Cell and Tissue Research

, Volume 364, Issue 2, pp 415–427 | Cite as

Possible involvement of inflammatory/reparative processes in the development of uterine fibroids

  • Olga Protic
  • Paolo Toti
  • Md Soriful Islam
  • Rossella Occhini
  • Stefano Raffaele Giannubilo
  • William H. Catherino
  • Saverio Cinti
  • Felice Petraglia
  • Andrea Ciavattini
  • Mario Castellucci
  • Boris Hinz
  • Pasquapina Ciarmela
Regular Article


Uterine leiomyomas are benign tumors in the smooth muscle layer of the uterus. The most common histological type is the “usual leiomyoma”, characterized by overexpression of ECM proteins, whereas the “cellular type” has higher cellular content. Our objective is to investigate the involvement of inflammatory and reparative processes in leiomyoma pathobiology. Using a morphological approach, we investigate the presence of inflammatory cells. Next, we determine the localization of the ECM, the presence/absence of fibrotic cells via α-sma and desmin and the immunohistochemical profile of the mesenchymal cells with respect to CD34. Finally, we explore the effect of inflammatory mediators (TNF-α, IL-1β, IL-6, IL-15, GM-CSF and IFN-γ) on pro-fibrotic factor activin A mRNA expression in vitro. Higher numbers of macrophages were found inside and close to leiomyomas as compared to the more distant myometrium. Cellular leiomyomas showed more macrophages and mast cells than the “usual type”. Inside the fibroid tissue, we found cells positive for α-sma, but negative for desmin and a large amount of collagen surrounding the nodule, suggestive of myofibroblasts producing ECM. In the myometrium and leiomyomas of the “usual type”, we identified numerous CD34+ fibroblasts, which are known to give rise to myofibroblasts upon loss of CD34 expression. In leiomyomas of the “cellular type”, stromal fibroblasts were CD34-negative. Finally, we found that TNF-α increased activin A mRNA in myometrial and leiomyoma cells. In conclusion, this study demonstrates the presence of inflammatory cells in uterine leiomyomas, which may contribute to excessive ECM production, tissue remodeling and leiomyoma growth.


Usual leiomyoma Cellular leiomyoma Inflammation ECM Myofibroblast CD34 TNF-α Activin A Myometrium 



O.P. and M.J. are recipients of a fellowship from the Polytechnic University of Marche, reserved for PhD students coming from universities of the UNIADRION, a network of universities established with the purpose of creating a permanent connection among universities and research centers from the Adriatic-Ionian Region (Italy). M.S.I. is recipient of a fellowship from the Polytechnic University of Marche, reserved for PhD students from non-EU countries. We thank Dr. Francesco Piva (Bio-engineer, Department of Specialistic Clinical and Odontostomatological Sciences, Polytechnic University of Marche, Ancona, Italy) for his valuable help to perform statistical data analysis.


This work was supported by the “Fondazione Cassa di Risparmio di Fabriano e Cupramontana” (to M.C. and P.C.) and by the Italian Ministry of University and Research (PRIN 2010–2011, No. 20102CHST5_007, to S.R.G.). B.H is funded by grants from the Canadian Institutes of Health Research (#210820, #286720, #286920, #497202).


  1. Arici A, Sozen I (2000) Transforming growth factor-beta3 is expressed at high levels in leiomyoma where it stimulates fibronectin expression and cell proliferation. Fertil Steril 73(5):1006–1011CrossRefPubMedGoogle Scholar
  2. Avritscher R, Iyer RB, Ro J, Whitman G (2001) Lipoleiomyoma of the uterus. Am J Roentgenol 177(4):856CrossRefGoogle Scholar
  3. Barth PJ, Ramaswamy A, Moll R (2002) CD34(+) fibrocytes in normal cervical stroma, cervical intraepithelial neoplasia III, and invasive squamous cell carcinoma of the cervix uteri. Virchows Arch 441(6):564–568CrossRefPubMedGoogle Scholar
  4. Barth PJ, Westhoff CC (2007) CD34+ fibrocytes: morphology, histogenesis and function. Curr Stem Cell Res Ther 2(3):221–227CrossRefPubMedGoogle Scholar
  5. Bloise E, Cassali GD, Ferreira MC, Ciarmela P, Petraglia F, Reis FM (2010) Activin-related proteins in bovine mammary gland: localization and differential expression during gestational development and differentiation. J Dairy Sci 93(10):4592–4601CrossRefPubMedGoogle Scholar
  6. Buttram VC Jr, Reiter RC (1981) Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 36(4):433–445PubMedGoogle Scholar
  7. Chegini N (2010) Proinflammatory and profibrotic mediators: principal effectors of leiomyoma development as a fibrotic disorder. Semin Reprod Med 28(3):180–203CrossRefPubMedPubMedCentralGoogle Scholar
  8. Chow MT, Moller A, Smyth MJ (2012) Inflammation and immune surveillance in cancer. Semin Cancer Biol 22(1):23–32CrossRefPubMedGoogle Scholar
  9. Ciarmela P, Bloise E, Gray PC, Carrarelli P, Islam MS, De Pascalis F, Severi FM, Vale W, Castellucci M, Petraglia F (2011a) Activin-A and myostatin response and steroid regulation in human myometrium: disruption of their signalling in uterine fibroid. J Clin Endocrinol Metab 96(03):755–765CrossRefPubMedPubMedCentralGoogle Scholar
  10. Ciarmela P, Carrarelli P, Islam MS, Janjusevic M, Zupi E, Tosti C, Castellucci M, Petraglia F (2014) Ulipristal acetate modulates the expression and functions of activin A in leiomyoma cells. Reprod Sci 21(9):1120–1125CrossRefPubMedGoogle Scholar
  11. Ciarmela P, Islam MS, Lammana P, Tranquilli AL, Castellucci M (2012) Healthy and pathological changes of myometrium: pregnant myometrium, uterine fibroids and leiomyosarcoma. Rev Arg Anat Clin 1(4):7–13Google Scholar
  12. Ciarmela P, Islam MS, Reis FM, Gray PC, Bloise E, Petraglia F, Vale W, Castellucci M (2011b) Growth factors and myometrium: biological effects in uterine fibroid and possible clinical implications. Hum Reprod Update 17(6):772–790CrossRefPubMedPubMedCentralGoogle Scholar
  13. Ciarmela P, Wiater E, Vale W (2008) Activin-A in myometrium: characterization of the actions on myometrial cells. Endocrinology 149(5):2506–2516CrossRefPubMedPubMedCentralGoogle Scholar
  14. Diaz-Flores L, Gutierrez R, Garcia MP, Saez FJ, Diaz-Flores L Jr, Valladares F, Madrid JF (2014) CD34+ stromal cells/fibroblasts/fibrocytes/telocytes as a tissue reserve and a principal source of mesenchymal cells. Location, morphology, function and role in pathology. Histol Histopathol 29(7):831–870PubMedGoogle Scholar
  15. Eldar-Geva T, Meagher S, Healy DL, MacLachlan V, Breheny S, Wood C (1998) Effect of intramural, subserosal, and submucosal uterine fibroids on the outcome of assisted reproductive technology treatment. Fertil Steril 70(4):687–691CrossRefPubMedGoogle Scholar
  16. Erdag G, Qureshi HS, Patterson JW, Wick MR (2007) Solitary fibrous tumors of the skin: a clinicopathologic study of 10 cases and review of the literature. J Cutan Pathol 34(11):844–850CrossRefPubMedGoogle Scholar
  17. Eyden B (2008) The myofibroblast: phenotypic characterization as a prerequisite to understanding its functions in translational medicine. J Cell Mol Med 12(1):22–37CrossRefPubMedPubMedCentralGoogle Scholar
  18. Ezugwu EC, Iyoke CA, Ezugwu FO, Ugwu G (2014) Successful pregnancy following myomectomy for giant uterine fibroid in an infertile woman. J Reprod Infertil 15(4):233–236PubMedPubMedCentralGoogle Scholar
  19. Fallowfield JA, Mizuno M, Kendall TJ, Constandinou CM, Benyon RC, Duffield JS, Iredale JP (2007) Scar-associated macrophages are a major source of hepatic matrix metalloproteinase-13 and facilitate the resolution of murine hepatic fibrosis. J Immunol 178(8):5288–5295CrossRefPubMedGoogle Scholar
  20. Ferreira MC, Cavallo IK, Florio P, Petraglia F, Reis FM (2008) Activin betaA subunit, follistatin and follistatin-like 3 are expressed in the endometrium of ovariectomized rats and regulated by estrogen replacement. J Mol Histol 39(5):535–541CrossRefPubMedGoogle Scholar
  21. Flake GP, Moore AB, Sutton D, Kissling GE, Horton J, Wicker B, Walmer D, Robboy SJ, Dixon D (2013) The natural history of uterine leiomyomas: light and electron microscopic studies of fibroid phases, interstitial ischemia, inanosis, and reclamation. Obstet Gynecol Int 2013:528376PubMedPubMedCentralGoogle Scholar
  22. Friedman AJ, Harrison-Atlas D, Barbieri RL, Benacerraf B, Gleason R, Schiff I (1989) A randomized, placebo-controlled, double-blind study evaluating the efficacy of leuprolide acetate depot in the treatment of uterine leiomyomata. Fertil Steril 51(2):251–256PubMedGoogle Scholar
  23. Fujita M (1985) Histological and biochemical studies of collagen in human uterine leiomyomas. Hokkaido Igaky Zasshi 60(4):602–615Google Scholar
  24. Gelse K, Poschl E, Aigner T (2003) Collagens--structure, function, and biosynthesis. Adv Drug Deliv Rev 55(12):1531–1546CrossRefPubMedGoogle Scholar
  25. Haller ST, Kennedy DJ, Shidyak A, Budny GV, Malhotra D, Fedorova OV, Shapiro JI, Bagrov AY (2012) Monoclonal antibody against marinobufagenin reverses cardiac fibrosis in rats with chronic renal failure. Am J Hypertens 25(6):690–696CrossRefPubMedPubMedCentralGoogle Scholar
  26. Hinz B (2007) Formation and function of the myofibroblast during tissue repair. J Invest Dermatol 127(3):526–537CrossRefPubMedGoogle Scholar
  27. Hinz B, Phan SH, Thannickal VJ, Galli A, Bochaton-Piallat ML, Gabbiani G (2007) The myofibroblast: one function, multiple origins. Am J Pathol 170(6):1807–1816CrossRefPubMedPubMedCentralGoogle Scholar
  28. Hinz B, Phan SH, Thannickal VJ, Prunotto M, Desmouliere A, Varga J, De Wever O, Mareel M, Gabbiani G (2012) Recent developments in myofibroblast biology: paradigms for connective tissue remodeling. Am J Pathol 180(4):1340–1355CrossRefPubMedPubMedCentralGoogle Scholar
  29. Hotamisligil GS, Shargill NS, Spiegelman BM (1993) Adipose expression of tumor necrosis factor-alpha: direct role in obesity-linked insulin resistance. Science 259(5091):87–91CrossRefPubMedGoogle Scholar
  30. Hubner G, Werner S (1996) Serum growth factors and proinflammatory cytokines are potent inducers of activin expression in cultured fibroblasts and keratinocytes. Exp Cell Res 228(1):106–113CrossRefPubMedGoogle Scholar
  31. Islam MS, Catherino WH, Protic O, Janjusevic M, Gray PC, Giannubilo SR, Ciavattini A, Lamanna P, Tranquilli AL, Petraglia F, Castellucci M, Ciarmela P (2014) Role of activin-A and myostatin and their signaling pathway in human myometrial and leiomyoma cell function. J Clin Endocrinol Metab:jc20132623Google Scholar
  32. Islam MS, Protic O, Giannubilo SR, Toti P, Tranquilli AL, Petraglia F, Castellucci M, Ciarmela P (2013a) Uterine leiomyoma: available medical treatments and new possible therapeutic options. J Clin Endocrinol Metab 98(3):921–934CrossRefPubMedGoogle Scholar
  33. Islam MS, Protic O, Stortoni P, Grechi G, Lamanna P, Petraglia F, Castellucci M, Ciarmela P (2013b) Complex networks of multiple factors in the pathogenesis of uterine leiomyoma. Fertil Steril 100(1):178–193CrossRefPubMedGoogle Scholar
  34. Karmon AE, Cardozo ER, Rueda BR, Styer AK (2014) MicroRNAs in the development and pathobiology of uterine leiomyomata: does evidence support future strategies for clinical intervention? Hum Reprod Update 20(5):670–687CrossRefPubMedGoogle Scholar
  35. Kisseleva T, Brenner DA (2008) Mechanisms of fibrogenesis. Exp Biol Med (Maywood) 233(2):109–122CrossRefGoogle Scholar
  36. Leppert PC, Baginski T, Prupas C, Catherino WH, Pletcher S, Segars JH (2004) Comparative ultrastructure of collagen fibrils in uterine leiomyomas and normal myometrium. Fertil Steril 82(Suppl 3):1182–1187CrossRefPubMedPubMedCentralGoogle Scholar
  37. Leppert PC, Catherino WH, Segars JH (2006) A new hypothesis about the origin of uterine fibroids based on gene expression profiling with microarrays. Am J Obstet Gynecol 195(2):415–420CrossRefPubMedPubMedCentralGoogle Scholar
  38. Ligon AH, Morton CC (2000) Genetics of uterine leiomyomata. Gene Chromosomes Cancer 28(3):235–245CrossRefGoogle Scholar
  39. Lindenmayer AE, Miettinen M (1995) Immunophenotypic features of uterine stromal cells. CD34 expression in endocervical stroma. Virchows Arch 426(5):457–460CrossRefPubMedGoogle Scholar
  40. Luna LG (1968) Manual of Histologic staining methods of the Armed Forces Institute of Pathology: Blakiston Division. McGraw-Hill, New YorkGoogle Scholar
  41. Malik M, Norian J, McCarthy-Keith D, Britten J, Catherino WH (2010) Why leiomyomas are called fibroids: the central role of extracellular matrix in symptomatic women. Semin Reprod Med 28(3):169–179CrossRefPubMedGoogle Scholar
  42. Malik M, Webb J, Catherino WH (2008) Retinoic acid treatment of human leiomyoma cells transformed the cell phenotype to one strongly resembling myometrial cells. Clin Endocrinol (Oxf) 69(3):462–470CrossRefGoogle Scholar
  43. Mantovani A, Sica A, Sozzani S, Allavena P, Vecchi A, Locati M (2004) The chemokine system in diverse forms of macrophage activation and polarization. Trends Immunol 25(12):677–686CrossRefPubMedGoogle Scholar
  44. Mashal RD, Fejzo ML, Friedman AJ, Mitchner N, Nowak RA, Rein MS, Morton CC, Sklar J (1994) Analysis of androgen receptor DNA reveals the independent clonal origins of uterine leiomyomata and the secondary nature of cytogenetic aberrations in the development of leiomyomata. Gene Chromosomes Cancer 11(1):1–6CrossRefGoogle Scholar
  45. Nielsen JS, McNagny KM (2008) Novel functions of the CD34 family. J Cell Sci 121(Pt 22):3683–3692CrossRefPubMedGoogle Scholar
  46. Norian JM, Malik M, Parker CY, Joseph D, Leppert PC, Segars JH, Catherino WH (2009) Transforming growth factor beta3 regulates the versican variants in the extracellular matrix-rich uterine leiomyomas. Reprod Sci 16(12):1153–1164CrossRefPubMedPubMedCentralGoogle Scholar
  47. Okolo S (2008) Incidence, aetiology and epidemiology of uterine fibroids. Best Pract Res Clin Obstet Gynaecol 22(4):571–588CrossRefPubMedGoogle Scholar
  48. Petraglia F, Woodruff TK, Botticelli G, Botticelli A, Genazzani AR, Mayo KE, Vale W (1992) Gonadotropin-releasing hormone, inhibin, and activin in human placenta: evidence for a common cellular localization. J Clin Endocrinol Metab 74(5):1184–1188PubMedGoogle Scholar
  49. Rosai (2011) Rosai and Ackerman’s Surgical Pathology, 10th edn. Mosby, Edinburgh, pp 1508–1513Google Scholar
  50. Sarrazy V, Billet F, Micallef L, Coulomb B, Desmoulière A (2011) Mechanisms of pathological scarring: role of myofibroblasts and current developments. Wound Repair Regen 19(s1):s10–s15CrossRefPubMedGoogle Scholar
  51. Shao L, Frigon NL Jr, Sehy DW, Yu AL, Lofgren J, Schwall R, Yu J (1992) Regulation of production of activin A in human marrow stromal cells and monocytes. Exp Hematol 20(10):1235–1242PubMedGoogle Scholar
  52. Shao LE, Frigon NL Jr, Yu A, Palyash J, Yu J (1998) Contrasting effects of inflammatory cytokines and glucocorticoids on the production of activin A in human marrow stromal cells and their implications. Cytokine 10(3):227–235CrossRefPubMedGoogle Scholar
  53. Sierra-Filardi E, Puig-Kroger A, Blanco FJ, Nieto C, Bragado R, Palomero MI, Bernabeu C, Vega MA, Corbi AL (2011) Activin A skews macrophage polarization by promoting a proinflammatory phenotype and inhibiting the acquisition of anti-inflammatory macrophage markers. Blood 117(19):5092–5101CrossRefPubMedGoogle Scholar
  54. Skalli O, Ropraz P, Trzeciak A, Benzonana G, Gillessen D, Gabbiani G (1986) A monoclonal antibody against alpha-smooth muscle actin: a new probe for smooth muscle differentiation. J Cell Biol 103(6):2787–2796CrossRefPubMedGoogle Scholar
  55. Stewart EA, Friedman AJ, Peck K, Nowak RA (1994) Relative overexpression of collagen type I and collagen type III messenger ribonucleic acids by uterine leiomyomas during the proliferative phase of the menstrual cycle. J Clin Endocrinol Metab 79(3):900–906PubMedGoogle Scholar
  56. Strauss LC, Skubitz KM, August JT, Civin CI (1984) Antigenic analysis of hematopoiesis: II. Expression of human neutrophil antigens on normal and leukemic marrow cells. Blood 63(3):574–578PubMedGoogle Scholar
  57. Takahashi S, Uchimaru K, Harigaya K, Asano S, Yamashita T (1992) Tumor necrosis factor and interleukin-1 induce activin A gene expression in a human bone marrow stromal cell line. Biochem Biophys Res Commun 188(1):310–317CrossRefPubMedGoogle Scholar
  58. Tavassoli FADP (2003) Pathology and Genetics of Tumors of the Breast and female Genital Organs. IARC, LyonGoogle Scholar
  59. Toledo G, Oliva E (2008) Smooth muscle tumors of the uterus: a practical approach. Arch Pathol Lab Med 132(4):595–605PubMedGoogle Scholar
  60. Truong LD, Rangdaeng S, Cagle P, Ro JY, Hawkins H, Font RL (1990) The diagnostic utility of desmin. A study of 584 cases and review of the literature. Am J Clin Pathol 93(3):305–314CrossRefPubMedGoogle Scholar
  61. Wallach EE, Vlahos NF (2004) Uterine myomas: an overview of development, clinical features, and management. Obstet Gynecol 104(2):393–406CrossRefPubMedGoogle Scholar
  62. Werner S, Alzheimer C (2006) Roles of activin in tissue repair, fibrosis, and inflammatory disease. Cytokine Growth Factor Rev 17(3):157–171CrossRefPubMedGoogle Scholar
  63. Wynn TA (2008) Cellular and molecular mechanisms of fibrosis. J Pathol 214(2):199–210CrossRefPubMedPubMedCentralGoogle Scholar
  64. Wynn TA, Barron L (2010) Macrophages: master regulators of inflammation and fibrosis. Semin Liver Dis 30(3):245–257CrossRefPubMedPubMedCentralGoogle Scholar
  65. Zaragosi LE, Wdziekonski B, Villageois P, Keophiphath M, Maumus M, Tchkonia T, Bourlier V, Mohsen-Kanson T, Ladoux A, Elabd C, Scheideler M, Trajanoski Z, Takashima Y, Amri EZ, Lacasa D, Sengenes C, Ailhaud G, Clement K, Bouloumie A, Kirkland JL, Dani C (2010) Activin a plays a critical role in proliferation and differentiation of human adipose progenitors. Diabetes 59(10):2513–2521CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Olga Protic
    • 1
  • Paolo Toti
    • 2
  • Md Soriful Islam
    • 1
    • 3
  • Rossella Occhini
    • 2
  • Stefano Raffaele Giannubilo
    • 4
  • William H. Catherino
    • 5
  • Saverio Cinti
    • 1
    • 6
  • Felice Petraglia
    • 7
  • Andrea Ciavattini
    • 4
  • Mario Castellucci
    • 1
  • Boris Hinz
    • 8
  • Pasquapina Ciarmela
    • 1
    • 9
  1. 1.Department of Experimental and Clinical Medicine, Faculty of MedicinePolytechnic University of MarcheAnconaItaly
  2. 2.Department of Medical BiotechnologyUniversity of SienaSienaItaly
  3. 3.Biotechnology and Microbiology Laboratory, Department of BotanyUniversity of RajshahiRajshahiBangladesh
  4. 4.Department of Clinical SciencePolytechnic University of MarcheAnconaItaly
  5. 5.Department of Obstetrics and GynecologyUniformed Services University of the Health SciencesBethesdaUSA
  6. 6.Center of ObesityPolytechnic University of Marche – United HospitalsAnconaItaly
  7. 7.Department of Molecular and Developmental Medicine, Obstetrics, and GynecologyUniversity of SienaSienaItaly
  8. 8.Laboratory of Tissue Repair and Regeneration, Matrix Dynamics Group, Faculty of DentistryUniversity of TorontoTorontoCanada
  9. 9.Department of Information EngineeringPolytechnic University of MarcheAnconaItaly

Personalised recommendations