Molecular Bio-Imaging Probe for Non-Invasive Differentiation Between Human Leiomyoma Versus Leiomyosarcoma

  • Shahinaz Shalaby
  • Mostafa Khater
  • Archana Laknaur
  • Ali Arbab
  • Ayman Al-HendyEmail author
Original Article


Leiomyosarcoma is the most frequent subtype of the deadly uterine sarcoma and shares many common clinical grounds with leiomyoma, which is in turn the most common solid benign uterine neoplasm. With the recent progress in minimally invasive techniques for managing leiomyomas, accurate preoperative diagnosis of uterine masses has become the most important selection criterion for the safest therapeutic option. Therefore, different imaging modalities would be playing a key role in management of uterine masses. Testing for a sarcoma-specific promoter that expresses its downstream reporter gene only in leiomyosarcoma and not in leiomyoma or healthy uterine tissue. Adenoviral vectors were utilized both in vitro and in vivo to test the specificity of the promoters. Quantitative studies of downstream gene expression of these promoters was carried out both in vitro and in vivo. Our data indicated that human leiomyosarcoma cells highly expressed the reporter gene downstream to survivin promoter (Ad-SUR-LUC) when compared with benign leiomyoma or normal cells (p value of 0.05). Our study suggested that survivin is the unique promoter capable of distinguishing between the deadly sarcoma and the benign counterparts.


Molecular imaging probe Leiomyosarcoma Sarcoma-specific promoter 


Authors Contribution

Dr. Al-Hendy conceived the idea, developed the theory, designed the study, edited and revised the manuscript; Dr. Shahinaz Shalaby and Dr. Mostafa Khater collected, analyzed the data, wrote the manuscript. Ms. Archana Laknaur prepared for the experiments. Dr. Arbab facilitated the spectral imaging studies, revised the protocols, and edited the manuscript. All authors provided critical feedback and helped shape the research, analysis, and manuscript.

Funding Information

This study was funded by the National Institute of Health (R01 ES 028615–01, R01HD 087417, R01 HD 094378, R01 HD 094380).

Compliance with Ethical Standards

Conflict of Interest

Dr. Ayman Al-Hendy is consulting Abbvie, Bayer, Allergan, MD Stem Cells for research support. Dr. Ali Arbab declares that he has no conflict of interest. Ms. Archana Laknaur declares that she has no conflict of interest. Dr.Mostafa Khater declares that he has no conflict of interest. Dr. Shahinaz Shalaby declares that she has no conflict of interest.

Ethical Approval

All applicable international, national, and/or institutional guidelines for the care and use of animals were followed, and IACUC approval of Augusta University was taken. This article does not contain any studies with human participants performed by any of the authors.


  1. 1.
    Perri T, Korach J, Sadetzki S, Oberman B, Fridman E, Ben-Baruch G. Uterine leiomyosarcoma: does the surgical procedure matter? Int J Gynecol Cancer. 2009;19(2):257–60.CrossRefGoogle Scholar
  2. 2.
    Pritts EA, Parker WH, Brown J, Olive DL. Outcome of occult uterine leiomyosarcoma after surgery for presumed uterine fibroids: a systematic review. J Minim Invasive Gynecol. 2015;22(1):26–33.CrossRefGoogle Scholar
  3. 3.
    Ottarsdottir H, Cohen SL, Cox M, Vitonis A, Einarsson JI. Trends in mode of hysterectomy after the US Food and Drug Administration power morcellation advisory. Obstet Gynecol. 2017;129(6):1014–21.CrossRefGoogle Scholar
  4. 4.
    Schatz F, et al. The role of decidual cells in uterine hemostasis, menstruation, inflammation, adverse pregnancy outcomes and abnormal uterine bleeding. Hum Reprod Update. 2016;22(4):497–515.CrossRefGoogle Scholar
  5. 5.
    Wright JD, et al. Economic and survival implications of use of electric power morcellation for hysterectomy for presumed benign gynecologic disease. J Natl Cancer Inst. 2015;107(11):djv251.CrossRefGoogle Scholar
  6. 6.
    Mao J, et al. Population-based estimates of the prevalence of uterine sarcoma among patients with leiomyomata undergoing surgical treatment. JAMA Surgery. 2015;150(4):368–70.CrossRefGoogle Scholar
  7. 7.
    Hayashi T, et al. A novel diagnostic biomarker for human uterine leiomyosarcoma: PSMB9/β1i. Chin Clin Oncol. 2017;6(2).CrossRefGoogle Scholar
  8. 8.
    Jitsumori M, et al. Hyperphosphatasemia in leiomyosarcoma of the uterus: two case reports and a literature review. J Obstet Gynaecol Res. 2017;43(9):1498–503.CrossRefGoogle Scholar
  9. 9.
    Wu TI, et al. Prognostic factors and impact of adjuvant chemotherapy for uterine leiomyosarcoma. Gynecol Oncol. 2006;100(1):166–72.CrossRefGoogle Scholar
  10. 10.
    White M. Uterine smooth muscle tumors of uncertain malignant potential (stump): review of pathophysiology, classification, diagnosis, treatment, and surveillance. J Health Commun. 2017;2:4.
  11. 11.
    Goto A, Takeuchi S, Sugimura K, Maruo T. Usefulness of Gd-DTPA contrast-enhanced dynamic MRI and serum determination of LDH and its isozymes in the differential diagnosis of leiomyosarcoma from degenerated leiomyoma of the uterus. Int J Gynecol Cancer. 2002;12(4):354–61.CrossRefGoogle Scholar
  12. 12.
    Cui RR, Wright JD. Risk of occult uterine sarcoma in presumed uterine fibroids. Clin Obstet Gynecol. 2016;59(1):103–18.CrossRefGoogle Scholar
  13. 13.
    Peters A, Sadecky AM, Winger DG, Guido RS, Lee TTM, Mansuria SM, et al. Characterization and preoperative risk analysis of leiomyosarcomas at a high-volume tertiary care center. Int J Gynecol Cancer. 2017;27(6):1183–90.CrossRefGoogle Scholar
  14. 14.
    Hyoeun CB, et al. Tumor-specific imaging through progression elevated gene-3 promoter-driven gene expression. Nat Med. 2011;17(1):123–9.CrossRefGoogle Scholar
  15. 15.
    Mohan K, et al. Sub-nanomolar detection of prostate-specific membrane antigen in synthetic urine by synergistic, dual-ligand phage. J Am Chem Soc. 2013;135(20):7761–7.CrossRefGoogle Scholar
  16. 16.
    Ambrosini G, Adida C, Altieri DC. A novel anti-apoptosis gene, survivin, expressed in cancer and lymphoma. Nat Med. 1997;3(8):917–21.CrossRefGoogle Scholar
  17. 17.
    Gianani R, Jarboe E, Orlicky D, Frost M, Bobak J, Lehner R, et al. Expression of survivin in normal, hyperplastic, and neoplastic colonic mucosa. Hum Pathol. 2001;32(1):119–25.CrossRefGoogle Scholar
  18. 18.
    Kami K, Doi R, Koizumi M, Toyoda E, Mori T, Ito D, et al. Survivin expression is a prognostic marker in pancreatic cancer patients. Surgery. 2004;136(2):443–8.CrossRefGoogle Scholar
  19. 19.
    Shariat SF, Lotan Y, Saboorian H, Khoddami SM, Roehrborn CG, Slawin KM, et al. Survivin expression is associated with features of biologically aggressive prostate carcinoma. Cancer. 2004;100(4):751–7.CrossRefGoogle Scholar
  20. 20.
    Tanaka K, et al. Expression of survivin and its relationship to loss of apoptosis in breast carcinomas. Clin Cancer Res. 2000;6(1):127–34.PubMedGoogle Scholar
  21. 21.
    Ansell S, Arendt BK, Grote DM, Jelinek DF, Novak AJ, Wellik LE, et al. Inhibition of survivin expression suppresses the growth of aggressive non-Hodgkin's lymphoma. Leukemia. 2004;18(3):616–23.CrossRefGoogle Scholar
  22. 22.
    Mita AC, et al. Survivin: key regulator of mitosis and apoptosis and novel target for cancer therapeutics. Clin Cancer Res. 2008;14(16):5000–5.CrossRefGoogle Scholar
  23. 23.
    Zhu ZB, et al. Transcriptional targeting of tumors with a novel tumor-specific survivin promoter. Cancer Gene Ther. 2004;11(4):256–62.CrossRefGoogle Scholar
  24. 24.
    Bao R, Connolly DC, Murphy M, Green J, Weinstein JK, Pisarcik DA, et al. Activation of cancer-specific gene expression by the survivin promoter. J Natl Cancer Inst. 2002;94(7):522–8.CrossRefGoogle Scholar
  25. 25.
    Monzó M, et al. A novel anti-apoptosis gene: re-expression of survivin messenger RNA as a prognosis marker in non–small-cell lung cancers. J Clin Oncol. 1999;17(7):2100.CrossRefGoogle Scholar
  26. 26.
    Hassan MH, Khatoon N, Curiel DT, Hamada FM, Arafa HM, al-Hendy A. Toward gene therapy of uterine fibroids: targeting modified adenovirus to human leiomyoma cells. Hum Reprod. 2008;23(3):514–24.CrossRefGoogle Scholar
  27. 27.
    Al-Hendy, Ayman, et al. "Ovarian cancer gene therapy: repeated treatment with thymidine kinase in an adenovirus vector and ganciclovir improves survival in a novel immunocompetent murine model." American journal of obstetrics and gynecology 182.3 (2000);553-559.CrossRefGoogle Scholar
  28. 28.
    Al-Hendy, A., Lee, E. J., Wang, H. Q., & Copland, J. A. Gene therapy of uterine leiomyomas: adenovirus-mediated expression of dominant negative estrogen receptor inhibits tumor growth in nude mice. American journal of obstetrics and gynecology, (2004);191(5):1621-1631.Google Scholar
  29. 29.
    Salama, S. A., Kamel, M., Christman, G., Wang, H. Q., Fouad, H. M., & Al-Hendy, A. Gene therapy of uterine leiomyoma: adenovirus-mediated herpes simplex virus thymidine kinase/ganciclovir treatment inhibits growth of human and rat leiomyoma cells in vitro and in a nude mouse model. Gynecologic and obstetric investigation, (2007);63(2):61-70.Google Scholar
  30. 30.
    Henriques C, et al. In vivo imaging of mice infected with bioluminescent Trypanosoma cruzi unveils novel sites of infection. Parasit Vectors. 2014;7:89.CrossRefGoogle Scholar
  31. 31.
    Kotz S, Balakrishnan N, Read CB, Vidakovic B. Encyclopedia of statistical sciences. 2nd ed. Hoboken: Wiley-Interscience; 2006.Google Scholar
  32. 32.
    Nair, S., Curiel, D. T., Rajaratnam, V., Thota, C., & Al-Hendy, A. Targeting adenoviral vectors for enhanced gene therapy of uterine leiomyomas. Human Reproduction, (2013);28(9):2398-2406.Google Scholar
  33. 33.
    Fogh J, Fogh JM, Orfeo T. One hundred and twenty-seven cultured human tumor cell lines producing tumors in nude mice. J Natl Cancer Inst. 1977;59(1):221–6.CrossRefGoogle Scholar
  34. 34.
    Kishimoto H, Kojima T, Watanabe Y, Kagawa S, Fujiwara T, Uno F, et al. In vivo imaging of lymph node metastasis with telomerase-specific replication-selective adenovirus. Nat Med. 2006;12(10):1213–9.CrossRefGoogle Scholar
  35. 35.
    Ray S, Paulmurugan R, Patel MR, Ahn BC, Wu L, Carey M, et al. Noninvasive imaging of therapeutic gene expression using a bidirectional transcriptional amplification strategy. Mol Ther. 2008;16(11):1848–56.CrossRefGoogle Scholar
  36. 36.
    Qiao J, Doubrovin M, Sauter BV, Huang Y, Guo ZS, Balatoni J, et al. Tumor-specific transcriptional targeting of suicide gene therapy. Gene Ther. 2002;9(3):168–75.CrossRefGoogle Scholar
  37. 37.
    Iyer M, et al. Two-step transcriptional amplification as a method for imaging reporter gene expression using weak promoters. Proc Natl Acad Sci. 2001;98(25):14595–600.CrossRefGoogle Scholar
  38. 38.
    Iyer M, Salazar FB, Lewis X, Zhang L, Carey M, Wu L, et al. Noninvasive imaging of enhanced prostate-specific gene expression using a two-step transcriptional amplification-based lentivirus vector. Mol Ther. 2004;10(3):545–52.CrossRefGoogle Scholar
  39. 39.
    Huyn ST, et al. A potent, imaging adenoviral vector driven by the cancer-selective mucin-1 promoter that targets breast cancer metastasis. Clin Cancer Res. 2009;15(9):3126–34.CrossRefGoogle Scholar
  40. 40.
    Kim JW, et al. A comparative study of replication-incompetent and-competent adenoviral therapy-mediated immune response in a murine glioma model. Mol Ther Oncol. 2017;5:97–104.CrossRefGoogle Scholar
  41. 41.
    Jönsson F, Kreppel F. Barriers to systemic application of virus-based vectors in gene therapy: lessons from adenovirus type 5. Virus Genes. 2017;53(5):692–9.CrossRefGoogle Scholar
  42. 42.
    Park JY, Kricka LJ. Prospects for the commercialization of chemiluminescence-based point-of-care and on-site testing devices. Anal Bioanal Chem. 2014;406(23):5631–7.CrossRefGoogle Scholar

Copyright information

© Society for Reproductive Investigation 2020

Authors and Affiliations

  • Shahinaz Shalaby
    • 1
  • Mostafa Khater
    • 2
  • Archana Laknaur
    • 3
  • Ali Arbab
    • 4
  • Ayman Al-Hendy
    • 3
    • 5
    Email author
  1. 1.Tanta Medical SchoolTanta UniversityTantaEgypt
  2. 2.Department of Pharmacology and toxicology, Medical College of GeorgiaAugusta UniversityAugustaUSA
  3. 3.Department of Obstetrics and Gynecology, Medical College of GeorgiaAugusta UniversityAugustaUSA
  4. 4.Cancer Centre, Medical College of GeorgiaAugusta UniversityAugustaUSA
  5. 5.Department of Obstetrics and GynecologyUICChicagoUSA

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