Histopathologic evaluation of the inflammatory factors and stromal cells in the endometriosis lesions: A case-control study
Background: Endometriosis is a multifaceted gynecological disorder defined as a benign estrogen-dependent chronic inflammatory process in which endometrial glands and stroma-like tissues are located outside the uterine cavity. It affects around 2-10% of all women during their reproductive years.
Objective: This study aimed to evaluate the traffic of mesenchymal stem cells and inflammatory factors toward the lesions.
Materials and Methods: Ten samples of normal endometrium and eutopic endometrium were studied as a control group and 10 ectopic samples were considered as a case group. Hematoxylin and eosin staining was used to evaluate stromal cells and inflammatory cells. Immunohistochemical staining was performed to show the presence of proliferating cell nuclear antigen in the lesions. The cells were digested and cultured in the laboratory to study cell proliferation. The number of cells and vessels were counted with Image J software, and data analysis was performed with Prism software.
Results: Data analysis showed that the number of stromal cells and vessels in ectopic tissue were significantly higher than the control group (p < 0.001). Also, the number of inflammatory cells, including neutrophils, monocytes, lymphocytes, and macrophages, in the ectopic group was much higher than in the control group (p < 0.005).
Conclusion: By expanding the number of blood vessels, blood flow increases, and cell migration to tissues is facilitated. The accumulation of inflammatory cells, especially macrophages, stimulates the growth of stem cells and helps implant cells by creating an inflammatory process.
Key words: Endometriosis, PCNA, Stem cell, Inflammation.
 Becker ChM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, et al. ESHRE guideline: Endometriosis. Hum Reprod Open 2022; 2022: hoac 009.
 Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: Clinical challenges and novel innovations. Lancet 2021; 397: 839–852.
 Kolanska K, Bendifallah S, Owen C, Thomassin-Naggara I, Bazot M, d’Argent EM, et al. Genital endometriosis: Epidemiology and etiological factors. Medecine de la Reproduction 2020; 22: 111–114.
 Wu M-H, Su P-F, Chu W-Y, Lin C-W, Huey NG, Lin C-Y, et al. Quality of life among infertile women with endometriosis undergoing IVF treatment and their pregnancy outcomes. J Psychosom Obstet Gynecol 2021; 42: 57–66.
 Wang Y, Li B, Zhou Y, Wang Y, Han X, Zhang S, et al. Does endometriosis disturb mental health and quality of life? A systematic review and meta-analysis. Gynecol Obstet Invest 2021; 86: 315–335.
 Andres MP, Arcoverde FV, Souza CC, Fernandes LFC, Abrao MS, Kho RM. Extrapelvic endometriosis: A systematic review. J Minim Invasive Gynecol 2020; 27: 373–389.
 Zondervan KT, Becker CM, Missmer SA. Endometriosis. New Engl J Med 2020; 382: 1244–1256.
 Cable J, Fuchs E, Weissman I, Jasper H, Glass D, Rando TA, et al. Adult stem cells and regenerative medicine: A symposium report. Ann N Y Acad Sci 2020; 1462: 27–36.
 Lv Q, Wang L, Luo X, Chen X. Adult stem cells in endometrial regeneration: Molecular insights and clinical applications. Mol Reprod Dev 2021; 88: 379–394.
 Akyash F, Javidpou M, Farashahi Yazd E, Golzadeh J, Hajizadeh-Tafti F, Aflatoonian R, et al. Characteristics of the human endometrial regeneration cells as a potential source for future stem cell-based therapies: A lab resources study. Int J Reprod BioMed 2020; 18: 943–950.
 Deane JA, Gualano RC, Gargett CE. Regenerating endometrium from stem/progenitor cells: Is it abnormal in endometriosis, Asherman’s syndrome and infertility? Curr Opin Obstet Gynecol 2013; 25: 193–200.
 Jin Sh. Bipotent stem cells support the cyclical regeneration of endometrial epithelium of the murine uterus. Proc Natl Acad Sci U S A 2019; 116: 6848–6857.
 Yu CW, Hall P, Fletcher C, Camplejohn R, Waseem N, Lane D, et al. Haemangiopericytomas: The prognostic value of immunohistochemical staining with a monoclonal antibody to proliferating cell nuclear antigen (PCNA). Histopathology 1991; 19: 29–34.
 Inoue A, Kikuchi S, Hishiki A, Shao Y, Heath R, Evison BJ, et al. A small molecule inhibitor of monoubiquitinated proliferating cell nuclear antigen (PCNA) inhibits repair of interstrand DNA cross-link, enhances DNA double strand break, and sensitizes cancer cells to cisplatin. J Biol Chem 2014; 289: 7109–7120.
 Laginha PA, Arcoverde FVL, Riccio LGC, Andres MP, Abrão MS. The role of dendritic cells in endometriosis: A systematic review. J Reprod Immunol 2022; 149: 103462.
 Kralickova M, Vetvicka V. Immunological aspects of endometriosis: A review. Ann Transl Med 2015; 3: 153.
 Lagana AS, Naem A. The pathogenesis of endometriosis: Are endometrial stem/progenitor cells involved? In: Virant- Klun I. Stem cells in reproductive tissues and organs. Switzerland: Humana Press; 2022: 193–216.
 Canosa S, Carosso AR, Sestero M, Revelli A, Bussolati B. Endometrial stem cells and endometriosis. In: Virant-Klun I. Stem cells in reproductive tissues and organs. Switzerland: Humana Press; 2022: 179–192.
 Shariati F, Favaedi R, Ramazanali F, Ghoraeian P, Afsharian P, Aflatoonian B, et al. Increased expression of stemness genes REX-1, OCT-4, NANOG, and SOX-2 in women with ovarian endometriosis versus normal endometrium: A case-control study. Int J Reprod BioMed 2018; 16: 783– 790.
 Chen P, Mamillapalli R, Habata S, Taylor HS. Endometriosis stromal cells induce bone marrow mesenchymal stem cell differentiation and PD-1 expression through paracrine signaling. Mol Cell Biochem 2021; 476: 1717–1727.
 Chen P, Mamillapalli R, Habata S, Taylor HS. Endometriosis cell proliferation induced by bone marrow mesenchymal stem cells. Reprod Sci 2021; 28: 426–434.
 Noori E, Nasri S, Janan A, Mohebbi A, Moini A, Ramazanali F, et al. Expression of vascular endothelial growth factor receptors in endometriosis. Int J Fertil Steril 2013; 7 (Suppl.): 114.
 Nanda A, Thangapandi K, Banerjee P, Dutta M, Wangdi T, Sharma P, et al. Cytokines, angiogenesis, and extracellular matrix degradation are augmented by oxidative stress in endometriosis. Ann Lab Med 2020; 40: 390–397.
 Keenan JA, Chen TT, Chadwell NL, Torry DS, Caudle MR. IL-1β TNF-α, and IL-2 in peritoneal fluid and macrophage-conditioned media of women with endometriosis. Am J Reprod Immunol 1995; 34: 381–385.
 Kempuraj D, Papadopoulou N, Stanford EJ, Christodoulou S, Madhappan B, Sant GR, et al. Increased numbers of activated mast cells in endometriosis lesions positive for corticotropin-releasing hormone and urocortin. Am J Reprod Immunol 2004; 52: 267–275.
 Sikora J, Mielczarek-Palacz A, Kondera-Anasz Z. Role of natural killer cell activity in the pathogenesis of endometriosis. Curr Med Chem 2011; 18: 200–208.
 Tarokh M, Ghaffari Novin M, Poordast T, Tavana Z, Nazarian H, Norouzian M, et al. Serum and peritoneal fluid cytokine profiles in infertile women with endometriosis. Iran J Immunol 2019; 16: 151–162.
 Olovsson M. Immunological aspects of endometriosis: An update. Am J Reprod Immunol 2011; 66: 101–104.
 Machairiotis N, Vasilakaki S, Thomakos N. Inflammatory mediators and pain in endometriosis: A systematic review. Biomedicines 2021; 9: 54.
 Jurikova M, Danihel Ľ, Polak S, Varga I. Ki67, PCNA, and MCM proteins: Markers of proliferation in the diagnosis of breast cancer. Acta Histochem 2016; 118: 544–552.
 Cardano M, Tribioli C, Prosperi E. Targeting proliferating cell nuclear antigen (PCNA) as an effective strategy to inhibit tumor cell proliferation. Curr Cancer Drug Targets 2020; 20: 240–252.
 Montenegro ML, Bonocher CM, Meola J, Portella RL, Ribeiro-Silva A, Brunaldi MO, et al. Effect of physical exercise on endometriosis experimentally induced in rats. Reprod Sci 2019; 26: 785–793.
 Riccio L, Santulli P, Marcellin L, Abrão MS, Batteux F, Chapron C. Immunology of endometriosis. Best Pract Res Clin Obstet Gynaecol 2018; 50: 39–49.
 Vallve-Juanico J, Houshdaran S, Giudice LC. The endometrial immune environment of women with endometriosis. Hum Reprod Update 2019; 25: 565–592.
 Symons LK, Miller JE, Kay VR, Marks RM, Liblik K, Koti M, et al. The immunopathophysiology of endometriosis. Trends Mol Med 2018; 24: 748–762.
 Burney RO, Giudice L. Pathogenesis and pathophysiology of endometriosis. Fertil Steril 2012; 98: 511–519.
 Smycz-Kubanska M, Kondera-Anasz Z, Sikora J, Wendlocha D, Krolewska-Daszczynska P, Englisz A, et al. The role of selected chemokines in the peritoneal fluid of women with endometriosis-participation in the pathogenesis of the disease. Processes 2021; 9: 2229.
 Haney A, Muscato JJ, Weinberg JB. Peritoneal fluid cell populations in infertility patients. Fertil Steril 1981; 35: 696– 698.
 Jeung I, Cheon K, Kim M-R. Decreased cytotoxicity of peripheral and peritoneal natural killer cell in endometriosis. Biomed Res Int 2016; 2016: 2916070.
 Ramirez-Pavez TN, Martinez-Esparza M, Ruiz-Alcaraz AJ, Marin-Sanchez P, Machado-Linde F, Garcia-Penarrubia P. The role of peritoneal macrophages in endometriosis. Int J Mol Sci 2021; 22: 10792.