IRCAD Barretos 1-8-16 Philippe R. Koninckx, Anastasia Ussia Gruppo Italo Belga Prof em KU leuven Belgium, Univ Oxford UK, Univ Sacro Cuore, Italy, Honorary Consultant UK, Hon Prof Moscow Univ Gruppo Italo Belga, Leuven –Rome, Belgium Italy. Endometrial cell migration and endometriosis What is endometriosis ? The definition 1 disease ? Progressive and recurrent ? Hereditary – cancer risk ? Only in women and primate The endometrium – placentation - JZ
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IRCAD Barretos 1-8-16
Philippe R. Koninckx, Anastasia Ussia
Gruppo Italo Belga Prof em KU leuven Belgium, Univ Oxford UK, Univ Sacro Cuore, Italy, Honorary Consultant UK, Hon Prof Moscow Univ Gruppo Italo Belga, Leuven –Rome, Belgium Italy.
Endometrial cell migration and endometriosis
What is endometriosis ? The definition 1 disease ?
Progressive and recurrent ?
Hereditary – cancer risk ?
Only in women and primates The endometrium – placentation - JZ
P koninckx A Ussia, Gruppo italo belga
The Endometrium
• Glands & stroma
• during menstrual cyle = dating
• Pregnancy-> decidualisation
• Functionalis and basalis
• Different hormonal control
• Junctional zone & spiral arteries
P koninckx A Ussia, Gruppo italo belga
P koninckx A Ussia, Gruppo italo belga
The Endometrial function
• The most regenerative tissue
• Hormonal sensitivity
• Peristalsis
• Pregnancy
• Invasion
• immunology
Brosens 68
Leyendecker 85
Archimetra
Endometriosis : Facts 1
different presentations – prevalences - histology
100% Retrograde menstruation
80% Subtle with remodeling
15% typical 10% cystic 1% deep
adenomyosis, mullerianosis, stromatosis, pockets,
active no fibrosis
Inactive with fibrosis
P koninckx A Ussia, Gruppo italo belga
Pathophysiology : Sampson Theory
Sampson : retrograde menstruation Viable cells in menstruation
Retrograde menstruation
Viable cells in PF
Implantation potential
Keebiel WC, Stein RJ. Am J Obstet Gynecol 1951; 61:440-442.
Koninckx PR et al. J.Reprod.Med. 1980; 24:257-260.
In humans, in primates, in nude mice, in vitro
Metaplasia Subtle lesions Retrograde
menstruation,
Microscopical
Remodeling P koninckx A Ussia, Gruppo italo belga
P koninckx A Ussia, Gruppo italo belga
Prevalence of subtle lesions
Koninckx et al 1991
0
20
40
60
80
Inf Pain Inf+pain
n= 1297 918 267
P koninckx A Ussia, Gruppo italo belga
• In normal peritoneum • 10-15%
• In lymph nodes
• 15% in deep endo
• In bowel deep endo
Microscopical endometriosis
P koninckx A Ussia, Gruppo italo belga Fertil steril, 2016, 105,305-6
P koninckx A Ussia, Gruppo italo belga
Conclusion 1: subtle - microscopic
Glands and stroma outside the uterine cavity
• Are not always pathology
• We need another definition
P koninckx A Ussia, Gruppo italo belga
Sampson’s speculation
Sampson Viable cells in menstruation
Retrograde menstruation
Viable cells in PF
Implantation potential
Keebiel WC, Stein RJ. Am J Obstet Gynecol 1951; 61:440-442.
Koninckx PR et al. J.Reprod.Med. 1980; 24:257-260.
In humans, in primates, in nude mice, in vitro
We see We Imagine
Abdominal wall growth stops fibrosis
P koninckx A Ussia, Gruppo italo belga
Evidence for progression ? • Subtle to typical ?
• Typical to severe cystic ?
deep ?
• At diagnosis most lesions are no longer progressive
No evidence
in the human
in primates
Circomstantial evidence of the
contrary
historical data in Leuven :
typical in 1980 ; deep in the 90’s
in primates : no evolution
P koninckx A Ussia, Gruppo italo belga
A recurrent disease ?
• Subtle 100% • Typical 20% • Cystic 5% • Deep 1%
P koninckx A Ussia, Gruppo italo belga
Clonality in endometriosis
Monoclonal neoplasm
Genetic damage to single
progenitor cell Clonal
expansion
Cystic ovarian endometriosis Yes
• Jimbo et al (1997) Am J Pathol 150, 1173 ;21 samples from 11
endometriomas ; Marker = X-linked HUMARA gene
21/21 samples monoclonal
• Tamura et al (1998) Lab Invest 78, 213 ;25 epithelial cells from 25
Endometriosis in Rhesus Monkeys chronically exposed to dioxin
Rier SE, Martin DC, Bowman RE, Dmowski, WP, Becker JL Fundam. Appl. Toxicol,
1991,111,422-431
Dioxin dose (ppt)
n
rAFS
P koninckx A Ussia, Gruppo italo belga
Endometriosis in Rhesus Monkeys
• Spontaneous :
• clinical endo in autopsy 30% after 13 years
• Following
• dioxin : increased and dose dependent (Rier 1991)
• PCB : increased ( Campbell , unpublished)
• single energy & mixed energy proton irradiation, X rays (Wood 83, Fanton 91, Wood 91)
THE SHORTEST TIME
BETWEEN IRRADIATION AND
ENDOMETRIOSIS IS 6 YEARS
P koninckx A Ussia, Gruppo italo belga
Dioxin Concentrations in women with endometriosis
Mayani A, Barel S, Soback S, Almagor M. Human Repr 1997, 12, 373-375
0
5
10
15
20
25
No I+II III+IV
% of women with detectable dioxin in blood
Stage of Endometriosis
1/35
3/24
5/20
Dioxin concentration (part per trillion)
0 I-II III-IV0.00
0.25
0.50
0.75
1.00
1.25
Stage of Endometriosis
P koninckx A Ussia, Gruppo italo belga
Plasma Dioxin concentrations & risk
• Rhesus monkeys 25ppt 4 years (Bowman, 1989)
• T1/2 : 180-780 days
• adipose tissue concentration : 250-810 ppt
• Humans (Mocarelli, 1991)
• T1/2 : 7 years
• Seweso subjects : 2.000-35.000 ppt
• Area under time-concentration curve for 14 years • rhesus monkeys 388-1.400 (*1000)
• humans Seweso 5.500-112.000 (*1000) AUC T1/2=7 years
Bois FY, Eskenazi B, Environ. Health Perspect. 1994, 102,476
P koninckx A Ussia, Gruppo italo belga
Dioxin and Radiation
• Dioxin binds to the DNA through specific receptor • Pseudo steroid
• Direct DNA effect
• transmissible effect eg sperm up to third generation
• Radiation has a direct DNA effect
Mutagenic factors
P koninckx A Ussia, Gruppo italo belga
Genetic predisposition
• Loss of heterozygosity • Germ cell predisposition
P koninckx A Ussia, Gruppo italo belga
Loss of Heterozygocity
X
X
X
Germline
Mutation
=Heredity
Somatic
Mutation
1st Hit Deletion or
Translocation
X X X
Duplication
X X
Point
Mutation
First
Hit
Second
Hit
Where should we look for a first hit ?
in the endometrium of women
with & without endometriosis
P koninckx A Ussia, Gruppo italo belga
• loss of heterozygosity on p16(Ink4), GALT, and p53, as well as on APOA2, a region
frequently lost in ovarian cancer, occurs in endometriosis Goumenou AG, Arvanitis DA, Matalliotakis IM, Koumantakis EE, Spandidos DA. Microsatellite DNA assays reveal an allelic imbalance in p16(Ink4), GALT, p53, and APOA2 loci in patients with endometriosis. Fertil Steril 2001; 75(1):160-165.
• endometrium from women with endometriosis releases more ICAM-1, which can inhibit NK activity Somigliana E, Vigano P, Gaffuri B, Guarneri D, Busacca M, and Vignali M. (1996) Human endometrial stromal cells as a source of soluble intercellular adhesion molecule (ICAM)-1 molecules. Hum. Reprod. 11, 1190-1194
• P450aromatase transcripts & IL-6 and IL-11 transcripts in endometriosis women Noble LS, Simpson ER, Johns A, and Bulun SE. (1996) Aromatase expression in endometriosis. J. Clin. Endocrinol. Metab. 81, 174-179
• . Increased expression of heat shock protein 27 Ota H, Igarashi S, Hatazawa J, and Tanaka T. (1997) Distribution of heat shock proteins in eutopic and ectopic endometrium in endometriosis and adenomyosis. FERT. STERIL. 68, 23-28
Endometrium in Endometriosis
P koninckx A Ussia, Gruppo italo belga
Genetics of endometriosis
Which Gene ?
Oxegene project
Stephen Kennedy
University of Oxford
Specific genes
Non hypothesis driven
Linkage analysis
S. Kennedy , 2005
Molecular genetic evidence
P koninckx A Ussia, Gruppo italo belga
Linkage analysis 2006
• Extremely expensive
• Probably 2 chromosomes identified
• Highly secretive for patent reasons
• Clinically irrelevant for the next 10 years
• Potentially very important
Philippe R. Koninckx Anastasia Ussia
New Frontiers in Endometriosis
Ara Pacis Museum, Rome 28-10-2011
www.mondoginecologico.it Gruppo Italo Belga
Sub;itted
Gynaecological surgery, 2016
Ackowledged : Jacquez Donnez, Camran Nezhat, Charles Koh, Antonio Setubal
• increases the cancer risk Hysterectomy increases the risk of renal cancer,10,11
and total joint arthroplasty elevate the risk of prostate cancer.12
• promotes cancer metastasis.
• activates adrenergic signaling,
• which suppresses cell-mediated immunity
• promotes angiogenesis
• and metastasis
• and accelerates the growth of endometriotic
lesions in mice, - abrogated by b-blockade
Long, Q., Liu, X., and Guo, S. W. Surgery accelerates the development of endometriosis in mice. Am.J.Obstet.Gynecol. 215(3), 320. 2016.
P koninckx A Ussia, Gruppo italo belga
Long, Q., Liu, X., and Guo, S. W. Surgery accelerates the development of endometriosis in mice. Am.J.Obstet.Gynecol. 215(3), 320. 2016.
P koninckx A Ussia, Gruppo italo belga
P koninckx A Ussia, Gruppo italo belga
Haematologic and lymphogenic spread
• Haematologic
• Lung endometriosis
Lymphatic
•Deep endo
•Umbilical ? •
P koninckx A Ussia, Gruppo italo belga
• Mesothelial cells are very sensitive • React by retraction and bulging thus exposing intracellular spaces
• An acute inflammation of the entire exposed area : fast within hours
• With as consequences pain, adhesion formation, fluid resorbtion, ....
• Full- conditioning = prevention of this acute inflammation
• Surgery • = access to the cavity = air, CO2, fuids
• = manipulation, surgical trauma and irrigation
The mesothelial cell
P koninckx A Ussia, Gruppo italo belga
Peritoneal fluid
• An ovarian exudate
• Volume
// with ovarian activity
(Koninckx PR, Renaer M, and Brosens IA. (1980) Origin
of peritoneal fluid in women: An ovarian exudation
product. Br. J. Obstet. Gynaecol. 87, 177-183).
P koninckx A Ussia, Gruppo italo belga
Peritoneal fluid
• An ovarian exudate
• Volume
// with ovarian activity
• steroid hormone concentrations
always higher than in plasma
• protein concentrations :
60% of plasma
lower for larger molecules
(Koninckx PR, Renaer M, and Brosens IA. (1980) Origin of peritoneal fluid in women: An ovarian
exudation product. Br. J. Obstet. Gynaecol. 87, 177-183).
Koninckx PR, Heyns W, Verhoeven G, Van Baelen H, Lissens W, and De Moor P. (1980) Biochemical
characterisation of peritoneal fluid in women during the menstrual cycle. J. Clin. Endocrinol. Metab. 51,
1239-1244
P koninckx A Ussia, Gruppo italo belga
LUF as a cofactor for Endometriosis
• Since
• steroid hormone concentrations are low Koninckx PR, De Moor P, and
Brosens IA. (1980) Diagnosis of the luteinized unruptured follicle syndrome by steroid hormone assays on peritoneal fluid. Br. J.
Obstet. Gynaecol. 87, 929-934
• association with endometriosis Brosens IA, Koninckx PR, and Corveleyn PA. (1978)
A study of plasma progesterone, oestradiol-17b, prolactin and LH levels, and of the luteal phase appearance of the ovaries in
patients with endometriosis and infertility. Br. J. Obstet. Gynaecol. 85, 246-250
• A cofactor in endometriosis Koninckx PR, Ide P, Vandenbroucke W, and
Brosens IA. (1980b) New aspects of the pathophysiology of endometriosis and associated infertility. J Reprod
Med, 24, 257-260
P koninckx A Ussia, Gruppo italo belga
Peritoneal fluid in Endometriosis
• Low grade inflammation
with more and activated macrophages • increase in chemotactic activity by 20kD protein Weil SJ, Wang SY, Perez MC, and Lyttle CR.
(1997) Chemotaxis of macrophages by a peritoneal fluid protein in women with endometriosis. FERT. STERIL. 67, 865-869
• decreased by medical therapy Leiva MC, Hasty LA, Pfeifer S, Mastroianni L, Jr., and Lyttle CR. (1993) Increased
chemotactic activity of peritoneal fluid in patients with endometriosis. Am J Obstet. Gynecol. 168, 592-598
• in vitro secretion of a monocyte chemoattractant Akoum A, Lemay A, Brunet C, and
Hebert J. (1995) Cytokine-induced secretion of monocyte chemotactic protein-1 by human endometriotic cells in culture. the groupe d'investigation en
gynecologie. Am. J. Obstet. Gynecol. 172, 594-600
• RANTES Hornung D, Ryan IP, Chao VA, Vigne JL, Schriock ED, and Taylor RN. (1997) Immunolocalization and regulation of the chemokine RANTES in
hunan endothelial and endometriosis tissues and cells. JOURNAL OF CLINICAL ENDOCRINOLOGY AND METABOLISM, 82, 1621-1628
P koninckx A Ussia, Gruppo italo belga
Peritoneal fluid in Endometriosis
• More and activated Macrophages = secretion products
• Bax+ macrophages McLaren J, Prentice A, Charnock-Jones DS, Sharkey AM, and Smith SK. (1997) Immunolocalization
of the apoptosis regulating proteins Bcl-2 and Bax in human endometrium and isolated peritoneal fluid macrophages in endometriosis.
HUMAN REPRODUCTION, 12, 146-152
• angiogenic activity
in vivo Oosterlynck D. (1993a) Angiogenic activity of peritoneal fluid from women with endometriosis. Fertil. Steril. 59, 778-782.
TGF Oosterlynck DJ, Meuleman C, Waer M, and Koninckx PR. (1994) Transforming Growth Factor-beta Activity Is
Increased in Peritoneal Fluid from Women with Endometriosis. Obstet. Gynecol. 83, 287-292 VEGF McLaren J, Prentice A, Charnock Jones DS, and Smith SK. (1996) Vascular endothelial growth factor (VEGF)
concentrations are elevated in peritoneal fluid of women with endometriosis. Hum. Reprod. 11, 220-223.
McLaren J, Prentice A, Charnock Jones DS et al. (1996) Vascular endothelial growth
factor is produced by peritoneal fluid macrophages in endometriosis and is regulated by ovarian steroids. J. Clin. Invest.
98, 482-489
• Cytokines Koninckx PR, Kennedy SH, Barlow DH.(1999) Pathogenesis of endometriosis: the role of