such as cirrhosis, NASH, NAFLD, and HCC; further research regarding activins may provide diagnostic or therapeutic opportunity for those suffering from various liver diseases.
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Affiliation(s)
- Matthew Hamang
- Department of Biology, School of Science, Indiana University - Purdue University Indianapolis, IN, United States.
| | - Benjamin Yaden
- Department of Biology, School of Science, Indiana University - Purdue University Indianapolis, IN, United States.
| | - Guoli Dai
- Department of Biology, School of Science, Indiana University - Purdue University Indianapolis, IN, United States.
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Refaat B, Ashshi AM, El-Shemi AG, Azhar E. Activins and Follistatin in Chronic Hepatitis C and Its Treatment with Pegylated-Interferon-α Based Therapy. Mediators Inflamm 2015; 2015:287640. [PMID: 25969625 PMCID: PMC4417604 DOI: 10.1155/2015/287640] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 02/27/2015] [Accepted: 02/27/2015] [Indexed: 12/12/2022] Open
Abstract
Pegylated-interferon-α based therapy for the treatment of chronic hepatitis C (CHC) is considered suboptimal as not all patients respond to the treatment and it is associated with several side effects that could lead to dose reduction and/or termination of therapy. The currently used markers to monitor the response to treatment are based on viral kinetics and their performance in the prediction of treatment outcome is moderate and does not combine accuracy and their values have several limitations. Hence, the development of new sensitive and specific predictor markers could provide a useful tool for the clinicians and healthcare providers, especially in the new era of interferon-free therapy, for the classification of patients according to their response to the standard therapy and only subscribing the novel directly acting antiviral drugs to those who are anticipated not to respond to the conventional therapy and/or have absolute contraindications for its use. The importance of activins and follistatin in the regulation of immune system, liver biology, and pathology has recently emerged. This review appraises the up-to-date knowledge regarding the role of activins and follistatin in liver biology and immune system and their role in the pathophysiology of CHC.
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Affiliation(s)
- Bassem Refaat
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al-'Abdiyah Campus, P. O. Box 7607, Makkah, Saudi Arabia
| | - Ahmed Mohamed Ashshi
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al-'Abdiyah Campus, P. O. Box 7607, Makkah, Saudi Arabia
| | - Adel Galal El-Shemi
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al-'Abdiyah Campus, P. O. Box 7607, Makkah, Saudi Arabia
- Department of Pharmacology, Faculty of Medicine, Assiut University, Assiut 6515, Egypt
| | - Esam Azhar
- Special Infectious Agents Unit, King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia
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Kreidl E, Oztürk D, Metzner T, Berger W, Grusch M. Activins and follistatins: Emerging roles in liver physiology and cancer. World J Hepatol 2009; 1:17-27. [PMID: 21160961 PMCID: PMC2999257 DOI: 10.4254/wjh.v1.i1.17] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 09/10/2009] [Accepted: 09/17/2009] [Indexed: 02/06/2023] Open
Abstract
Activins are secreted proteins belonging to the TGF-β family of signaling molecules. Activin signals are crucial for differentiation and regulation of cell proliferation and apoptosis in multiple tissues. Signal transduction by activins relies mainly on the Smad pathway, although the importance of crosstalk with additional pathways is increasingly being recognized. Activin signals are kept in balance by antagonists at multiple levels of the signaling cascade. Among these, follistatin and FLRG, two members of the emerging family of follistatin-like proteins, can bind secreted activins with high affinity, thereby blocking their access to cell surface-anchored activin receptors. In the liver, activin A is a major negative regulator of hepatocyte proliferation and can induce apoptosis. The functions of other activins expressed by hepatocytes have yet to be more clearly defined. Deregulated expression of activins and follistatin has been implicated in hepatic diseases including inflammation, fibrosis, liver failure and primary cancer. In particular, increased follistatin levels have been found in the circulation and in the tumor tissue of patients suffering from hepatocellular carcinoma as well as in animal models of liver cancer. It has been argued that up-regulation of follistatin protects neoplastic hepatocytes from activin-mediated growth inhibition and apoptosis. The use of follistatin as biomarker for liver tumor development is impeded, however, due to the presence of elevated follistatin levels already during preceding stages of liver disease. The current article summarizes our evolving understanding of the multi-faceted activities of activins and follistatins in liver physiology and cancer.
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Affiliation(s)
- Emanuel Kreidl
- Emanuel Kreidl, Deniz Öztürk, Thomas Metzner, Walter Berger, Michael Grusch, Institute of Cancer Research, Department of Medicine I, Medical University of Vienna, Borschkegasse 8a, Vienna A-1090, Austria
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Lafferty-Whyte K, Cairney CJ, Jamieson NB, Oien KA, Keith WN. Pathway analysis of senescence-associated miRNA targets reveals common processes to different senescence induction mechanisms. BIOCHIMICA ET BIOPHYSICA ACTA 2009; 1792:341-52. [PMID: 19419692 DOI: 10.1016/j.bbadis.2009.02.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Revised: 02/02/2009] [Accepted: 02/03/2009] [Indexed: 01/07/2023]
Abstract
Multiple mechanisms of senescence induction exist including telomere attrition, oxidative stress, oncogene expression and DNA damage signalling. The regulation of the cellular changes required to respond to these stimuli and create the complex senescent cell phenotype has many different mechanisms. MiRNAs present one mechanism by which genes with diverse functions on multiple pathways can be simultaneously regulated. In this study we investigated 12 miRNAs previously identified as senescence regulators. Using pathway analysis of their target genes we tested the relevance of miRNA regulation in the induction of senescence. Our analysis highlighted the potential of these senescence-associated miRNAs (SA-miRNAs) to regulate the cell cycle, cytoskeletal remodelling and proliferation signalling logically required to create a senescent cell. The reanalysis of publicly available gene expression data from studies exploring different senescence stimuli also revealed their potential to regulate core senescence processes, regardless of stimuli. We also identified stimulus specific apoptosis survival pathways theoretically regulated by the SA-miRNAs. Furthermore the observation that miR-499 and miR-34c had the potential to regulate all 4 of the senescence induction types we studied highlights their future potential as novel drug targets for senescence induction.
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Affiliation(s)
- Kyle Lafferty-Whyte
- University of Glasgow, Cancer Research UK Beatson Laboratories, Bearsden, Glasgow G61 1BD, UK
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Deli A, Kreidl E, Santifaller S, Trotter B, Seir K, Berger W, Schulte-Hermann R, Rodgarkia-Dara C, Grusch M. Activins and activin antagonists in hepatocellular carcinoma. World J Gastroenterol 2008; 14:1699-709. [PMID: 18350601 PMCID: PMC2695910 DOI: 10.3748/wjg.14.1699] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In many parts of the world hepatocellular carcinoma (HCC) is among the leading causes of cancer-related mortality but the underlying molecular pathology is still insufficiently understood. There is increasing evidence that activins, which are members of the transforming growth factor β (TGFβ) superfamily of growth and differentiation factors, could play important roles in liver carcinogenesis. Activins are disulphide-linked homo- or heterodimers formed from four different β subunits termed βA, βB, βC, and βE, respectively. Activin A, the dimer of two βA subunits, is critically involved in the regulation of cell growth, apoptosis, and tissue architecture in the liver, while the hepatic function of other activins is largely unexplored so far. Negative regulators of activin signals include antagonists in the extracellular space like the binding proteins follistatin and FLRG, and at the cell membrane antagonistic co-receptors like Cripto or BAMBI. Additionally, in the intracellular space inhibitory Smads can modulate and control activin activity. Accumulating data suggest that deregulation of activin signals contributes to pathologic conditions such as chronic inflammation, fibrosis and development of cancer. The current article reviews the alterations in components of the activin signaling pathway that have been observed in HCC and discusses their potential significance for liver tumorigenesis.
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Endo D, Maku-Uchi M, Kojima I. Activin or follistatin: which is more beneficial to support liver regeneration after massive hepatectomy? Endocr J 2006; 53:73-8. [PMID: 16543675 DOI: 10.1507/endocrj.53.73] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The present study was conducted to compare the effects of exogenous follistatin and activin A on liver regeneration in 90% hepatectomized rats. Intraportal administration of follistatin markedly accelerated liver regeneration, and nuclear BrdU labeling and liver regeneration rate were greatly increased by follistatin. In contrast, administration of activin A attenuated liver regeneration. After 120 h of 90% hepatectomy, histological analysis showed that the hepatic architecture was restored in control and activin-treated rats. However, it was not restored in follistatin-treated rats. The serum bilirubin levels were significantly increased in follistatin-treated rats, and the serum glucose level was significantly lower in follistatin-treated rats. Although follistatin markedly accelerated liver regeneration, it reduced the function of the remnant liver. Treatment with activin A instead may be beneficial to support liver regeneration after massive hepatectomy.
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Affiliation(s)
- Daisuke Endo
- Institute for Molecular and Cellular Regulation, Gunma University, Maebashi, Japan
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Ho J, de Guise C, Kim C, Lemay S, Wang XF, Lebrun JJ. Activin induces hepatocyte cell growth arrest through induction of the cyclin-dependent kinase inhibitor p15INK4B and Sp1. Cell Signal 2005; 16:693-701. [PMID: 15093610 DOI: 10.1016/j.cellsig.2003.11.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2003] [Revised: 11/12/2003] [Accepted: 11/14/2003] [Indexed: 01/07/2023]
Abstract
In this report, we examined the role of activin in the regulation of cell growth inhibition of human hepatocarcinoma cells. Using RNase protection assay for various cell cycle regulators and Western blotting experiments, we show that activin treatment of HepG2 cells leads to increased gene expression of the cyclin-dependent kinase inhibitor (CDKI) p15INK4B. Furthermore, transient co-transfection studies of the p15INK4B promoter/luciferase construct performed in HepG2 cells demonstrates that activin induction of the p15INK4B promoter is mediated through the Smad pathway. p15INK4B gene promoter mapping analysis revealed a 66-bp region within the proximal domain of the promoter, which contains a consensus site for the transcription factor Sp1, as critical for mediating the activin effect on p15INK4B gene expression. Finally, gel mobility shift experiments, using the Sp1 consensus site, revealed increased DNA binding of Sp1 in response to activin treatment of HepG2 cells, further confirming the involvement of Sp1 in activin-mediated p15INK4B gene promoter activation. Together, our data indicates an important role for the cyclin-dependent kinase inhibitor p15INK4B in activin-induced cell cycle arrest in liver cells.
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Affiliation(s)
- Joanne Ho
- Hormones and Cancer Research Unit, Department of Medicine, Royal Victoria Hospital, McGill University, Montreal, Canada H3A 1A1
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Borgnon J, Djamouri F, Lorand I, Rico VD, Loux N, Pages JC, Franco D, Capron F, Weber A. Follistatin allows efficient retroviral-mediated gene transfer into rat liver. Biochem Biophys Res Commun 2005; 328:937-43. [PMID: 15707968 DOI: 10.1016/j.bbrc.2005.01.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2004] [Indexed: 10/25/2022]
Abstract
Retroviral vectors are widely used tools for gene therapy. However, in vivo gene transfer is only effective in dividing cells, which, in liver, requires a regenerative stimulus. Follistatin is effective in promoting liver regeneration after 90% and 70% hepatectomy in rats. We studied its efficacy on liver regeneration and retroviral-mediated gene delivery in 50% hepatectomized rats. When human recombinant follistatin was infused into the portal vein immediately after 50% hepatectomy, hepatocyte proliferation was significantly higher than in control 50% hepatectomized rats. A single injection of virus particles administered 23 h after follistatin infusion resulted in more than 20% gene transduction efficiency in hepatocytes compared to 3% in control rats. It is concluded that a single injection of follistatin induces onset of proliferation in 50% hepatectomized rats and allows efficient retroviral-mediated gene transfer to the liver.
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Affiliation(s)
- Josephine Borgnon
- INSERM EMI 00-20 and University Paris XI, Bicêtre Hospital, Kremlin-Bicêtre, France
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Takabe K, Wang L, Leal AMO, Macconell LA, Wiater E, Tomiya T, Ohno A, Verma IM, Vale W. Adenovirus-mediated overexpression of follistatin enlarges intact liver of adult rats. Hepatology 2003; 38:1107-15. [PMID: 14578849 DOI: 10.1053/jhep.2003.50483] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Under normal physiologic conditions, liver size is under strict regulatory control. Activin, a member of the transforming growth factor beta (TGF-beta) superfamily, is expressed in the intact adult liver and is an inhibitor of hepatocyte growth. However, the exact role played by endogenous activin in maintaining the size of a normal adult liver has yet to be completely examined in vivo. Here, we report the development of an adenoviral vector (AdexCAFS288) that expressed human follistatin-288, which binds to activin and neutralizes its biologic activities. AdexCAGFP, a control virus, expressed green fluorescent protein. AdexCAFS288 effectively expressed follistatin-288, as measured both in HepG2 cell lysate and conditioned medium and blocked activin signaling and its biologic functions in vitro. Intraperitoneal injection of AdexCAFS288 in vivo resulted in significant liver growth (146% of control) in intact liver of adult male rats 12 days following treatment without significant dysfunctions. The increase in liver size was attributed to increased hepatocyte proliferation, as monitored by the mitotic index. Furthermore, there was a significant correlation between serum follistatin levels and liver weight. In conclusion, our results suggest that activin plays a critical role in maintaining optimal liver size and implicates the endogenous activin system as a therapeutic target in the treatment of liver disease.
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Affiliation(s)
- Kazuaki Takabe
- The Clayton Foundation Laboratories for Peptide Biology, The Salk Institute, La Jolla, CA 92037, USA
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Liu QH, Li DG, Huang X, You HN, Pan Q, Xu LM, Xu QF, Lu HM. Effect of Activin on extracelluar matrix secretion in isolated rat hepatic stellate cell. Shijie Huaren Xiaohua Zazhi 2003; 11:745-748. [DOI: 10.11569/wcjd.v11.i6.745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the effect of activin A on the extracelluar matrix secretion of rat hepatic stellate cell.
METHODS Hepatic stellate cells were isolated and purified from normal male Sprague-Dawley rat liver by a combination of pronase-collagenase perfusion and density gradient centrifugation. Passaged hepatic stellate cells were divided randomly into eight groups: control group(A group), ACTA 1 μg/L group (B group), ACTA 10 μg/L group(C group), ACTA 100 μg/L group (D group), TGF β1 10 μg/L group(E group), TGF β1 10 μg/L plus ACTA 1 μg/L group(F group), TGF β1 10 μg/L plus ACTA 10 μg/L group(G group), TGF β1 10 μg/L plus ACTA 100 μg/L group(H group). 24 h after incubation secretion of procollagen Ⅲ, collagen Ⅳ and mRNA of collagen Ⅲ in hepatic stellate cells were detected by radioimmunoassays and semi-quantitative RT-PCR method respectively.
RESULTS Extracellular matrix secretion in passaged hepatic stellate cells was enhanced by activin A according to its concentration, the capacity of extracellular matrix secretion by 100 μg/L activin A was equal to that of 10 μg/L TGF β1, extracellular matrix secretion and type Ⅲ collagen mRNA expression in passaged hepatic stellate cells was enhanced by activin A and TGFβ1 in a synergistic manner.
CONCLUSION Activin A may contribute to hepatic fibrogenesis.
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Affiliation(s)
- Qing-Hua Liu
- Department of Gastroenterology of Xinhua Hospital, Shanghai Second Medical University, Shanghai 200092, China
| | - Ding-Guo Li
- Department of Gastroenterology of Xinhua Hospital, Shanghai Second Medical University, Shanghai 200092, China
| | - Xin Huang
- Department of Gastroenterology of Xinhua Hospital, Shanghai Second Medical University, Shanghai 200092, China
| | - Han-Ning You
- Department of Gastroenterology of Xinhua Hospital, Shanghai Second Medical University, Shanghai 200092, China
| | - Qin Pan
- Department of Gastroenterology of Xinhua Hospital, Shanghai Second Medical University, Shanghai 200092, China
| | - Lei-Ming Xu
- Department of Gastroenterology of Xinhua Hospital, Shanghai Second Medical University, Shanghai 200092, China
| | - Qin-Fang Xu
- Department of Gastroenterology of Xinhua Hospital, Shanghai Second Medical University, Shanghai 200092, China
| | - Han-Ming Lu
- Department of Gastroenterology of Xinhua Hospital, Shanghai Second Medical University, Shanghai 200092, China
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Abstract
Inhibin and activin are members of the TGF beta superfamily of growth and differentiation factors. They were first identified as gonadal-derived regulators of pituitary FSH and were subsequently assigned multiple actions in a wide range of tissues. More recently, the inhibin alpha subunit was considered as a tumor suppressor based on functional studies employing transgenic mouse models. This review evaluates the functional and molecular evidence that the inhibin alpha subunit is a tumor suppressor in endocrine cancers. The evaluation highlights the discrepant results from the human and mouse studies, as well as the differences between endocrine tumor types. In addition, we examine the evidence that the activin-signaling pathway is tumor suppressive and identify organ-specific differences in the actions and putative roles of this pathway in endocrine tumors. In summary, there is a considerable body of evidence to support the role of inhibins and activins in endocrine-related tumors. Future studies will define the mechanisms by which inhibins and activins contribute to the process of initiation, promotion, or progression of endocrine-related cancers.
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Affiliation(s)
- G P Risbridger
- Centre for Urological Research, Institute of Reproduction and Development, Monash University, Melbourne, Victoria 3168, Australia.
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Otani T, Minami S, Yamoto M, Umesaki N. Production of activin A in hyperplasia and adenocarcinoma of the human endometrium. Gynecol Oncol 2001; 83:31-8. [PMID: 11585411 DOI: 10.1006/gyno.2001.6350] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To examine the possible localization and production of activin A in human normal endometrium, endometrial hyperplasia, and adenocarcinoma tissues. METHODS Human endometrial tissues were collected from 45 patients who were undergoing abdominal hysterectomy. Tissue sections were stained with monoclonal antibodies against the inhibin/activin alpha- and beta A-subunits and activin A using an avidin-biotin-peroxidase complex technique. Concentrations of activin A and inhibin A in tissue extracts of the endometrial tissues were measured using enzyme-linked immunosorbent assays (ELISAs). The expressions of the inhibin alpha-subunit and activin beta A-subunit messenger RNA (mRNA) in the endometrial tissues were demonstrated by reverse transcription-polymerase chain reaction (RT-PCR) analysis. RESULTS No immunostaining with an antibody against the inhibin alpha-subunit was observed in human normal endometrium, endometrial hyperplasia, and adenocarcinoma. By contrast, immunostaining for the activin beta A-subunit and activin A was observed in the cytoplasm of glandular cells in normal endometrium, endometrial hyperplasia, and tumor cells of endometrial adenocarcinoma. The percentages of stained cells in endometrial adenocarcinoma were higher than those in normal endometrium. Also, the percentages of stained tumor cells with poor differentiation were higher than those with good and moderate differentiation of the endometrium. The stromal cells in normal endometrium, endometrial hyperplasia, and adenocarcinoma were weakly immunoreactive with antibodies against the beta A-subunit and activin A. Immunoreactivity of activin A in tissue extracts from normal endometrium and endometrial adenocarcinoma was detected by the two-site ELISA. Immunoreactivity of activin A was significantly higher in adenocarcinoma than in normal endometrium. On the other hand, the immunoreactive inhibin A was not detected. The expression of the alpha-subunit mRNA in endometrial tissues was demonstrated as the RT-PCR products migrated at 905 bp and the PCR products of the beta A-subunit showed a band at 366 bp. CONCLUSIONS It is suggested that activin A, but not inhibins, are produced by endometrial tissues. The amounts of produced activin A were higher in adenocarcinoma tissues than in normal endometrium. Activin A might be involved in human endometrial tumorigenesis.
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Affiliation(s)
- T Otani
- Department of Obstetrics and Gynecology, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama 641-0012, Japan
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