Histologic and immunohistochemical study of the invasive process in extragenital endometriosis: 311.02 – Anatomatomical pathology: Summary of PhD thesis in medical sciences

Abstract

The topicality and importance of the problem. Endometriosis is a chronic gynecological condition characterized by the presence of functional endometrial tissue outside the uterine cavity. Although the typical location of this disease is in the pelvic area - ovaries, fallopian tubes, peritoneum - in some cases, endometrial tissue can be found outside the genital sphere, causing what is called extragenital endometriosis [1, 10]. This rarer form of endometriosis can affect a variety of structures and organs outside the reproductive tract, including the urinary tract, digestive tract, diaphragm, lungs and even the nervous system. Symptoms are often nonspecific and can vary depending on location, making diagnosis difficult [2]. Endometriosis remains a controversial disease with multiple symptoms (chronic pelvic pain, dysmenorrhea, profound dyspareunia, infertility, dysuria, dyschezia), with significant negative effects on social, occupational and psychological activity, substantially affecting the quality of life of patients [3,8]. According to the latest World Health Organization data from 2023, endometriosis globally affects 10% (190 million) of women of reproductive age and girls causing pain and/or infertility [10]. Histologic confirmation is essential as in many cases the origin of endometriosis lesions is not confirmed. Extragenital endometriosis involves an abnormal ability of endometrial cells to migrate, adhere and invade tissues distant from the uterine cavity. A central role in these processes is played by the EMT – epithelial-mesenchymal transition and MMP – matrix metalloproteinases [5]. The epithelial-mesenchymal transition is an essential biological process during embryonic development, but also in the pathogenesis of diseases such as cancer and endometriosis. In EMT, epithelial cells lose their cohesive and polarity characteristics and acquire mesenchymal properties such as migration and tissue invasion. In extragenital endometriosis, EMT facilitates the dissemination of endometrial cells through blood or lymphatic vessels to ectopic sites, where they can form viable implants [6]. On the other hand, matrix metalloproteinases play a crucial role in the degradation of the extracellular matrix, allowing endometrial cells to penetrate and settle in new tissues. MMP-2 and MMP-9, in particular, have been implicated in the pathogenesis of endometriosis by facilitating the invasion of endometrial cells into non-genital structures. Increased activity of these enzymes has been correlated with a more aggressive and extensive form of the disease [4]. The interaction between EMT and MMP is essential in the formation of extragenital lesions. Proinflammatory factors, such as TNF-α and IL-1β, as well as TGF-β signaling, stimulate EMT and In conclusion, the epithelial-mesenchymal transition and activation of matrix metalloproteinases are key mechanisms that explain the invasive behavior of endometrial cells and the development of extragenital endometrio-genesis, supporting the idea that this condition has features similar to those of tumor processes. Research aim: Immuno-morphologic evaluation of extragenital endometriosis foci in order to determine potential invasiveness and diagnostic criteria. Research objectives: 1. Histopathologic identification of lesions of extragenital endometriosis with the outlining of a macroscopic and microscopic picture particular to these lesions; 2. Immunohistochemical evaluation of endometriosis lesions using markers for ER, PR and CD10; 3. Immunohistochemical evaluation of the invasiveness potential of extra-genital endometriosis lesions by investigating MMP-1 (interstitial collagenase), MMP-2 (gelatinase-A), MMP-9 (gelatinase- B) and MMP-14 (transmembrane protease type 1) markers; 4. Determination of changes in the SDF-1/CXCR-4 axis in ectopic endometrial invasion and metastasis processes; 5. Evaluation of the expression of specific markers of the epithelial-mesenchymal transition process (E-cadherin/Vimentin) in extragenital endometriosis. Methodology of scientific research. The positive opinion of the Research Ethics Committee for carrying out the study was obtained on March 16, 2017, verbal report no. 63. The doctoral studies were conducted in the period 2015-2020 at the Department of Pathology, Discipline of Morphopathology, Faculty of Medicine No. 1 of the Public Institution Nicolae Testemitanu State University of Medicine and Pharmacy, the Republic of Moldova and the Discipline of Morphopathology, University of Medicine and Pharmacy of Craiova, Romania. Scientific novelty of research. For the first time, prognostic markers have been identified with the highest predictive capacity of local aggressive and recurrent potential of these lesions. The MMP study, although not new, provides original data on their involvement in extracellular matrix modeling and local invasiveness of endometriosis lesions. An element of novelty is the panel of MMPs selected by us (MMP1 - interstitial collagenase, MMP-2 - gelatinase-A, MMP-9 - gelatinase-B, MMP-14 - type 1 transmembrane protease), which has not been used in any of the accessible studies to date. Previous research has only considered MMP-1 and MMP-2 or MMP-9 and MMP-14 in genital endometriosis and not in lesions with extragenital localization. In addition, MMP expression was determined not only in glandular and stromal elements of endometriosis lesions, but also in extragenital tissues to assess the correlation between the disease lesions and the tissues in which they develop. For the first time, SDF-1 and CXCR-4 expression were simultaneously investigated in 3 compartments: endometrial glandular cells, endometrial stromal cells and stroma adjacent to extragenital implants. In this study we focused on the concomitant expression of E-cadherin/Vimentin markers in extragenital endometriosis lesions. For the first time, the lesions in which the epithelial-mesenchymal transition (EMT) process is the most active and with the highest potential for loco-regional invasiveness were determined. The scientific problem solved was to determine the degree of expression of aggressiveness markers such as E-cadherin, Vimentin, N-cadherin and Twist in the progression of endometriosis. Theoretical significance and application value of the thesis. The study revealed new data on the origin and development of extragenital endometriosis lesions of various localizations and the involvement of molecular mechanisms in the pathogenesis of this condition. The determination of the most useful biomarkers of the prognosis of extragenital endometriosis contributes to the correct stratification of patients for a targeted and effective treatment, assessment of the evolution, invasiveness and risk of recurrence of the disease. Approval of thesis results. The results of the study have been presented and discussed at the following national and international scientific forums: 14th National Symposium on Microscopic Morphology with international participation, Tirgu Mures, Romania, 2016; Annual scientific conference of the scientific-teaching staff, doctoral students, master’s students, residents and students of Nicolae Testemitanu University, Chisinau, the Republic of Moldova, 2016; Annual scientific conference of the scientific-teaching staff, doctoral students, master’s students, residents and students of Nicolae Testemitanu University, Chisinau, the Republic of Moldova, 2017; The 7th International Medical Congress for Students and Young Doctors “MedEspera” Chisinau, the Republic of Moldova, 2018; Annual scientific conference of the scientific-teaching staff, doctoral students, master’s students, residents and students of Nicolae Testemitanu University, Chisinau, the Republic of Moldova, 2018; The USCAP 108 The Annual Meeting, National Harbor, Maryland, USA, 2019; The Congress dedicated to the 75th anniversary of the foundation of Nicolae Testemitanu University, Chisinau, the Republic of Moldova, 2020; The 8th International Medical Congress for Students and Young Doctors “MedEspera” Chisinau, the Republic of Moldova, 2020; 17th National Symposium of the Romanian Society of Morphology, Craiova, Romania, 2021; 18th National Symposium of the Romanian Society of Morphology, Craiova, Romania, 2022; Al 19th National Symposium of the Romanian Society of Morphology, Craiova, Romania, 2024; National scientific-practical conference with international participation „History, actuality and perspectives of pathologic anatomy service”, Cisinau, the Republic of Moldova, 2025. Publications on the thesis topic. In the subject of the thesis 27 scientific papers were published, Including 1 articles in SCOPUS Journals, 1 articles in foreign journals, 3 articles in national reviewed journals. At the same time 1 certificate of innovator and 1 act of implementation of innovation in the scientific-practical process were obtained. Volume and structure of the thesis. The work is presented on 124 pages, which includes all the mandatory elements stipulated by the Guide in force (2017), iconographically represented by 5 tables, 1 statistical formula and 45 figures, included in the text, 231 bibliographical sources.