M2 Phenotype Macrophages Colocalize with Schwann Cells in Human Dental Pulp.

Macrophages are immune cells with high plasticity that perform many functions related to tissue injury and repair. They are generally categorized as 2 functional phenotypes: M1 (proinflammatory) and M2 (anti-inflammatory and prohealing). To investigate the role of macrophages in human dental pulp, we examined the localization and distributional alterations of macrophages in healthy dental pulp as well as during the reparative process of pulp capping with mineral trioxide aggregate (MTA) and in cariously inflamed pulp of adult human teeth. We also quantified the populations of M1/M2 macrophages in healthy dental pulp by flow cytometric analysis. CD68+CD86+ cells (M1 phenotype) and CD68+CD163+ cells (M2 phenotype) were 2.11% ± 0.50% and 44.99% ± 2.22%, respectively, of 2.96% ± 0.41% CD68+ cells (pan-macrophages) in whole healthy dental pulp. Interestingly, M2 phenotype macrophages were associated with Schwann cells in healthy pulp, during mineralized bridge formation, and in pulp with carious infections in vivo. Furthermore, the M2 macrophages associated with Schwann cells expressed brain-derived neurotrophic factor (BDNF) under all in vivo conditions. Moreover, we found that plasma cells expressed BDNF. Coculture of Schwann cells isolated from human dental pulp and human monocytic cell line THP-1 showed that Schwann cells induced M2 phenotypic polarization of THP-1 cell-derived macrophages. The THP-1 macrophages that maintained contact with Schwann cells were stimulated, leading to elongation of their cell shape and expression of M2 phenotype marker CD163 in cocultures. In summary, we revealed the spatiotemporal localization of macrophages and potent induction of the M2 phenotype by Schwann cells in human dental pulp. M2 macrophages protect neural elements, whereas M1 cells promote neuronal destruction. Therefore, suppressing the neurodestructive M1 phenotype and maintaining the neuroprotective M2 phenotype of macrophages by Schwann cells may be critical for development of effective treatment strategies to maintain the viability of highly innervated dental pulp.

Detection of bone marrow-derived fibrocytes in human dental pulp repair.

AIM: To explore the expression profile of CD45+/pro-collagen I+ fibrocytes in intact dental pulps as well as during wound healing in adult dental pulp tissue. METHODOLOGY: A total of 16 healthy permanent teeth were obtained from young patients (18 to 25 years) undergoing orthodontic treatment. Routine pulp capping with mineral trioxide aggregate (MTA) was performed under local anaesthesia to induce a mineralized barrier at the exposed surface. Teeth were extracted from patients after 7, 14 and 35 days. Sections of the extracted teeth were prepared and stained for various markers using indirect immunofluorescence. Fibrocytes were counted, and the data were statistically evaluated using the Dunnett test. RESULTS: In uninflammed pulp tissue, a pro-collagen I-positive reaction was detected in odontoblasts, as well as in perivascular cells. Most of the CD45-positive cells were negative for pro-collagen I in normal pulp tissue, whereas CD45+/pro-collagen I+ fibrocytes were detected 7 days after injury. At day 14, fibrocytes were recognized under the fibrous matrix in contact with MTA and had infiltrated into regions of new capillary formation, where the fibrocytes were positively stained for vascular endothelial growth factor. By 35 days, fibrocytes were few, coincident with the formation of dentine bridges. The number of fibrocytes peaked 7 days post-injury and decreased at 14 days. CONCLUSIONS: The presence of fibrocytes in human pulp wound healing was observed. The spatiotemporal distribution of fibrocytes suggests that fibrocytes are involved in the early stages of pulp wound healing, specifically by contributing to new blood vessel formation.

GLCCI1 variant accelerates pulmonary function decline in patients with asthma receiving inhaled corticosteroids.

BACKGROUND: In steroid-naive patients with asthma, several gene variants are associated with a short-term response to inhaled corticosteroid (ICS) treatment; this has mostly been observed in Caucasians. However, not many studies have been conducted for other ethnicities. Here, we aimed to determine the relationship between the annual decline in forced expiratory flow volume in one second (FEV1 ) and the variant of the glucocorticoid-induced transcript 1 gene (GLCCI1) in Japanese patients with asthma receiving long-term ICS treatment, taking into account the effect of high serum periostin levels, a known association factor of pulmonary function decline and a marker of refractory eosinophilic/Th2 inflammation. METHODS: In this study, 224 patients with asthma receiving ICS treatment for at least 4 years were enrolled. The effects of single-nucleotide polymorphisms (SNPs) in GLCCI1, stress-induced phosphoprotein 1 (STIP1), and T gene on the decline in FEV1 of 30 ml/year or greater were determined. RESULTS: Besides the known contributing factors, that is, the most intensive treatment step, ex-smoking, and high serum periostin levels (≥95 ng/ml), the GG genotype of GLCCI1 rs37973, and not other SNPs, was independently associated with a decline in FEV1 of 30 ml/year or greater. When patients were stratified according to their serum periostin levels, the GG genotype of rs37973 was significantly associated with blood eosinophilia (≥250/µl) in the high serum periostin group. CONCLUSIONS: A GLCCI1 variant is a risk factor of pulmonary function decline in Japanese patients with asthma receiving long-term ICS treatment. Thus, GLCCI1 may be associated with response to ICS across ethnicities.

Effects of highly ripened cheeses on HL-60 human leukemia cells: antiproliferative activity and induction of apoptotic DNA damage.

To establish cheese as a dairy product with health benefits, we examined the multifunctional role of cheeses. In this report, we clarify whether different types of commercial cheeses may possess antiproliferative activity using HL-60 human promyelocytic leukemia cell lines as a cancer model. Among 12 cheese extracts tested, 6 (Montagnard, Pont-l'Eveque, Brie, Camembert, Danablue, and Blue) revealed strong growth inhibition activity and induction of DNA fragmentation in HL-60 cells. Based on the quantification of nitrogen contents in different cheese samples, a positive correlation between the ripeness of various cheeses and their antiproliferative activity tested in HL-60 cells was displayed. Four varieties of Blue cheese ripened for 0, 1, 2, or 3 mo demonstrated that the Blue cheese ripened for a long term was capable of causing the strong suppression of the cell growth and the induction of apoptotic DNA damage as well as nucleic morphological change in HL-60 cells. Collectively, these results obtained suggest a potential role of highly ripened cheeses in the prevention of leukemic cell proliferation.

Menin, a gene product responsible for multiple endocrine neoplasia type 1, interacts with the putative tumor metastasis suppressor nm23.

Although the gene responsible for multiple endocrine neoplasia type 1 (MEN1) has been identified, the function of its gene product, menin, is unknown. To examine the biological role of the MEN1 gene, we searched for associated proteins with a yeast two-hybrid system using the MEN1 cDNA fragment as bait. On screening a rat fetal brain embryonic day 17 library, in which a high level of MEN1 expression was detected, we identified a putative tumor metastasis suppressor nm23/nucleoside diphosphate (NDP) kinase as an associated protein. This finding was confirmed by in vitro interaction assays based on glutathione S-transferase pull down experiments. The association required almost the entire menin protein, and several missense MEN1 mutations reported in MEN1 patients caused a loss of the binding activity for nm23. This result suggests that this interaction may play important roles in the biological functions of the menin protein, including tumor suppressor activity.

Highly increased plasma concentrations of the nicked form of beta(2) glycoprotein I in patients with leukemia and with lupus anticoagulant: measurement with a monoclonal antibody specific for a nicked form of domain V.

beta(2)-Glycoprotein I (beta(2)GPI) consists of five tandem repeated domains (I, II, III, IV, and V). The nicked form of beta(2)GPI (N-beta(2)GPI ) which was cleaved by plasmin in vitro at Lys 317-Thr 318 in domain V, showed reduced affinity for the negatively charged phospholipids, especially cardiolipin (CL). Recently, the N-beta(2)GPI was detected in the plasma of patients with disseminated intravascular coagulation syndrome (DIC) by an immunological method. In the present study, we prepared monoclonal antibodies for the nicked form, and demonstrated that the concentrations of this form of beta(2)GPI, which were analyzed by a sandwich ELISA using two specially prepared monoclonal antibodies, were significantly increased in the plasma of patients with leukemia (n = 51, mean +/- SD: 162.0 +/- 118.3 ng/ml) and with lupus anticoagulant (LA) (n =40, mean +/- SD: 3,041.5 +/- 16,579.7 ng/ml), compared to the normals (n = 33, mean +/- SD: 1.04 +/- 1.54 ng/ml). We found a significant correlation between the concentrations of N-beta(2)GPI and those of typical molecular markers for a fibrinolytic state such as plasmin-alpha(2) plasmin inhibitor complex (PIC) and D-dimer in patients with leukemia, but not in patients with LA. These results suggested that the generation of N-beta(2)GPI was caused by plasmin in the patients with leukemia, and by unknown proteases in the patients with LA. In the patients with LA, the levels of N-beta(2)GPI tended to be higher in those without thrombosis than in those with thrombosis.

Complementary DNA structure and genomic organization of Drosophila menin.

Menin is a protein product of a tumor supressor gene MEN1, mutations of which are responsible for multiple endocrine neoplasia type 1, an autosomal dominant familial cancer syndrome. We determined the nucleotide sequence of the Drosophila menin cDNA using RT-PCR and RACE, and confirmed it by direct sequencing of genomic DNA. Gene expression of Drosophila menin was detected by Northern blot analysis in adult and embryo as two types of transcripts, one identical in size to the cDNA, and the other larger but detected only in embryo. The Drosophila menin gene was composed of five exons in which the protein was encoded in exon 2 through 5, and spanned approximately 6.3 kb. The deduced amino acid (AA) sequence of Drosophila menin consisted of 751 AAs with a calculated molecular mass of 81.7 kDa, and showed 44-47% identity to human, rat, mouse and zebrafish menin over the entire length. Among the AA residue substitutions that have been reported as disease-associated missense mutations and single AA deletions, 53 out of 71 were completely conserved in Drosophila. The presence of menin ortholog in insect indicates that menin is an evolutionally conserved protein with a fundamental role in biological processes.

Early induction of the orphan nuclear receptor NOR-1 during cell death of the human breast cancer cell line MCF-7.

The neuron-derived orphan receptor (NOR-1) is a member of the NGFI-B subfamily within the nuclear receptor superfamily. In T-cell apoptosis, where NGFI-B plays an essential role, a functional redundancy between NGFI-B and NOR-1 has been demonstrated. Here, we examined the regulation and expression of the NOR-1 gene during cell death induced by a calcium ionophore A23187 in the human breast cancer cell line MCF-7. A23187 caused a transient increase in NOR-1 mRNA levels within 6 h after treatment. To delineate the sequences required for the transitional response to A23187, a series of promoter deletion mutants were constructed. From the transient transfection experiments, the element responsive to A23187 was identified between -94 and -42 base pairs upstream from the transcription initiation site. This 53-base pairs region contains three copies of the cAMP response element (CRE). Furthermore, phosphorylation of the CRE-binding protein (CREB), which affects the transcription of the CRE dependent-genes, was detected 30 min after A23187 stimulation. Our findings are consistent with NOR-1 involvement in A23187-induced cell death via the CRE-CREB signaling pathway.

Structure and distribution of rat menin mRNA.

Menin is a protein product of a tumor suppressor gene MEN1, mutations of which are responsible for multiple endocrine neoplasia type 1, an autosomal dominant familial cancer syndrome. We isolated rat menin cDNA clones from a fetal rat brain cDNA library. We also determined the nucleotide sequence of the protein coding region of mouse menin cDNA, which was partly registered in the expressed sequence tag (EST) database. Deduced amino acid sequences of rat and mouse menin are highly homologous to human menin. All of the previously reported disease-associated missense mutations and single amino acid deletions were observed at the residues that are conserved among these three species. Rat MEN1 transcripts were detected not only in the endocrine tissues but also in the tissues of the nervous, digestive, reproductive and immune systems. The MEN1 transcripts were abundantly expressed in the developing rat brain on day 14-18 of gestation. Immunoblotting and immunocytochemical analysis of the COS-7 cells transfected with a rat menin-expression vector revealed that the translated product has a molecular mass of approximately 70 kDa, and is localized mainly in the nucleus. These findings are consistent with those reported on human menin.

Isolation and amino acid sequence of a phospholipase A2 inhibitor from the blood plasma of the sea krait, Laticauda semifasciata.

A phospholipase A2 (PLA2) inhibitor was purified from the blood plasma of a sea krait, Laticauda semifasciata, by sequential chromatography on Sephadex G-200, Mono Q, and Phenyl Sepharose columns. The purified inhibitor was found to be the same type as the PLA2 inhibitors, named PLIgamma, that had been purified from the blood plasma of the Thai cobra Naja naja kaouthia [Ohkura et al. (1994) Biochem. Biophys. Res. Commun. 200, 784-788] and Chinese mamushi Agkistrodon blomhoffii siniticus [Ohkura et al. (1997) Biochem. J. 325, 527-531]. Like other PLIgammas, the L. semifasciata inhibitor (LsPLIgamma) inhibited equally all of the PLA2s investigated including Elapid venom PLA2s (group I), Crotalid and Viperid venom PLA2s (group II), and honeybee PLA2 (group III). The LsPLIgamma was a 100-kDa glycoprotein composed of two distinct subunits, LsPLIgamma-A and LsPLIgamma-B, with an approximate molar ratio of 2:1. The amino acid sequences of the two subunits were determined by alignment of the peptides obtained by lysyl endopeptidase, endoproteinase Asp-N, and staphylococcal V8 protease digestions. LsPLIgamma-A and LsPLIgamma-B were composed of 182 and 181 amino acid residues, respectively; and the former subunit was a glycoprotein containing one asparagine-linked sugar chain at the position 157. The sequences of LsPLIgamma-A and LsPLIgamma-B showed 65 and 74% homology, respectively, to those of the corresponding subunits of N. naja kaouthia PLIgamma, and had two tandem patterns of cysteine residues, characteristic of the urokinase-type plasminogen activator receptor (uPAR) and members of the Ly-6 superfamily.

An isoform of Nurr1 functions as a negative inhibitor of the NGFI-B family signaling.

NGFI-B, Nurr1 and NOR-1 constitute a distinct subfamily within the nuclear receptor superfamily. To clarify the transcriptional regulation by the NGFI-B family, we searched for other components that can bind to the NBRE response element, a known target sequence for these transcription factors. By low stringency hybridization using the DNA binding domain of NOR-1 as a probe, a C-terminal truncated Nurr1 isoform, named Nurr2, was isolated from a mouse MC3T3-E1 cell cDNA library. Nurr2 had a novel cryptic exon located upstream in the Nurr1 promoter region, and was generated by alternative splicing at exons 1, 2 and 6. The C-terminal region was encoded by frame-shifted exon 6, and so Nurr2 lacked the C-terminal sequences corresponding to the putative ligand binding domain or dimerization domain. Quantitative reverse transcriptase-PCR experiments confirmed the presence of the Nurr2 isoform in mouse, rat and human. It was, like Nurr1, highly expressed in the pituitary and the cerebral cortex. Nurr2 and Nurr1 were also concomitantly induced by forskolin in NIH3T3 cells. Functional analysis using a reporter gene, containing NBRE response elements, indicated that while the isoform was inactive by itself, it could inhibit transactivation by the members of the NGFI-B family. These results indicate that the C-terminal truncated isoform, Nurr2, may act as a negative regulator of the NGFI-B family signaling.

The NGFI-B subfamily of the nuclear receptor superfamily (review).

NGFI-B, Nurr1 and NOR-1 have structural features of ligand-activated transcriptional regulators and constitute the NGFI-B subfamily within the nuclear receptor superfamily. Since specific ligands for these molecules have not yet been identified, they are often called orphan nuclear receptors. Genes of the NGFI-B subfamily are classified as immediate-early genes that are induced rapidly but transiently by a variety of stimuli. Evidence accumulated over the past decade suggests this subfamily is involved in important physiological processes and cancer development. In this communication, we summarize and discuss their structural features, gene expression, physiological roles and oncological significance.

Plasmin can reduce the function of human beta2 glycoprotein I by cleaving domain V into a nicked form.

beta2-Glycoprotein I (beta2GPI) is a highly glycosylated plasma protein with the ability to bind negatively charged substances such as DNA, heparin, dextran sulfate, and negatively charged phospholipids. The most relevant physiological role of beta2GPI is supposed to be the regulation of the function of anionic phospholipids like cardiolipin (CL). beta2GPI consists of a single polypeptide chain (326 amino acid residues) with a molecular mass of about 50 kD and with five tandem repeated domains (I, II, III, IV, and V). In the previous study, we found that factor Xa can produce the nicked form by cleaving Lys 317-Thr 318, using recombinant human domain V (r-Domain V). However, the reaction was extremely slow. In the present paper, we found that plasmin can produce the nicked form of domain V, using recombinant domain V (r-Domain V) and beta2GPI from human plasma. On sodium dodecyl sulfate-polyacrylamide gel electrophoresis, r-Domain V was rapidly cleaved into a nicked form by plasmin, very slowly by factor Xa, but not by thrombin, tissue-type plasminogen activator, urokinase, and tissue factor/factor VIIa. The cleavage site of r-Domain V and beta2GPI by plasmin was proved to be Lys 317-Thr 318 by amino acid sequence analysis of the digest and of the C-terminal peptide isolated by high-performance liquid chromatography. The cleavage was completely inhibited by plasmin inhibitor (alpha2PI). The nicked form was demonstrated to show reduced affinity for CL with a dissociation constant of one order of magnitude larger than that of the intact beta2GPI. To determine whether the specific cleavage of beta2GPI by plasmin can occur also in plasma, human plasma was first acid-treated to inactivate alpha2PI and then incubated with urokinase. About 12% of beta2GPI in plasma was nicked when alpha2PI activity decreased to 80%. The nicked form was not generated in plasminogen-depleted plasma. These results suggest that plasmin can produce the nicked form of beta2GPI with the reduced ability to bind phospholipids in vivo.

Mechanical agitation induces gene expression of NOR-1 and its closely related orphan nuclear receptors in leukemic cell lines.

NOR-1, NGFI-B and Nurr1 are closely related transcription factors that constitute a distinct subfamily within the nuclear receptor superfamily. Genes for these proteins are immediate-early genes, and are inducible in diverse cell types by various stimuli. In the present study, we investigated the effect of mechanical agitation on the gene expression of these transcription factors in cultured suspension cells by the quantitative reverse transcription-polymerase chain reaction. We found that mechanical agitation transiently induced NOR-1, NGFI-B and Nurr1 mRNAs in several leukemic cell lines in a dose-dependent manner. This induction was most pronounced in the HL-60 promyelocytic leukemia cell line, but also occurred to a lesser extent in other cell lines including KG-1, THP-1 and U937 cells. The induction was attenuated by serum or albumin, which are shear stress protectants for suspension culture cells. These reagents did not suppress forskolin-induced NOR-1 gene expression. These findings suggest the involvement of fluid shear stress in agitation-induced immediate-early gene expression. Since even moderate agitation could cause the induction, investigators should be cautious when evaluating the expression of immediate-early genes in some leukemic cell lines.

Specificity of two types of phospholipase A2 inhibitors from the plasma of venomous snakes.

Specificity of two different types of phospholipase A2 (PLA2) inhibitory proteins from the blood plasma of venomous snakes was investigated. Two Crotalidae inhibitors, having a carbohydrate recognition domain (CRD) in their sequences, inhibited specifically the group-II acidic PLA2s of their own snake venom. On the other hand, Elapidae inhibitor, having two tandem patterns of cysteine residues found in proteins of the Ly-6 superfamily, inhibited not only the group-I PLA2 from its own snake venom but also the group-I, -II, and -III PLA2s from other snake venom. Amino acid sequences of PLA2s that were specifically inhibited by the inhibitors were compared with those of the other PLA2s. A unique aromatic patch structure appeared on the group-II acidic PLA2s was suggested to be involved in the binding to the Crotalidae inhibitors; and residues located in or close to the Ca2+ binding loop of PLA2, in the binding to the Elapidae inhibitor.

Retinoic acids differentially regulate NOR-1 and its closely related orphan nuclear receptor genes in breast cancer cell line MCF-7.

NOR-1, NGFI-B, and Nurr1 are closely related orphan nuclear receptors implicated in diverse biological processes including cell growth and differentiation. We examined the effect of retinoic acids on the expression of these putative transcription factor genes in the breast cancer cell line MCF-7 by a quantitative reverse transcription and polymerase chain reaction. Both all-trans and 9-cis retinoic acids markedly induced NOR-1 mRNA and slightly increased Nurr1 mRNA. In contrast, NGFI-B mRNA was decreased. In the presence of cycloheximide, all-trans retinoic acid superinduced NOR-1 mRNA, whereas all-trans and 9-cis retinoic acids strongly suppressed the NGFI-B mRNA accumulation. The differential effects of retinoic acids on the expression of these genes are in contrast with the effects of forskolin and 12-O-tetradecanoylphorbol-13-acetate, both of which induced mRNAs of all three genes. These findings suggest that NOR-1, NGFI-B, and Nurr1 play distinct roles in the retinoic acid signaling in MCF-7 cells.

Optimal timing of a second-look operation for advanced epithelial ovarian cancer.

To clarify the optimal timing of second look operation (SLO) for advanced ovarian cancer, we retrospectively reviewed the records of 53 patients with FIGO stage 2, 3 and 4 epithelial ovarian cancer. SLOs were performed more than 12 months after primary surgery in 35 patients (late SLOs), and immediately after first-line chemotherapy in 18 patients (early SLOs). We examined data on SLO findings and patients' clinical courses. SLO findings were positive 5 (27.7%) of 18 in the early SLO group and in 11 (31.4%) of 35 in late SLO group. Positive findings were detected by washing cytology in 3 (60%) of the 5 in the early SLO group compared with 2 (18.2%) of the 11 in the late SLO group. Patients with microscopic disease had better prognosis than patients with macro lesions. False-negative SLO findings were 30.8% in the early SLO group and 12.5% in the late SLO group. All patients who recurred after negative SLOs had grade 2 and 3 tumors. The benefits of SLO were limited to accurate evaluation of first-line chemotherapy and early detection of persistent disease. In these implications, early performance of SLO is recommended.

Relation between CA125 levels and second-look operation for ovarian cancer.

We investigated the relationship between the serum level of CA125 before a second-look operation (SLO) and SLO findings in 196 patients with adenocarcinoma of the ovary. SLO findings were positive in 38 (19.4%) of 196 patients. The positive rate tended to increase with the clinical stage, but SLO findings were positive even in a patient with stage Ia disease. The pre-SLO serum level of CA125 was positive in 11 patients before SLO, SLO findings were positive in 8 of these 11 patients. The highest diagnostic accuracy (37.9%) for the pre-SLO serum level of CA125 was obtained at a cut-off value of 11 U/ml. Our findings suggest that a positive pre-SLO serum level of CA125 does not necessarily indicate tumor positivity. In addition, we suggest that the cut-off value for prediction of SLO findings should be below 35 U/ml, which is a commonly used cut-off value.

Structure, mapping and expression of a human NOR-1 gene, the third member of the Nur77/NGFI-B family.

We identified a human homologue of NOR-1 (neuron-derived orphan receptor) from the fetal brain. There are two transcripts for human NOR-1, encoding 626 amino acid residues with a calculated molecular mass of 68 kDa. The high homology between hNOR-1, mNur77/rNGFI-B/hTR3, and mNurr1/rRNR-1/hNOT indicated that these three orphan receptors form a distinct subfamily within the steroid/thyroid receptor superfamily. Human NOR-1 mRNA was detected in the adult heart and skeletal muscle as well as in the fetal brain, indicating that its expression is not restricted to events that occur during neural development. The hNOR-1 gene is more than 35 kilobases long and interrupted by seven introns. The exon-intron structure of the gene is generally conserved when compared with the steroid/thyroid receptor superfamily and is remarkably similar to that of the Nur77/NGFI-B genes. This suggests that the Nur77/NGFI-B family has evolved from a common ancestral gene. Fluorescence in situ hybridization (FISH) revealed that the gene is located on chromosome 9q.

Reassessment of second look operation for epithelial ovarian cancer.

We retrospectively reviewed 91 patients with epithelial ovarian cancer who underwent second-look operation (SLO). SLO identified a persistent tumor in 18 (19.8%) of 91 patients. Of these 18 patients, 13 (72.2%) showed disease progression after SLO. Patients with a positive SLO in which the identification of the persistent disease was only possible by washing cytological study showed better prognosis than patients with macroscopic lesions. Of the 73 patients with a negative SLO, 12 (16.4%) developed recurrence after cessation of treatment. These 12 patients were from stage 1c to 3 with Grade 2 and 3 tumors. The SLO findings were more sensitive than the serum tumor marker in identifying persistent disease. Also we reviewed 55 patients having no SLO. Among 57 cases in stage 1 and 2 with Grade 1 tumor, there were no cases of recurrence, regardless of whether they had SLO or not. Our results suggest that SLO findings correlate well with the patient's prognosis. SLO may not be needed for patients in stage 1 and 2 with Grade 1 tumor. Patients with advanced stage disease with Grade 2 and 3 tumors have high-risk for recurrence after negative SLO. While SLO is still of benefit in management of ovarian cancer, refinements are needed to determine its indication and scheduling.