Artificial intelligence deep learning model assessment of leukocyte counts and proliferation in endometrium from women with and without polycystic ovary syndrome.

OBJECTIVE: To study whether artificial intelligence (AI) technology can be used to discern quantitative differences in endometrial immune cells between cycle phases and between samples from women with polycystic ovary syndrome (PCOS) and non-PCOS controls. Only a few studies have analyzed endometrial histology using AI technology, and especially, studies of the PCOS endometrium are lacking, partly because of the technically challenging analysis and unavailability of well-phenotyped samples. Novel AI technologies can overcome this problem. DESIGN: Case-control study. SETTING: University hospital-based research laboratory. PATIENT(S): Forty-eight women with PCOS and 43 controls. Proliferative phase samples (26 control and 23 PCOS) and luteinizing hormone (LH) surge timed LH+ 7-9 (10 control and 16 PCOS) and LH+ 10-12 (7 control and 9 PCOS) secretory endometrial samples were collected during 2014-2019. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Endometrial samples were stained with antibodies for CD8+ T cells, CD56+ uterine natural killer cells, CD68+ macrophages, and proliferation marker Ki67. Scanned whole slide images were analyzed with an AI deep learning model. Cycle phase differences in leukocyte counts, proliferation rate, and endometrial thickness were measured within the study populations and between the PCOS and control samples. A subanalysis of anovulatory PCOS samples (n = 11) vs. proliferative phase controls (n = 18) was also performed. RESULT(S): Automated cell counting with a deep learning model performs well for the human endometrium. The leukocyte numbers and proliferation in the endometrium fluctuate with the menstrual cycle. Differences in leukocyte counts were not observed between the whole PCOS population and controls. However, anovulatory women with PCOS presented with a higher number of CD68+ cells in the epithelium (controls vs. PCOS, median [interquartile range], 0.92 [0.75-1.51] vs. 1.97 [1.12-2.68]) and fewer leukocytes in the stroma (CD8%, 3.72 [2.18-4.20] vs. 1.44 [0.77-3.03]; CD56%, 6.36 [4.43-7.43] vs. 2.07 [0.65-4.99]; CD68%, 4.57 [3.92-5.70] vs. 3.07 [1.73-4.59], respectively) compared with the controls. The endometrial thickness and proliferation rate were comparable between the PCOS and control groups in all cycle phases. CONCLUSION(S): Artificial intelligence technology provides a powerful tool for endometrial research because it is objective and can efficiently analyze endometrial compartments separately. Ovulatory endometrium from women with PCOS did not differ remarkably from the controls, which may indicate that gaining ovulatory cycles normalizes the PCOS endometrium and enables normalization of leukocyte environment before implantation. Deviant endometrial leukocyte populations observed in anovulatory women with PCOS could be interrelated with the altered endometrial function observed in these women.

Niche matters: The comparison between bone marrow stem cells and endometrial stem cells and stromal fibroblasts reveal distinct migration and cytokine profiles in response to inflammatory stimulus.

OBJECTIVE: Intrinsic inflammatory characteristics play a pivotal role in stem cell recruitment and homing through migration where the subsequent change in niche has been shown to alter these characteristics. The bone marrow mesenchymal stem cells (bmMSCs) have been demonstrated to migrate to the endometrium contributing to the stem cell reservoir and regeneration of endometrial tissue. Thus, the aim of the present study was to compare the inflammation-driven migration and cytokine secretion profile of human bmMSCs to endometrial mesenchymal stem cells (eMSCs) and endometrial fibroblasts (eSFs). MATERIALS AND METHODS: The bmMSCs were isolated from bone marrow aspirates through culturing, whereas eMSCs and eSFs were FACS-isolated. All cell types were tested for their surface marker, proliferation profiles and migration properties towards serum and inflammatory attractants. The cytokine/chemokine secretion profile of 35 targets was analysed in each cell type at basal level along with lipopolysaccharide (LPS)-induced state. RESULTS: Both stem cell types, bmMSCs and eMSCs, presented with similar stem cell surface marker profiles as well as possessed high proliferation and migration potential compared to eSFs. In multiplex assays, the secretion of 16 cytokine targets was detected and LPS stimulation expanded the cytokine secretion pattern by triggering the secretion of several targets. The bmMSCs exhibited higher cytokine secretion of vascular endothelial growth factor (VEGF)-A, stromal cell-derived factor-1 alpha (SDF)-1α, interleukin-1 receptor antagonist (IL-1RA), IL-6, interferon-gamma inducible protein (IP)-10, monocyte chemoattractant protein (MCP)-1, macrophage inflammatory protein (MIP)1α and RANTES compared to eMSCs and/or eSFs after stimulation with LPS. The basal IL-8 secretion was higher in both endometrial cell types compared to bmMSCs. CONCLUSION: Our results highlight that similar to bmMSCs, the eMSCs possess high migration activity while the differentiation process towards stromal fibroblasts seemed to result in loss of stem cell surface markers, minimal migration activity and a subtler cytokine profile likely contributing to normal endometrial function.

A Selective Biomarker Panel Increases the Reproducibility and the Accuracy in Endometrial Biopsy Diagnosis.

Grading and histologic typing of endometrial cancer in biopsy material has a direct impact on the decision to perform lymphadenectomy and/or omentectomy in many cancer centers. Endometrial biopsies are among the most common general surgical pathology specimens. Multiple studies have shown that biopsy diagnosis suffers from a lack of reproducibility. Although many biomarkers have been proposed, none have been demonstrated to improve the diagnosis in the biopsy setting. In this study, 70 biopsies with endometrial carcinoma were supplemented with a biomarker panel consisting of ER, PR, P53, and DNA ploidy. A representative H&E slide was scanned digitally and made available to 12 gynecologic pathologists in 4 Nordic countries: Finland, Denmark, Sweden, and Norway. Reviewers diagnosed the cases both before and after being provided with the biomarker results. The interobserver percent agreement and Cohen κ improved from 75.8% (κ=0.52, moderate) to 84% (κ=0.68, substantial) with inclusion of the biomarker panel. Agreement with the subsequent hysterectomy diagnosis also improved from 83.6% (κ=0.67) to 88.7% (κ=0.77). There was no statistical improvement between a reflex (84% agreement) and a reflective testing algorithm (82.9% agreement), suggesting that the selective use of biomarkers is appropriate. Difficult cases were almost exclusively high-grade tumors. Finally, a statistical model indicated that only P53 and DNA ploidy, in conjunction with an H&E review, had an impact on the decision to upgrade or downgrade cases.

Cancer Stem Cell Properties as Factors Predictive of Chemoresistance in Neoadjuvantly-treated Patients with Ovarian Cancer.

BACKGROUND/AIM: The nuclear factor erytheroid 2-related factor 2-kelch-like ECH-associated protein (NRF2-KEAP1) system and stem cell-like cancer cells are associated with platinum resistance in ovarian cancer. Our objective was to investigate the possible association between platinum resistance, cellular redox-state regulation and stem cell properties in ovarian cancer. PATIENTS AND METHODS: Thirty-eight patients with epithelial ovarian cancer were included. All patients had undergone primary diagnostic laparoscopy, platinum-based neoadjuvant chemotherapy, and debulking surgery. Tumor samples were analyzed for NRF2, KEAP1, protein deglycase 1 (DJ1/PARK7), cluster of differentiation molecules 44 (CD44) and 117 (CD117) and aldehyde dehydrogenase 1 (ALDH1) by immunohistochemistry. RESULTS: Positive pre-treatment expression of CD44 (p=0.013) and stable/increased post-therapy CD44 expression were associated with platinum resistance (p=0.001). Negative pre-treatment expression of cytoplasmic ALDH1 predicted sensitivity to platinum (p=0.017). Pre-treatment nuclear KEAP1 expression was greater in stage II-III cancer (p=0.0003). After neoadjuvant treatment, all samples were nuclear KEAP1-positive (p=0.025) and increased nuclear KEAP1 expression was associated with higher tumor stage (p=0.0001). CONCLUSION: CD44 and cytoplasmic ALHD1 could be potential indicators of platinum resistance during neoadjuvant chemotherapy for ovarian cancer.

Down-regulation of 8-hydroxydeoxyguanosine and peroxiredoxin II in the pathogenesis of endometriosis-associated ovarian cancer.

AIM: To evaluate the roles of oxidative stress marker 8-hydroxydeoxyguanosine (8-OHdG) and peroxiredoxin (PRX) antioxidants in the development of endometriosis and endometriosis-associated ovarian cancer (EAC). MATERIALS AND METHODS: Tissue expressions of 8-OHdG, PRX II and PRX IV were determined immunohistochemically in tissue from 22 women with benign endometriosis (BE) and 33 women with EAC, among whom endometriosis and cancer tissues were analyzed separately. RESULTS: When all three groups were compared simultaneously, EAC tumor cells had significantly weaker nuclear 8-OHdG and PRX II expression (p<0.05 and p<0.01, respectively) and significantly weaker cytoplasmic 8-OHdG expression (p<0.01) than EAC endometriosis and BE epithelial cells. This same trend was also observed when groups were compared pair-wise. CONCLUSION: Nuclear PRX II and 8-OHdG were down-regulated in EAC tumorous tissue compared with BE and EAC endometriotic tissue, suggesting a role of oxidative stress in the pathogenesis of EAC.

Postnatal developmental changes in the pituitary-ovarian axis in preterm and term infant girls.

CONTEXT: Postnatal pituitary-testicular activation in infant boys is well characterized. However, the ovarian response to pituitary activation in infancy is less well understood. OBJECTIVE: The aim of the study was to compare postnatal developmental changes in the pituitary-ovarian axis in preterm and term infant girls. PARTICIPANTS AND DESIGN: Sixty-three infant girls, divided into three groups according to gestational age (GA) [i.e. full term (FT; n = 29; GA, 37-42 wk), near term (NT; n = 17; GA, 34-37 wk), and preterm (PT; n = 17; GA, 24-34 wk)] were examined monthly from 1 wk (D7) to 6 months (M1-M6) of age and reexamined at the corrected age of 14 months (cM14). MAIN OUTCOME MEASURES: We performed a longitudinal follow-up of urinary FSH and serum anti-Müllerian hormone (AMH) levels and the number of follicles in transabdominal ovarian ultrasonography. RESULTS: The postnatal FSH surge was stronger and more prolonged in NT and PT girls than in FT girls (P ≤ 0.001). Increased folliculogenesis and a rise in AMH levels were observed in all three groups after the FSH surge. In NT and PT girls, follicular development was delayed in comparison with FT girls, and a decrease in high FSH levels around the 40th postmenstrual week was temporally associated with the appearance of antral follicles in ultrasonography and an increase in AMH levels. CONCLUSIONS: The postnatal FSH surge results in transient ovarian stimulation in term and preterm girls. A delay in ovarian folliculogenesis shown in ovarian ultrasonography and by low serum AMH levels may provide an explanation for the exaggerated FSH surge in NT and PT girls.

Regulation of cell death in human fetal and adult ovaries--role of Bok and Bcl-X(L).

Of eight million oocytes formed in fetal ovaries, only 400 are ovulated and the rest are degraded via apoptosis. Studies in rodents suggest an important role for Bok and Bcl-X(L) in ovarian apoptosis, but their expression patterns and roles in human ovaries are not well known. Protein expression of Bok and Bcl-X(L) as well as the death pathway effectors TNF and caspase-3 were determined in an important collection of samples consisting of human fetal and adult ovaries. A penetrant expression of Bok, Bcl-X(L), TNF and full length and cleaved caspase-3 were characterized in fetal ovaries, with specific patterns in oocytes and pre-granulosa/granulosa cells. Bok and Bcl-X(L) were detected also in adult ovaries. Lentiviral shRNA delivery demonstrated that loss of Bok markedly reduces vulnerability to apoptosis and, conversely, loss of Bcl-X(L) increases apoptosis in human granulosa tumour cell line. The results suggest important roles for Bok and Bcl-X(L) in human ovarian development, follicle maturation and apoptosis.

WNT4 is expressed in human fetal and adult ovaries and its signaling contributes to ovarian cell survival.

WNT4 plays an important role in female sexual development and ovarian function. WNT4-deficiency leads disturbed development of the internal genitalia in mouse and human, and to a dramatic reduction of mouse oocytes. However, the expression and role of WNT4 in human ovaries is yet unknown. The expression of WNT4 mRNA and protein was studied in human adult and fetal ovaries (gestational ages 12-41 weeks), and the role of WNT4 in oocyte apoptosis was investigated in WNT4-deficient mice. WNT4 mRNA and protein were present in human ovaries throughout fetal development and in different follicular stages in adult ovaries. Compared with wild-type mice, WNT4-deficient mice had a markedly enhanced rate of oocyte apoptosis, with the highest values at gestational ages of 14.5 and 16.5 days post-coitum. The current results support a view that WNT4 may have a role in oocyte selection and follicle formation and maturation in human ovaries.

Feasibility of endometrial assessment after thermal ablation.

OBJECTIVE: To evaluate the feasibility of endometrial assessment after endometrial thermal ablation. STUDY DESIGN: Prospective observational study. A total of 57 women (age 47-52 years), who had undergone endometrial thermal ablation as a treatment for heavy menstrual bleeding (HMB) 3-10 years (mean 6 years) earlier, were examined with transvaginal ultrasound and saline sonohysterography. Endometrial samples were collected with a Pipelle device. Visualisation of endometrium, access to uterine cavity, change in cavity length, success in outpatient endometrial sampling and success in sonohysterography were evaluated. RESULTS: Endometrial thickness was 4.5mm in amenorrhoeic women (n=17), 5.6mm in eumenorrhoeic women (n=37) and 6.6mm in hypermenorrhoeic women (n=3). An endometrial sample was successfully taken in 44 (77%) women, and in 13 (23%) women endometrial sample taking failed. The length of the uterine cavity compared to the length measured before endometrial thermal ablation was 0.5-5 cm (mean 2 cm) shorter in 34 women, unchanged in four women and longer in five women. The uterine cavity distended regularly in only nine (16%) women. In 14 (25%) women the cavity distended irregularly or only partly, and in 24 (42%) women the uterine cavity did not distend at all, but appeared as a narrow tube. In 10 (18%) women the sonohysterography catheter did not enter the uterine cavity at all. CONCLUSION: Endometrial assessment is compromised after previous endometrial thermal ablation. Both endometrial sampling and sonohysterography fail quite often, causing problems in diagnosis of abnormal bleeding. Intrauterine adhesions may also decrease the reliability of the endometrial sampling.

A mutant collagen XIII alters intestinal expression of immune response genes and predisposes transgenic mice to develop B-cell lymphomas.

Epithelial cells of mucosal surfaces are critical for maintaining immune homeostasis by aiding in the discrimination of pathogenic and commensal microorganisms and modulating the activities of antigen-presenting cells and lymphocytes. Functional breakdowns resulting in chronic infection and inflammation are associated with the development of hematologic and solid neoplasms for which detailed pathogenetic mechanisms are poorly understood. Mice heterozygous for a transgene Col13a1(del) expressing a mutant collagen XIII developed clonal mature B-cell lineage lymphomas originating in mesenteric lymph nodes (MLN). The tumors were associated with T cells and macrophages. The incidence of disease was reduced 2-fold in transgenic mice raised under specific pathogen-free conditions, suggesting a role for infectious agents. The lymphomas did not express the mutant collagen XIII, indicating that its influence on tumorigenesis was B-cell extrinsic and likely to be associated with collagen XIII-positive tissues drained by the MLN. Studies of the small intestines of transgenic mice showed that the subepithelial basement membranes (BM) were highly abnormal and that they exhibited heightened expression of genes involved in immune responses. These results define collagen XIII-dependent maintenance of the intestinal BM as a previously unappreciated component of immune responses and a critical determinant of cancer susceptibility.

Primary sex cord-like variant of endometrioid adenocarcinoma arising from endometriosis.

Endometriosis, a relatively common disease generally affecting women in the reproductive age group, is mostly found in the pelvic organs. Although endometriosis is a benign disease, some malignant tumors have been reported to develop in endometriotic lesions, most commonly in the ovary. The relationship between endometriosis and malignancy is not well known, but the majority of endometriosis-associated ovarian malignancies are usually endometrioid adenocarcinomas and clear cell carcinomas. The sex cord-like variant of endometrioid adenocarcinoma is a rare tumor that histologically closely resembles the sex cord-stromal tumor. Despite its rarity, the correct histological diagnosis of the sex cord-like variant of endometrioid adenocarcinoma is crucial to avoid misdiagnosis of a less aggressive tumor. We here report a 53-year-old woman who was diagnosed as having this very rare subtype of endometroid adenocarcinoma curiously arising from an endometriotic lesion at the site of previous salpingo-oophorectomy. The tumor was diagnosed based on light microscopy and immunohistochemistry.

Zona pellucida components are present in human fetal ovary before follicle formation.

The zona pellucida is a glycoprotein matrix surrounding oocytes and early-stage embryos in mammals. To elucidate the roles of the zona pellucida glycoproteins ZP1 and ZP3 and their key regulatory factor FIGLA in human ovarian development and folliculogenesis, their expression and localization was studied in human fetal and adult ovaries. FIGLA mRNA and ZP3 mRNA/protein were localized mainly in the oocytes, and during fetal development their maximal expression was observed around the 20th week, the time of follicle formation. The expression of ZP1 mRNA was low both in fetal and adult ovaries. Present findings demonstrate that ZP3 and FIGLA transcripts are expressed in the oocytes from early ovarian development. The function of ZP proteins during early fetal life is not clear, but the simultaneous expression of FIGLA and ZP3 suggests, that they may have a role in the development of primordial follicle before zona pellucida formation.

Morphology and microsatellite instability in sporadic serrated and non-serrated colorectal cancer.

Colorectal serrated adenocarcinoma originates from serrated adenoma, but definite histological criteria have not yet been established. It presents with frequent DNA microsatellite instability (MSI), but the frequency of low-level (MSI-L) and high-level MSI (MSI-H) and the expression of mismatch-repair (MMR) enzymes in serrated adenocarcinoma are not known. To address these questions, morphological criteria for serrated cancers were established, their validity was tested, and MSI analysis was performed with NIH consensus markers and MMR enzyme immunohistochemistry for hMLH1, hMSH2, and hMSH6 in 35 serrated and 75 non-serrated colorectal carcinomas. Serrated carcinomas frequently showed a serrated, mucinous or trabecular growth pattern; abundant eosinophilic cytoplasm; chromatin condensation; preserved polarity; and the absence of necrosis. With these features, it was possible to distinguish them from non-serrated cancers, with the mean kappa score for five observers being 0.509. MSI analysis was successful in 31 serrated and 73 non-serrated carcinomas. 54.8% of serrated carcinomas were microsatellite-stable (MSS), 29.0% presented with MSI-L, and 16.1% presented with MSI-H, whereas 78.1% of non-serrated carcinomas were MSS, 13.7% were MSI-L, and 8.2% were MSI-H. MSI-L was more common in serrated cancers (p=0.035) and it was associated with patchy immunohistochemical staining (33.3%) of MLH1. MSI-H did not differ between serrated and non-serrated cancers (p=0.14). These results suggest that the biological background of serrated carcinomas differs from sporadic non-serrated colorectal cancer, but is not directly related to MSI.

Distribution of basement membrane anchoring molecules in normal and transformed endometrium: altered expression of laminin gamma2 chain and collagen type XVII in endometrial adenocarcinomas.

Basement membranes (BMs) play an important role in anchoring epithelial cells and separating them from the adjacent stroma. Altered composition and assembly of BMs may influence carcinoma cell growth and invasion. Using immunohistochemistry and in situ hybridization, we investigated the expressions of the BMs components laminin-5 (Ln-5) subunits and collagen types IV, VII and XVII in normal endometrium and compared them to the expression pattern in hyperplastic and neoplastic endometrium. Chains of Ln-5 (alpha3beta3gamma2) and types IV, VII and XVII collagens were observed in normal endometrium. In hyperplastic endometrium, laminin gamma2 chain and type XVII collagen showed intensified expression in foci of dispersed epithelial cells. Individual carcinoma cells in adenocarcinomas of low differentiation grade displayed increased laminin gamma2 chain and type XVII collagen immunoreactivity and mRNA synthesis, whereas type VII collagen usually showed decreased expression. Laminin and type IV collagen showed BM disruptions, especially in tumors with low differentiation. Our results indicate that all the BM anchoring molecules investigated are expressed in normal endometrium, but the expression of laminin gamma2 chain and collagen type XVII is altered in endometrial adenocarcinomas, which support their role in malignant growth.

Differential expression of basement membrane components in lymphatic tissues.

Peripheral lymphoid tissues act as important organs of immunological defense. Characteristic of their architecture is the rich reticular fiber meshwork composed of various extracellular matrix (ECM) molecules with which the stationary non-lymphatic cells stay in intimate contact and form channels through which the lymphatic cells travel. Here we studied the distribution of various laminin (Ln) chains and different types of collagens in human spleen, lymph node, and tonsil to clarify their chain-specific distribution. The most widely distributed proteins in all these organs were Ln chains alpha5, beta1, gamma1 and collagen types IV and XVIII, which were present in practically all compartments. Conversely, Ln alpha1, alpha2, alpha4, and type VII collagen showed a more restricted expression pattern. A unique feature was that Ln alpha3-, beta3-, and gamma2-chains, which normally are not localized to the vascular wall in non-lymphatic tissues, were present also in capillary basement membranes (BMs) of the follicular structures of lymph node and tonsil and in Ln alpha1-chain and type VII collagen also in the splenic white pulp. We also found that collagen XVII was exclusively present in the ring fibers of the spleen. The results indicate that BMs of lymphatic tissues contain a variety of macromolecules that probably contribute strongly to immunological events. In addition, capillaries of the lymphoid tissue exhibit a specified BM composition resembling that in epithelial BMs of non-lymphoid tissues.