Systematic molecular and clinical analysis of uterine leiomyomas from fertile-aged women undergoing myomectomy.

STUDY QUESTION: What are the distributions and associated clinical characteristics of mediator complex subunit 12 (MED12), high mobility group AT-hook 2 (HMGA2) and fumarate hydratase (FH) aberrations in uterine leiomyomas from fertile-aged myomectomy patients? SUMMARY ANSWER: These driver mutations account for the majority (83%) of tumours in fertile-aged patients. WHAT IS KNOWN ALREADY: Alterations affecting MED12, HMGA2 and FH account for 80-90% of uterine leiomyomas from middle-aged hysterectomy patients, while the molecular background of tumours from young myomectomy patients has not been systematically studied. STUDY DESIGN, SIZE, DURATION: A retrospective series of 361 archival uterine leiomyoma samples from 234 women aged ≤45 years undergoing myomectomy in 2009-2014 was examined. Associations between the molecular data and detailed clinical information of the patients and tumours were analysed. PARTICIPANTS/MATERIALS, SETTING, METHODS: DNA was extracted from formalin-fixed paraffin-embedded samples and MED12 exons 1 and 2 were sequenced to identify mutations. Level of HMGA2 expression was evaluated by immunohistochemistry. Biallelic FH inactivation was analysed with 2-succinylcysteine staining, which is an indirect method of assessing FH deficiency. All patients' medical histories were reviewed, and clinical information of patients and tumours was combined with molecular data. MAIN RESULTS AND THE ROLE OF CHANCE: The median age at operation was 34 years. The majority (58%) of patients were operated on for a single leiomyoma. Known driver mutations were identified in 83% of tumours (71% MED12; 9% HMGA2; 3% FH). In solitary leiomyomas, the MED12 mutation frequency was only 43%, and 29% were wild-type for all driver alterations. MED12 mutations were associated with multiple tumours, smaller tumour size and subserosal location. LIMITATIONS, REASONS FOR CAUTION: Although comprehensive, the study is retrospective in nature and all samples have been collected for routine diagnostic purposes. The use of paraffin-embedded samples and immunohistochemistry may have led to an underestimation of mutations. Due to the limited sample size and rarity of especially FH-deficient leiomyomas, the data are partly descriptive. WIDER IMPLICATIONS OF THE FINDINGS: The contribution of driver mutations in leiomyomas from young myomectomy patients is comparable to tumours obtained from hysterectomies of mostly middle-aged women. Our results support the earlier findings that MED12 mutations are associated with multiple tumours, smaller tumour size and subserosal location. The study emphasizes the distinct molecular background of solitary leiomyomas, and more research is needed to clarify the underlying causes of the notable proportion of wild-type leiomyomas. STUDY FUNDING/COMPETING INTEREST(S): The study was supported by the Academy of Finland (307773), the Sigrid Jusélius Foundation, the Cancer Foundation Finland and the iCAN Digital Precision Cancer Medicine Flagship. The authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Thyrocyte-specific Dicer1 deficiency alters thyroid follicular organization and prevents goiter development.

MicroRNAs (miRNAs) are important regulators of posttranscriptional gene expression and involved in embryonic development, regulation of cell differentiation, and growth. Dicer1 is a key enzyme in the maturation process of functional miRNAs. However, miRNA-mediated regulation of normal thyroid function and growth is largely unknown. To understand the role of miRNAs in the thyroid, we generated constitutive and tamoxifen-inducible, thyrocyte-specific Dicer1 knockout mice. The mice with perinatal Dicer1 deletion (cTgDcrKO) showed impaired follicular organization, increased fibrosis, and accumulation of adipocytes in the thyroid. Similar histological changes were observed in tamoxifen-induced adult Dicer1-deficient mice (iTgDcrKO). The thyroid phenotype in both knockout (KO) lines was associated with significantly down-regulated mRNA expression of thyroid transcription factor 1 (Ttf-1/Nkx2-1), thyroid peroxidase, and thyroglobulin (Tg) and up-regulated expression of genes involved in Tgf-ß signaling. Furthermore, in cTgDcrKO mice, which developed mild hypothyroidism, the protein expression of Nkx2-1, thyroglobulin, Paired box 8, and TSH receptor were clearly down-regulated compared with controls. Despite similar down-regulation of Dicer1 in cTgDcrKO and iTgDcrKO compared with controls, Dicer1 deletion in adult mice thyrocytes did not lead to acute hypothyroidism. No significant differences in thyroid weights between cTgDcrKO, iTgDcrKO, and controls were observed. However, a goitrogenic diet induced a 4-fold increase in thyroid weight in control animals, whereas it had no effect on iTgDcrKO thyroids. In summary, Dicer1 deficiency in thyrocytes is associated with intrathyroid fibrosis, adipogenesis, and enhanced expression of Tgf-ß signaling genes. Furthermore, our data indicate that Dicer1 is required for thyroid follicular organization, thyrocyte differentiation, and goiter development.

Pituitary gonadotrophic hormone synthesis, secretion, subunit gene expression and cell structure in normal and follicle-stimulating hormone ß knockout, follicle-stimulating hormone receptor knockout, luteinising hormone receptor knockout, hypogonadal and ovariectomised female mice.

To investigate the relationship between gonadotroph function and ultrastructure, we have compared, in parallel in female mice, the effects of several different mutations that perturb the hypothalamic-pituitary-gonadal axis. Specifically, serum and pituitary gonadotrophin concentrations, gonadotrophin gene expression, gonadotroph structure and number were measured. Follicle-stimulating hormone ß knockout (FSHßKO), follicle-stimulating hormone receptor knockout (FSHRKO), luteinising hormone receptor knockout (LuRKO), hypogonadal (hpg) and ovariectomised mice were compared with control wild-type or heterozygote female mice. Serum levels of LH were elevated in FSHßKO and FSHRKO compared to heterozygote females, reflecting the likely decreased oestrogen production in KO females, as demonstrated by the threadlike uteri and acyclicity. As expected, there was no detectable FSH in the serum or pituitary and an absence of expression of the FSHß subunit gene in FSHßKO mice. However, there was a significant increase in expression of the FSHß and LHß subunit genes in FSHRKO female mice. The morphology of FSHßKO and FSHRKO gonadotrophs was not significantly different from the control, except that secretory granules in FSHRKO gonadotrophs were larger in diameter. In LuRKO and ovariectomised mice, stimulation of LHß and FSHß mRNA, as well as serum protein concentrations, were reflected in subcellular changes in gonadotroph morphology, including more dilated rough endoplasmic reticula and fewer, larger secretory granules. In the gonadotophin-releasing hormone deficient hpg mouse, gonadotrophin mRNA and protein levels were significantly lower than in control mice and gonadotrophs were correspondingly smaller with less abundant endoplasmic reticula and reduced numbers of secretory granules. In summary, major differences in pituitary content and serum concentrations of the gonadotrophins LH and FSH were found between control and mutant female mice. These changes were associated with changes in expression of the gonadotrophin subunit genes and were reflected in the cellular structure and secretory granule appearance within the gonadotroph cells.

Laparoscopic vs robotic-assisted surgery for endometrial carcinoma in a centre with long laparoscopic experience.

Surgical outcomes and costs of laparoscopic and robotic hysterectomy for the treatment of endometrial carcinoma were compared in a centre with lengthy experience with laparoscopic surgery. The robotic cohort (n = 67) had a longer operative time than the laparoscopic cohort (n = 150) (p < 0.0001). Lymph node yields were similar for both surgical modalities, but the median of estimated blood loss was lower in the robotic group (50 ml vs 100 ml; p < 0.0001). The proportion of patients with hospital stay > 2 days and rate of overall complications were similar in both groups. Operative costs were (Euros) €1,680 and €3,860 for the laparoscopic and robotic procedure, respectively. We conclude that robotic technology is feasible but does not provide short-term benefits for the treatment of endometrial carcinoma in a centre where laparoscopy has been established as the standardised minimally invasive surgical method.

An investigation into pituitary gonadotrophic hormone synthesis, secretion, subunit gene expression and cell structure in normal and mutant male mice.

To investigate brain-pituitary-gonadal inter-relationships, we have compared the effects of mutations that perturb the hypothalamic-pituitary-gonadal axis in male mice. Specifically, serum and pituitary gonadotrophin concentrations, gonadotrophin gene expression, and gonadotroph structure and number were measured. Follicle-stimulating hormone (FSH)ß knockout (FSHßKO), FSH receptor knockout (FSHRKO), luteinising hormone (LH) receptor knockout (LuRKO), hypogonadal (hpg), testicular feminised (tfm) and gonadectomised mice were compared with control wild-type mice or heterozygotes. Serum levels of LH were similar in FSHßKO, FSHRKO and heterozygote males despite decreased androgen production in KO males. As expected, there was no detectable FSH in the serum or pituitary and an absence of expression of the FSHß subunit gene in FSHßKO mice. However, there was a significant increase in expression of the common α and LHß subunit genes in FSHRKO males. The morphology of FSHßKO and FSHRKO gonadotrophs was not significantly different from controls, except that the subpopulation of granules consisting of an electron-dense core and electron-lucent 'halo' was not observed in FSHßKO gonadotrophs and the granules were smaller in diameter. In the gonadotrophin-releasing hormone deficient hpg mouse, gonadotrophin mRNA and hormone levels were significantly lower compared to control mice and gonadotrophs were correspondingly smaller, with less abundant endoplasmic reticulum and reduced secretory granules. In LuRKO, tfm and gonadectomised mice, hyperstimulation of LHß and FSHß mRNA and serum protein concentrations was reflected by subcellular changes in gonadotroph morphology, including more dilated rough endoplasmic reticulum and more secretory granules distributed adjacent to the plasma membrane. In summary, major differences in pituitary content and serum concentrations of the gonadotrophins LH and FSH have been found between normal and mutant male mice. These changes are associated with changes in transcriptional activity of the gonadotrophin subunit genes and are reflected by changes in the cellular structure and secretory granule architecture within the gonadotroph cells.

Effects of levonorgestrel-releasing intra-uterine system on the expression of vascular endothelial growth factor and adrenomedullin in the endometrium in adenomyosis.

BACKGROUND: The levonorgestrel-releasing intra-uterine system (LNg-IUS) has been used to control menorrhagia, but irregular bleeding during the first 3 months of use was the most notable side effect. Endometrial angiogenesis is believed to be regulated by angiogenic factors. The study aim was to evaluate the effects of LNg-IUS on vascular endothelial growth factor (VEGF) and adrenomedullin (AM) expression in the endometrium. METHODS: VEGF and AM expression were analysed using the avidin-biotin immunoperoxidase method on endometrial curettage specimens from menorrhagic women associated with adenomyosis before and 3 months after LNg-IUS insertion. RESULTS: VEGF expression was abundant both in the endometrial glands and stroma before LNg-IUS insertion, but became scanty 3 months after insertion. No immunostaining for AM was noted in the endometrial glands and stroma before LNg-IUS insertion, whereas AM immunostaining became prominent in the endometrial glands and stroma 3 months after LNg-IUS use. CONCLUSIONS: This is the first study to demonstrate that LNg-IUS insertion results in decreased expression of VEGF and increased expression of AM in the endometrial glands and stroma after 3 months of use. The results obtained suggest that the increase in AM expression in the endometrium may be responsible for the frequent occurrence of irregular bleeding during the initial 3 months of LNg-IUS use.

Age-related uterine and ovarian hypertrophy in FSH receptor knockout and FSHbeta subunit knockout mice.

Female mice in which the gene encoding the follicle-stimulating hormone FSH receptor (FSHR) knockout (KO) or its ligand (FSHbetaKO) have been disrupted were infertile. Ovaries of these mice were significantly smaller than those of heterozygous littermates but significantly larger than those of hypogonadal mice of the same age. Uterine masses in all three mutants were <6 mg, significantly reduced compared with heterozygous mice. At 1 year of age uterine mass had increased to >12 mg in 63% of FSHRKO females and 88% of FSHbetaKO females. Despite the increase in uterine size there was no evidence of contractility: uteri were flaccid and unresponsive to electrical or pharmacological stimulation. In most females in which uterine growth had occurred there was evidence of ovarian growth with hypertrophy of the interstitial tissue, occurrence of ovarian cysts and epithelial and tubular inclusions. There was no evidence of uterine or ovarian hypertrophy in hypogonadal (hpg) mice at any age or in 1 year old females in which the FSH mutations were bred onto the hpg background. There was an inverse correlation of plasma LH concentrations and uterine mass in 1 year old mutant females with uterine hypertrophy. Ovariectomy of both FSHRKO and FSHbetaKO females with large uteri resulted in decreased uterine mass and increased plasma concentration of LH. The number of mice with ovarian pathology, reminiscent of the serous ovarian adenocarcinomas found in humans, was significantly greater in the FSHbetaKO mice, indicating that the presence of an intact FSH receptor on ovarian cells of FSHbetaKO females may allow constitutive basal stimulation of the ovary, which is absent in mice lacking FSH receptors.

How much LH do the Leydig cells see?

The purpose of this study was to assess the concentrations of LH that Leydig cells are exposed to upon in vivo stimulation of steroidogenesis. The concentrations of LH were measured in rats in testicular interstitial extracellular fluid, seminiferous tubular fluid and blood plasma from testicular veins from one testis before and from the other testis of the same rats after an intravenous injection of gonadotrophin-releasing hormone (GnRH) or saline, and compared with the concentrations in blood plasma from a peripheral vein. The concentrations of LH in interstitial fluid surrounding the Leydig cells before the injections were about 10% of the levels in blood plasma, and showed no significant rise at 15 min and a much smaller rise at later times in rats injected with GnRH than those seen in blood plasma from either of the two sources, which were similar. The concentrations of LH in tubular fluid were even lower and showed no change after GnRH. Testosterone concentrations in testicular cells, interstitial fluid and testicular venous blood plasma were significantly increased by 15 min after GnRH, when compared with saline-injected controls, with no change in the levels in tubular fluid. The rise in testosterone concentrations in testicular venous plasma after GnRH was smaller than those in the cells and interstitial fluid. In conclusion, the concentrations of LH reaching the testicular interstitial fluid were only about one-tenth of that measured in the circulation, presumably because the endothelial cells restrict access of the hormone to the interstitial fluid. This indicated that either the Leydig cells are extremely sensitive to LH stimulation or that testicular endothelial cells modulate the action of LH on the Leydig cells.

Lack of association of the common immunologically anomalous LH with endometriosis.

BACKGROUND: Subfertile women with endometriosis have been reported to demonstrate impaired follicular growth, ovulatory dysfunction and disturbed LH patterns. In addition, abnormal LH and/or LH receptors have been linked with endometriosis-associated infertility. Carriers of a variant of the beta-subunit of luteinizing hormone (V-LH) are largely healthy; however, differences in their gonadal function such as alterations in gonadal steroidogenesis, ovarian reserve, pubertal development and predisposition to diseases such as infertility and polycystic ovarian disease have been found. METHODS AND RESULTS: To explore the possible relationship between endometriosis and V-LH, we examined its frequency in 230 women undergoing laparoscopic surgery for the investigation of infertility. For the entire study population, 185 (80.4%) were wild type; 42 (18.3%) were heterozygous; and three (1.3%) were homozygous for V-LH. No difference was found between women with (n = 85) and without (n = 145) endometriosis concerning the frequency of the type of LH. CONCLUSION: Our results do not support the hypothesis that the variant form of LH is associated with an altered risk of endometriosis in the population tested.

Progestin-releasing intrauterine systems.

The levonorgestrel-releasing intrauterine system (LNG IUS) is an effective method for contraception. It has a strong antiproliferative action on the endometrium. The endometrium is transformed under the influence of local levonorgestrel and becomes unresponsive to ovarian estrogens. This process is associated with progressive reduction of menstrual blood loss and menstrual duration. Scanty and irregular bleeding and/or spotting is usual during the first 3 to 4 months. The reduction of menstrual blood loss continues and after the first 9 months many women have no bleeding at all. However, they have normal ovarian function. The absence of bleeding is a result of the local antiproliferative action of the LNG IUS on the endometrium, which is also responsible for many health benefits during the use of this method. As with oral contraceptives, the risk of pelvic inflammatory disease is reduced, because of reduced menstrual blood loss, endometrial suppression, and thickening of the cervical mucus. There are some steroidal side effects: mood changes, oily skin, and acne. Weight increase is similar to that associated with copper intrauterine devices: 500 g per year over 5 years. Users should be told that the LNG IUS does not prevent sexually transmitted infection, and therefore women at risk should also use condoms for their protection.