Endometriosis and oxidative stress -...

Endometriosis and oxidative stress ?

Pietro Santulli MD, PhD Université Paris Descartes, Sorbonne Paris Cité, Faculté de médecine, AP-HP, Cochin Saint Vincent de Paul, Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France Inserm, Unité de recherche U1016 – équipe Pr Batteux, Institut Cochin, Paris, France

Presentation outline

• Pathogenesis of inflammation

• Clinical consequences: Pain and infertility

• Oxidative stress

• Targeted treatments of endometriosis

Implantation theory of endometriosis

SUP, superficial lesion; OMA, endometrioma; DIE, deep infiltrating endometriosis

Adenomyosis SUP OMA DIE

Glands Stroma

Ectopic implantation

Cycle of pathogenesis in endometriosis

Kobayashi H et al. Arch Gynecol Obstet 2014; 289(1): 13–21.

Invasion

Proliferation

Steroidogenesis

Angiogenesis

Adhesion

Glands Stroma

Ectopic implantation

Mechanisms of pathogenesis in endometriosis

Adapted from Kobayashi H et al. Arch Gynecol Obstet 2014; 289(1): 13–21.

Chronic inflammatory response ++++

Excess oxidative stress

Attenuated progesterone

action

Altered immune functions

Neuroangiogenesis

Invasion

Proliferation

Steroidogenesis

Angiogenesis

Adhesion

Cholesterol

Androstenedione

STAR

CYP11A1

CYP17

EstroneCYP19A1

NR5A1 Estradiol

PGE2 PTGS2

+

+

+

+

VEGF

+

MMP

INSL3

Proliferation

Inflammation

Steroidogenesis

Adhesion-Migration

Angiogenesis

Molecular pathways involved in endometriosis

VEGF, vascular endothelial growth factor; PGE2, prostaglandin E2; PTGS2, prostaglandin-endoperoxide synthase 2; PTGER, prostaglandin E receptor; MMP, matrix metalloproteinase; INSL3, insulin-like 3; STAR, steroidogenic acute regulatory protein; CYP, cytochrome P; NR, nuclear receptor. Adapted from Bulun SE. N Engl J Med 2009; 360(3): 268–279.

PTGER

Cholesterol

Androstenedione

STAR

CYP11A1

CYP17

EstroneCYP19A1

NR5A1 Estradiol

PGE2 PTGS2

+

+

+

+

VEGF

+

MMP

INSL3

Proliferation

Inflammation

Steroidogenesis

Adhesion-Migration

Angiogenesis

Molecular pathways involved in endometriosis

PTGER

VEGF, vascular endothelial growth factor; PGE2, prostaglandin E2; PTGS2, prostaglandin-endoperoxide synthase 2; PTGER, prostaglandin E receptor; MMP, matrix metalloproteinase; INSL3, insulin-like 3; STAR, steroidogenic acute regulatory protein; CYP, cytochrome P; NR, nuclear receptor. Adapted from Bulun SE. N Engl J Med 2009; 360(3): 268–279.

Inflammatory response pathway leads to tissue injury and chronic pain

IL, interleukin; TNF, tumor necrosis factor; PG, prostaglandin; CXCL, chemokine; NGF, nerve growth factor; NF-Kβ, nuclear factor kappa beta.

! Iron

Oxidative stress

Increased pro-inflammatory

factors

Decreased anti-inflammatory

factors

Tissue injury

ê CXCL 10 ê IL-19,22

é TNF-α é IL-1β é IL-6,8,33 é Rantes é PGs

é PGsExcessive sensory

innervationé NGF

Neuroangiogenesis

Pelvic Pain

! NF- Kβ

Inflammation Regurgitation

Inflammatory response can contribute to infertility

de Ziegler D et al. Lancet 2010; 376(9742): 730–738.

Ovaries: • Decreased ovarian response • Altered oocyte quality? • Iron overload (proinflammatory factors)

Uterus: • Increased synthesis of prostaglandin &

altered receptivity • Production of estrogens in situ and

resistance to progestogen

Pelvic cavity: • Proliferation of macrophages • Phagocytic dysfunction • Release of proinflammatory factors

Sphingosines

MAPK pathway

PTGS2

Inflammation

Inflammation in endometriosis: Molecular intermediates and pathways

PTGS2, prostaglandin-endoperoxide synthase 2

Invasion

Proliferation

Steroidogenesis

Angiogenesis

Adhesion

Oxidative Stress

Sphingosines

MAPK pathway

PTGS2

Inflammation

Inflammation in endometriosis: Molecular intermediates and pathways

PTGS2, prostaglandin-endoperoxide synthase 2

Invasion

Proliferation

Steroidogenesis

Angiogenesis

Adhesion

Oxidative StressOxidative Stress

Inflammatory response is linked to an altered balance of oxidative stress

IL, interleukin; CXCL, chemokine; GSH, glutathione; NADPH, nicotinamide adenine dinucleotide phosphate-oxidase; AOPP, advanced oxidation protein products; PGs, prostaglandins.

Pro-OxidantsAnti-OxidantsPersistent inflammation

N=85 N=55 N=31 N=64

Oxidative stress is increased in endometriosis, especially in DIE

DIE, deep infiltrating endometriosis; SUP, superficial lesion; OMA, endometrioma; AOPP, advanced oxidation protein products. Santulli P et al. Hum Reprod 2015; 30(1): 49–60.

N=36 N=28

N=150

Oxidative stress is increased further in intestinal DIE

Hydrogen Peroxide (H2O2)

Endometrioma1

Increased oxidative stress correlates with increased cellular proliferation

1. Ngô C et al. Am J Pathol 2009; 175(1): 225–234. 2. Leconte M et al. Am J Pathol 2011; 179(2): 880–889.

Superoxide Anion (O2--) Hydrogen Peroxide (H2O2)

Superoxide Anion (O2--)Deep infiltrating endometriosis2

Epithelial Ce, control endometrial Ee, eutopic endometrial De, deep infiltrating endometriotic Stromal Cs, control endometrial Es, eutopic endometrial Ds, deep infiltrating endometriotic

Increased oxidative stress correlates with increased cellular proliferation: Link to MAPK pathway

NAC, N-acetyl-cysteine; ERK, Extracellular signal-regulated kinases; pERK, phosphorylated-ERK. Ngô C et al. Am J Pathol 2009; 175(1): 225–234.

Cont

rols

Euto

pic

Ecto

pic

NAC

ERK

pERK

Prol

ifera

tion

Prol

ifera

tion

NACLevel of untreated cells

Level of untreated cells

Opt

ic D

ensi

ty p

ERK

/ER

K

H2O

2 Pro

duct

ion

Sphingosines PTGS2

Inflammation

Inflammation in endometriosis: Molecular intermediates and pathways

PTGS2, prostaglandin-endoperoxide synthase 2

Invasion

Proliferation

Steroidogenesis

Angiogenesis

Adhesion

Oxidative Stress MAPK pathway

Cell proliferationTranscriptional regulation

Angiogenesis

NADPH oxidase

GSH ROS

IL-33RPDGFR VEGFR

S1P

MAPK pathway links increased oxidative stress and inflammatory response in endometriosis

IL, interleukin; NADPH, nicotinamide adenine dinucleotide phosphate-oxidase; GSH, glutathione; PDGFR, platelet-derived growth factor receptors; VEGFR, vascular endothelial growth factor receptor; ROS, reactive oxidative species. Ngô C et al. J Pathol 2010; 222(2): 148–159. Santulli P et al. Fertil Steril 2012; 97(4): 904–911. Santulli P et al. Hum Reprod 2012; 27(7): 2001–2009.

MAPK pathway

Endometriosis and MAPK Vemurafenib - braf

Endometriosis and MAPK Sorafenib – raf1- braf - tkr

Endometriosis and inflammation Targeting MAP Kinase pathway

2015

LOCAL SYSTEMIC

Future trends Targeting inflammation in endometriosis: MAPK

Future trends Targeting inflammation in endometriosis: MAPK

à " " New non hormonal targeted tretments of endometriosis

MAPK

Conclusions

• Endometriosis is an • Enigmatic • Heterogeneous • Neurologic • Inflammatory

• New treatments could target inflammation and oxidative stress pathways

disease

Gynecology Surgical unit: C Chapron, B Borghese, L Marcellin, P Santulli, H Foulot, MC Lafay-Pillet, A Bourret, G Pierre, MC Lamau, P Marzouk, F Decuypere, L Campin Medical unit: A Gompel, G Plu-Bureau, L Maitrot; J Hugon Reproductive endocrinology unit: P Santulli, V Gayet, M Bourdon, C Maignien, F Kefelian, S Eskenazi, S Douard, B Boquet, A Marszalek, A Fubini Intestinal surgery B Dousset, S Gaujoux, M Leconte Radiology AE Millischer, L Maitrot

Laboratory: Genetic D Vaiman, F Mondon, S Barbaux Laboratory: Imunulogy F Batteux, S Chouzenoux, C Nicco, C Chéreau, B Weill Laboratory: Reproducive biology JP Wolf, C Patrat, K Pocate, V Lange, JM Kuntzman, C Chalas Statistical unit F Goffinet, PY Ancel

A Gompel, Professor and Head, Medical Gynecological unit, P Santulli, Doctor and Head, Reproductive ART and Infertility unit,

C Chapron, Professor and Chair, Gynecology Obstetrics II and Reproductive Medicine