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Current pharmacological treatments for endometriosis are limited to hormonal agents that can relieve pain but cannot cure the disease. Therefore, the development of a disease-modifying drug for endometriosis is an unmet medical need. By studying human endometriotic samples, we found that the progression of endometriosis was associated with the development of inflammation and fibrosis. In addition, IL-8 expression was highly up-regulated in endometriotic tissues and closely correlated with disease progression. We created a long-acting recycling antibody against IL-8 (AMY109) and evaluated its clinical potency. Because rodents do not produce IL-8 and do not experience menstruation, we analyzed the lesions in cynomolgus monkeys that spontaneously developed endometriosis and in a surgically induced endometriosis monkey model. Both spontaneously developed and surgically induced endometriotic lesions demonstrated pathophysiology that was highly similar to that of human endometriosis. Once-a-month subcutaneous injection of AMY109 to monkeys with surgically induced endometriosis reduced the volume of nodular lesions, lowered the Revised American Society for Reproductive Medicine score as modified for monkeys, and ameliorated fibrosis and adhesions. In addition, experiments using cells derived from human endometriosis revealed that AMY109 inhibited the recruitment of neutrophils to endometriotic lesions and the production of monocyte chemoattractant protein-1 from neutrophils. Thus, AMY109 may represent a disease-modifying therapy for patients with endometriosis.

Study Question: Does spontaneous endometriosis in cynomolgus monkeys have the characteristics required of a good experimental model?, Summary Answer: Spontaneous endometriosis in cynomolgus monkeys exhibited similar clinicopathological characteristics to the human disease and was useful as an experimental model., What Is Known Already: The prevalence of endometriosis in autopsied cynomolgus monkeys (Macaca fascicularis) in a breeding colony was reported to be 28.7% in 1993. The histopathological findings we reported recently showed that components of spontaneous endometriosis were not only endometriotic epithelium and stromal cells (CD10-positive) with hemorrhage and inflammation, but also smooth muscle metaplasia and nerve fibers., Study Design, Size, Duration: During routine medical examinations at a research facility from 2008 to 2012, 614 female cynomolgus monkeys of reproductive age (6-25 years) were screened for endometriosis by the presence of regular menstrual bleeding, serum CA125 levels and palpation of the abdomen. In total, 29 monkeys were selected as subjects for the following study., Participants/materials, Setting, Methods: Of the 29 monkeys selected, 15 were diagnosed with endometriosis by laparoscopy and/or open surgery. The monkeys were monitored by observing their general condition, and eight of these were monitored using laparoscopy and MRI. In addition, to investigate appropriate screening parameters and endometriosis-associated biological parameters in monkeys, we retrospectively examined general laboratory parameters that correlate to the menstrual cycle and disease status., Main Results and the Role of Chance: The combination of CA125 serum levels (this was a useful marker for chocolate cysts), palpation of the abdomen, and fecal abnormalities was the most efficient screening method for diagnosing monkeys with endometriosis. Each animal could be diagnosed and assigned a disease stage by laparoscopy. While monitoring the disease stage by laparoscopy and/or MRI, disease status in individual monkeys was mainly stable or was progressive for 2-7 months. The detection rate by screening was low (15/614) but age-specific analysis suggests that screening would be more efficient if a colony for an endometriosis model is maintained with 11-20-year olds. As an endometriosis-associated biological parameter, the decrease in food consumption that coincided with menstruation was selected and correlated well (R2 value = 0.8239) with disease status (according to a modified adhesion revised American Fertility Society score)., Large Scale Data: N/A., Limitations, Reasons for Caution: Peritoneal fluid was not analyzed because a smaller amount is produced in cynomolgus monkeys than in baboons. Although clinical endometriosis-associated pain is evaluated in women using a visual analog scale, pain could not be directly evaluated in this non-human primate model., Wider Implications of the Findings: Although cynomolgus monkeys are relatively small (2-5 kg) primates, laparoscopy and MRI make it possible to evaluate spontaneous endometriosis in these monkeys and to monitor its development over time. Spontaneous endometriosis in cynomolgus monkeys is a useful model for evaluating disease progress and drug efficacy because they have similar lesions to those in humans, and conventional laboratory methods and parameters for assessment are well established., Study Funding/competing Interest(s): No external funds were used for this study. A.N.-K., K.T., H.T., A.K. and M.S. are full-time employees of Chugai Pharmaceutical Co., Ltd. R.K. received a consultancy fee from Chugai Pharmaceutical Co., Ltd. and lecture fees from Chugai Pharmaceuticals, Japan Vaccine Co. Ltd., Merck & Co., Mochida Co. Ltd., Roche Diagnostics, and BD, unrelated to the submitted work. S.N., S.O. and T.S. have nothing to declare.

Study Question: What are the characteristics of spontaneous endometriosis in cynomolgus monkeys?, Summary Answer: Spontaneous endometriosis in cynomolgus monkeys exhibited similar characteristics to the human disease., What Is Known Already: One previous report described the prevalence and the basic histopathology of spontaneous endometriosis in cynomolgus monkeys., Study Design, Size, Duration: Endometriotic lesions that had been histologically confirmed in 8 female cynomolgus monkeys between 5 and 21 years old were subjected to study., Participants/materials, Setting, Methods: The monkeys died of, or were sacrificed because of, sickness consequent on endometriosis. Specimens were evaluated histopathologically with haematoxylin and eosin staining, iron staining and immunohistochemistry (CD10, CD31, α-SMA and PGP9.5), and by observing them under a microscope., Main Results and the Role of Chance: Endometriotic and stromal cells (CD10-positive) with haemorrhage and inflammation were observed. Smooth muscle metaplasia and nerve fibres were also noted in the endometriotic lesions. Endometriotic lesions in lymph nodes were incidentally found., Limitations and Reasons for Caution: Since laparoscopic analysis for monitoring the disease state was not set as a parameter of the current study, time course changes (progression) of the disease were not assessed., Wider Implications of the Findings: Further investigation of spontaneous endometriosis in cynomolgus monkeys may contribute to better understanding of the disease pathobiology., Study Funding/competing Interests: No external funds were used for this study. A.N.K., S.M., S.H., T.I., O.K., A.K. and M.S. are full-time employees of Chugai Pharmaceutical Co., Ltd. R.K. received lecture fees from Chugai Pharmaceutical Co., Ltd., unrelated to the submitted work. S.N., S. O., L.Y., K.Y. and T.S. have nothing to declare., Trial Registration Number: N/A., (© The Author 2016. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology.)

Primary umbilical endometriosis is extremely rare, although cases secondary to previous surgery have occasionally been reported. Here, we report three cases of umbilical endometriosis: two cases with previous cesarean section and one case of primary umbilical endometriosis. The treatment of choice for umbilical endometriosis is the excision of the lesions, and we believe laparoscopic pelvic observation is a beneficial addition, as 13%-15% of umbilical endometriosis cases are accompanied by pelvic endometriosis., (© 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.)

Objective: To investigate the pathogenesis of endometriotic pain., Design: Retrospective nonrandomized immunohistochemical study., Setting: A university hospital, Department of Gynecology., Patient(s): Twenty human endometriotic specimens were selected from different lesions including ovarian endometrioma, peritoneal lesion, and deep infiltrating lesion. Premenopausal women with histologically diagnosed endometriosis were selected (mean age 39 years; range, 25-53 years). The chief complaint was dysmenorrhea, dyschezia, and dyspareunia. A rat endometriosis model was induced in 10 SLC-Sprague-Dawley rats (8 weeks old) by surgical autotransplantation of the uterus., Intervention(s): Immunohistochemical staining of endometriotic specimens for alpha-smooth muscle actin (ASMA), neural cell adhesion molecule (NCAM), and nerve growth factor (NGF) expression., Main Outcome Measure(s): Comparison of the immunoreactive staining of ASMA, NCAM, and NGF expression in human endometriosis and a rat endometriosis model., Result(s): Morphological analysis revealed thick interstitium in both human and rat endometriotic lesions. The major components of fibrotic interstitium are smooth muscle cells, stained by anti-ASMA antibody, and nerve cells, stained by anti-NCAM antibody. Inflammatory cells are also present (e.g., macrophages and lymphocytes) as revealed by anti-NGF antibody staining., Conclusion(s): These results suggest that the contraction of smooth muscle cells and the hyperalgia derived from innervation in the interstitial area is related to pain in endometriosis.

Objective: To investigate the anti-inflammatory effect of n-3 eicosapentaenoic acid (EPA) compared with n-6 linoleic acid (LA) in an endometriosis rat model. We focused on the relationship between lipid metabolism and inflammatory reactions in endometriosis based on the hypothesis that a lipid intake imbalance is one of the factors responsible for the recent increase of endometriosis., Design: Prospective, randomized experimental study., Setting: Animal surgery laboratory in a university hospital., Animal(s): Sprague-Dawley rats (female, 6 weeks old)., Intervention(s): Rats were fed a diet with EPA (n = 9) or with LA (n = 9) for 2 weeks. Two weeks after feeding, the uterus was autotransplanted to the peritoneum to construct an endometriosis model. Feeding was continued for a total of 6 weeks. Two and 4 weeks after autotransplantation, three rats of each group were killed and evaluated., Main Outcome Measure(s): Endometriotic lesions were morphologically evaluated and their fatty acid composition was examined. Gene expression in these tissues was evaluated by cDNA microarray analysis and quantative real-time reverse transcriptase-polymerase chain reaction (RT-PCR)., Result(s): In the EPA group, the n-3:n-6 ratio in each tissue significantly increased and the thickening of the interstitium, an active site for inflammation in endometriosis, was significantly suppressed (0.30 +/- 0.09 mm [EPA group] vs. 0.77 +/- 0.23 mm [LA group]). The mRNA of metalloproteinases, interleukin-1beta, interleukin-1r, prostaglandin E synthase (Ptges), and nuclear factor (NF)-kappaB were reduced in the EPA group., Conclusion(s): EPA supplementation might be a valid strategy for the treatment of endometriosis.

Problem: To investigate the molecular mechanism of endometriosis, gene expression profiling was analyzed in a rat endometriosis model., Method of Study: An endometriosis model was induced by uterine autotransplantation in the peritoneal cavity on a female-SD rat (8 weeks old). As control samples, the normal uterine tissues were used. The gene expression was compared between endometriotic lesions and normal uterine tissues by cDNA microarray analysis, quantitative real time RT-PCR and immunohistochemistry., Results: The expression of 71 genes was upregulated and that of 45 genes was downregulated in the endometriotic lesions compared to normal uterine tissues. The upregulated genes included genes encoding cytokines, chemokines, growth factors and cell adhesion molecules. The levels of transcripts of osteopontin, Lyn, Vav1, Runx1, and l-selectin in the endometriotic lesions were 130, 10, 10, 12 and 46-fold higher than the respective levels in the eutopic endometrial samples., Conclusion: The results suggest that osteopontin, Lyn, Vav1, Runx1, and l-selectin play important roles in the pathogenesis of endometriosis.

Objective: To investigate the localization of the proteins osteopontin (OPN) and L-selectin (SELL)., Design: Retrospective nonrandomized immunohistochemical study in a surgically induced rat model of peritoneal endometriosis and in samples of human endometriotic lesions of ovaries., Setting: Department of gynecology in a university hospital., Patient(s): A rat endometriosis model was induced in 10 8-week-old SLC-Sprague-Dawley rats by surgical autotransplantation of uterus. Fourteen premenopausal women with histologically diagnosed endometriosis were selected (mean age, 39 y; range, 25-53 y). Twenty endometriotic specimens were obtained from 14 patients who underwent laparoscopic surgery for enlarged endometriotic cysts., Intervention(s): Histopathological examination of endometriotic ovarian specimens for OPN and SELL expression by immunohistochemistry., Main Outcome Measure(s): Demonstration of the immunoreactive staining of OPN and SELL expressions in tissues of a rat endometriosis model and of human endometriosis., Result(s): In both tissues from a rat endometriosis model and from human endometriosis, OPN was stained more prominently in glandular epithelium than in interstitial space, whereas SELL stained more prominently in interstitial space (macrophages and lymphocytes) than in epithelium. The staining pattern of OPN in ectopic endometriotic lesions was very similar to that in eutopic normal human endometrium in the secretory phase., Conclusion(s): These results suggested important roles for OPN and SELL in the pathogenesis of endometriosis.

Problem: Although the presence of mast cells in endometriosis lesions has been reported, there have been no reports of their pathological localization in ovarian endometrial cysts., Methods of Study: The localization of mast cells in ovarian endometrial cysts were investigated using hematoxyline and eosin and toluidine blue staining with light microscopy, immunohistochemical c-kits, and electron microscopy., Results: Mast cells were identified in endometrial cyst tissues. Few mast cells were localized in the endometrial stroma, which is characteristic of endometrial gland-like regions. Many mast cells were noted around blood vessels and the interstitium with fibrosis, that is, the fibrotic interstitium of endometrial cysts., Conclusions: Mast cells may be involved in the development and progression of endometriosis. Localization of mast cells suggests a particularly close relationship with fibrosis and adhesion.

Study Objectives: To investigate the pathophysiology of human endometriosis, we examined by morphological and molecular biological methods., Methods: Samples of ovarian endometriosis and normal ovarian tissues were obtained laparoscopically after informed consent. A morphological study by toluidine blue staining, immunohistochemistry of c-kit and electron microscopy demonstrated the localization of mast cells in the stromal lesions of endometriosis. Oligonucleotide microarrays were used for gene expression analysis., Results: Infiltration of numerous mast cells and development of fibrosis was observed throughout the stromal lesions. Gene expression analysis by oligonucleotide microarrays indicated inflammatory immunoreactions in the lesions. Expressions of the FCER1G and PGDS, which are considered to be mast cell-specific genes, were upregulated in the ovarian endometriotic lesions as compared to the normal ovarian tissues. Furthermore, expressions of genes associated with immunological inflammation, such as IL-8, GRO1, GRO2, CXCR4, MCP1, and those related to tissue remodeling (MMP, COL4A2, and COL5A2) were also higher in endometriotic lesions than in the normal ovarian tissue., Conclusions: Thus it is likely that mast cells and their related inflammatory immunoreactions via chemokines play important roles in producing fibrosis and adhesions in endometriotic lesions.