ObjectiveThere is a continued need for improvement of second-line systemic treatment for metastatic and/or recurrent endometrial cancer.MethodsIn this phase II, open-label study, eligible patients... Show moreObjectiveThere is a continued need for improvement of second-line systemic treatment for metastatic and/or recurrent endometrial cancer.MethodsIn this phase II, open-label study, eligible patients had histologically or cytologically confirmed endometrial cancer, documented progressive disease, and a WHO performance status of <= 2. All participants received treatment with pazopanib 800 mg once daily until progression, unacceptable toxicity, or patient refusal. The primary endpoint was progression-free survival at 3 months, with secondary outcomes of overall response rate, progression-free survival, overall survival, and toxicity. The study was powered to demonstrate 50% progression-free survival at 3 months with alpha=0.05 and beta=80%.ResultsBetween January 2011 and February 2016, 60 eligible patients were included (intention-to-treat population). Median age was 68 (range, 53-85) years. Previous treatment included pelvic radiotherapy (58%), chemotherapy (90%), and hormonal therapy (43%). Three-month progression-free survival was 63.3% in the intention-to-treat population, with median progression-free survival and overall survival of 3.4 and 7.5 months, respectively. Overall response rate was 8.3%, and median follow-up 7.6 months. The most common grade 3 or higher adverse events were gastrointestinal toxicity in 21% of participants, including two patients with a gut perforation, one fatal gastrointestinal hemorrhage, one enterocutaneous fistula, and one fatal enterovaginal fistula. Extensive peritoneal disease existed in 80% of the patients with severe gastrointestinal toxicity. A definite correlation with previous radiotherapy could not be established.ConclusionsPazopanib met its primary endpoint of 3 months' progression-free survival in advanced endometrial cancer (63.3%), but response rates were modest. There may be a correlation for rare but severe gastrointestinal toxicity with previous treatments and/or disease site that has yet to be elucidated. Show less
Human reproductive success relies on the intricate interplay between the developing embryo and the maternal endometrium. These highly-coordinated interactions facilitate implantation, setting in... Show moreHuman reproductive success relies on the intricate interplay between the developing embryo and the maternal endometrium. These highly-coordinated interactions facilitate implantation, setting in motion a series of developmental programs to establish a sustained fetal-maternal interface. Understanding endometrial function and the early human embryo-maternal dialogue is thus an important prerequisite for refining clinical approaches to alleviate implantation failure, early pregnancy loss and other obstetric complications. Yet, many mediators of implantation remain elusive. Driven by endocrine factors, interactions at the embryo-maternal interface are tightly regulated and highly complex. Coupled to the inaccessibility of the in vivo environment and scarcity of research material, studying human implantation remains exceptionally challenging. Nevertheless, the field continues to gain momentum. Cutting-edge omics technologies and high-resolution imaging have revealed important structural and functional insights into endometrial biology, while emerging bioengineering tools are enhancing our ability to model the synergies and individual features of the embryo-maternal environment. Novel in vitro platforms using human cells and embryos are considerably more accessible and easier to manipulate compared to in vivo approaches, enhancing our ability to capture specific stages of implantation. This review aims to showcase current and emerging technologies used to study human endometrial biology and the early embryo-maternal interface, including single cell omics approaches, bioengineered endometrial models and embryo-endometrium co-culture platforms. We highlight the value of these approaches and provide our perspective on the current challenges faced by the field. Recognizing the physiological scope of these emerging technologies will be key for utilizing their full potential and driving future innovation. Show less
Vascularised, receptive endometrium is essential for implantation and for the success of the embryo-maternal interaction. Disturbances in vascular development may play an important role in... Show moreVascularised, receptive endometrium is essential for implantation and for the success of the embryo-maternal interaction. Disturbances in vascular development may play an important role in frequently occurring pathologies during pregnancy, such as early pregnancy wastage, pre-eclampsia and intrauterine growth restriction. Adaptation to implantation starts during the menstrual cycle by stromal decidualisation and the induction of angiogenesis, the formation of new vessels from existing vasculature. These processes continue throughout the 1st trimester. Angiogenesis is a multi-step process involving degradation of the basal membrane, activation, migration of endothelial cells and finally the formation of capillaries and the recruitment of pericellular smooth muscle cells. Numerous factors are involved in these processes. Three distinct groups of angiogenic factors, namely membrane bound proteases, vascular growth factors and its receptors and angiopoietins and its receptor, were analysed in this thesis. Pericellular proteolysis plays an important role in angiogenesis being required for endothelial cell migration, invasion and tube formation. In chapter 2 we studied the expression of proteases, matrix-metalloproteinase (MMPs) and uPA, by human endometrial microvascular endothelial cells (hEMVEC) and their involvement in the formation of capillary tubes in vitro. Inhibition of uPA and MMPs both reduced tube formation. hEMVEC expressed various MMPs mRNAs and proteins; in particular MMP-1, MMP-2, MT1-, MT3- and MT4-MMP. Immunohistochemistry confirmed the presence of MT3-MMP in endothelial cells of endometrial tissue. Overexpression of TIMP-1 or TIMP-3 by adenoviral transduction of hEMVEC reduced tube formation to the same extent. In addition, tube formation by hEMVEC was partly inhibited by the presence of anti-MT-3-MMP IgG. Thus, tube formation by hEMVEC is, at least in part, regulated by MT3-MMP. The study described in chapter 3 analyses the presence of MT-MMPs in human endometrium and their correlation with endometrial neovascularisation. The data show that all MT-MMP antigens are expressed in endometrium in a cycle-dependent pattern. The vascular expression of MT2- MT3- and MT4-MMP correlated with angiogenic episodes of the cycle. Since MT2- and MT3-MMP are known to regulate capillary-like tube formation, these findings support earlier in vitro data on the regulatory role of MT3-MMP in endometrial angiogenesis. Additionally, MT2-MMP appears to be associated with endometrial neovascularisation as well. Chapter 4 focuses on the role of proteases in decidual angiogenesis and remodelling in general. The expression of membrane-type matrix metalloproteinases (MT-MMPs) and urokinase/urokinase receptor (uPA/uPAR) were studied in decidua basalis (DB), decidua parietalis (DP) and decidual secretory endometrium (DSE) of human 1st trimester pregnancies. This enabled evaluation of decidual expression of the proteases, their regulation by pregnancy-induced hormones and/or the extra-villous trophoblast (EVT) and their relationship with decidual remodelling, trophoblast invasion and vascularisation. Pericellular-acting proteases appeared to be regulated by both pregnancy-induced hormones and EVT; uPAR and MT1-MMP by pregnancy-induced hormones and uPA, MT2-, MT3-, and MT5-MMP by EVT. All proteases were expressed by the EVT themselves and might be involved in trophoblast invasion. MT2- and MT3-MMP protein expression in endothelium was reduced in DB. Since these MT-MMPs are known regulators of angiogenesis, they may not only support decidual remodelling and trophoblast invasion but also partially regulate vascularisation at the embryonic implantation site. Chapter 5 describes the effect of human embryo-conditioned medium on in vitro endometrial angiogenesis. The conditioned media were shown to contain significant amounts of VEGF-A and stimulated in vitro tube formation by hEMVEC. This inducing effect was counteracted by adding soluble VEGF-R1. The other mediators, which have been described as produced by the early embryo/trophoblast, for instance Il-10, TGF_, PlGF, hCG and TGF_ had no effect on tube formation by hEMVEC. In conclusion, we show that the human embryo is able, via VEGF-A, to stimulate in vitro endometrial angiogenesis at the time of implantation. Chapter 6 evaluates vascular adaptation to implantation. We studied vascularisation and the expression of angiogenic factors in decidua basalis (DB), decidua parietalis (DP) and decidual secretory endometrium (DSE) of 1st trimester pregnancies. This enabled not only evaluation of decidual vascularisation and the expression of VEGF-A, PlGF, Flt-1, KDR, Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2) and TIE-2, but also their regulation by pregnancy-induced hormones and/or the extra-villous trophoblast (EVT). Both pregnancy-induced hormones and EVT influence vascularisation by enhancing vascular and luminal surface and reducing vessel density at the implantation site. These changes correlate with differences in gene and protein expression. PlGF mRNA and PlGF and Flt-1 protein expressions were elevated in DB under influence of EVT. Also the angiopoietins were differentially expressed, in favour of Ang-2, in DB. These data suggest that PlGF, Flt-1, Ang-1 and Ang-2 may be regulators of angiogenesis at the implantation site. Chapter 7 describes vascular adaptation to implantation in Missed Abortions by studying vascularisation and the expression of angiogenic factors and proteases in decidua basalis (DB), decidua parietalis (DP) and decidual secretory endometrium (DSE) of 1st trimester pregnancies which are complicated by a missed abortion. This enabled evaluation of decidual vascularisation, expression of VEGF-A, PlGF, Flt-1, KDR, Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), TIE-2, uPA, uPAR, MT1-, MT2-, MT3- and MT5-MMP and their regulation by pregnancy-induced hormones and/or the extra-villous trophoblast (EVT). In Chapter 8, the expression of angiogenic factors in the 1st trimester, obtained during chorion villus sampling, were correlated with the pregnancy outcome. This was performed to study the hypothesis that early imperfections in the formation of the placental bed may result in pre-eclampsia, eclampsia or intra uterine growth retardation (IUGR). The mRNA levels of VEGF-A, PlGF, Flt-1, KDR, Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2) and TIE-2 did not show a correlation with pregnancy outcome. This chapter is incorporated as a preliminary report since the provided samples were not sufficient but we do think this study is of value to the thesis. In Chapter 9 the results of the studies of this thesis are discussed and Chapter 10 gives a final conclusion and recommendations for future research. Show less
Vascular maladaptation prior and during implantation may lead to serious complications during pregnancy, perinatally, but also later in life (Barker hypothesis). The consequences later in life... Show moreVascular maladaptation prior and during implantation may lead to serious complications during pregnancy, perinatally, but also later in life (Barker hypothesis). The consequences later in life often appear to be related to endothelial dysfunction. Angiogenesis, the formation of new blood vessels from pre-existing ones, is an important endothelial function and plays a key role in the process of implantation and placentation. Two epidemiological studies described here, show that myocardial infarction is related to low birth weight and that assisted procreation adversely affects birth weight. An optimal intra-uterine environment forms the basis for a good perinatal outcome and is created by a receptive endometrium in which angiogenesis is crucial. To study endometrial angiogenesis, human endometrial endothelial cells were isolated. The high expression of u-PA by these cells was found to contribute to their high angiogenic properties. Furthermore, these cells depend on MT3-MMP to form tubes. The ovarian steroids overall regulate endometrial angiogenesis indirectly via the endometrial stromal cells. During implantation, the embryo takes over as the main (local) regulator by inducing angiogenesis at its implantation site through the expression of VEGF. These results provide more insight in the (patho-)physiology of endometrial angiogenesis and in the role of the embryo in this. Show less
