Sub theme 3.9
Gynaecological oncology; basics, epidemiology and clinical aspects

Goals of research: general outline
Scientific achievements
Future plans: special goals and approach
Running projects
Associated staff

Goals of research: general outline

The endometrium

Elevated levels of steroid hormones like estradiol and progesterone are important factors in the development of endometrial, breast and probably also ovarian cancer. Nevertheless, some medical interventions like hormone treatment for In Vitro Fertilization (IVF), Hormone Replacement Therapy (HRT) after menopause, and tamoxifen-treatment of breast cancer cause significant increases in steroid signalling. Therefore we are investigating whether transient changes (like observed in gonadotropin treatment for IVF), or sustained changes (as induced by HRT) in estradiol and/or progesterone signalling increase the relative risk for the above mentioned cancer types.  Furthermore, in our laboratory we are investigating the molecular mechanism behind the question why steroids are sometimes causing cancer development (increased estrogen signalling can cause endometrial cancer), while in other cases steroids seem to protect against cancer growth (progesterone inhibits estrogen induced carcinogenesis in the endometrium). In these investigations Wnt signaling plays an important role.

Vulvar disorders

The life-time risk for infection with HPV is around 80%. Fortunately most women are able to clear this infection, and less than 10% of women infected with a high-risk HPV develop a persistent infection, which is one of the leading causes of preneoplastic and neoplastic lesions in the female genital tract, including cervical and vulvar intraepithelial neoplasia (CIN and VIN). Acquisition and clearing of HPV infection, viral load and persistence, T-cell response, cytokine expression, changes in cellular genome, viral oncogene proteins E6 and E7, role of human tumour suppressor genes p53 and Rb, loss of heterozygosity and telomerase activation are all factors that are studied to understand HPV-induced carcinogenesis. In addition to these molecular studies we are also investigating clinical aspects like the consequences of a national based primary screening program for cervical cancer and the role of HPV testing in the management of women with premalignant cervical lesions. Furthermore, in a number of randomized clinical trials alternative treatments, to otherwise mutilating surgery for VIN, are evaluated.

Ovarian stimulation and the risk of gynaecological and breast malignancies

The long-term effects of ovarian stimulation are unknown. In view of the assumed role of incessant ovulation and increased gonadotrophin levels in ovarian cancer pathogenesis, concerns have been raised that ovarian stimulation may increase the risk of gynaecological and breast malignancies, as well as other hormone sensitive tumours. We identified a nationwide historical cohort of 27.750 subfertile women who received at least one IVF treatment cycle with ovarian stimulation between 1983 and 1998. To obtain a comparison group of subfertile women not treated with IVF, 11.615 women who were diagnosed with fertility problems between 1980 and 1998 and did not receive IVF were selected. The total cohort will be linked with the Netherlands Cancer Registry for incident cancers in the period 1998-2005, and with PALGA (Dutch National Pathology Data Base) for incident cancers 2005-2008. Results will be available in 2009-2012.

Scientific achievements

A. The endometrium

Estrogen signaling during the first two weeks of the menstrual cycle is counterbalanced by progestagen signaling during the third week of the menstrual cycle. This equilibrium between proliferation and differentiation of the endometrium is necessary to prevent hyperplasia which, over time, may develop further into endometrial cancer, and to prevent ectopic endometrial homing (endometriosis). Based on our own work and on a small number of reports in literature our hypothesis is that the canonical Wnt/β-catenin pathway pays an important role in maintaining this important endometrial homeostasis. For the endometrium we have been able to show that at the gene-level progesterone is dominant over estradiol in its ability to induce differentiation and inhibition of proliferation. Furthermore, progesterone can do so because it efficiently inhibits Wnt signalling by the induction of two inhibitors of Wnt signalling: DKK1 and FOXO1.

B. Vulvar disorders

Recently our group reported in a placebo-controlled, double-blinded, randomized trial on the efficacy of imiquimod treatment for usual type VIN. During this trial an imiquimod-induced reduction in lesion size by more than 25% in 81% of patients was measured, while a complete response was observed in 35% of patients. Moreover, when we defined the histological diagnoses in accordance to the ISSVD guidelines in uVIN or normal tissue instead of VIN 1, 2 or 3, complete histologic regression of uVIN was observed in 58% of patients. Our study was also among the first to characterize the distribution of immunocompetent cells in epidermis and dermis of vulvar skin in HPV-positive patients with uVIN compared to HPV-negative healthy controls. The study demonstrated that reduction in lesion size was correlated with partial normalization of the numbers of immunocompetent cells and it was also shown that arousal of type 1 cellular immunity by induction of local inflammation by imiquimod was involved in regression of HPV related VIN lesions.

C. Ovarian stimulation and the risk of gynaecological and breast malignancies

This project is in collaboration with the Netherlands Cancer Institute (prof dr FE van Leeuwen) and CW Burger. This collaboration exists from 1995 on. From 1997 on 14 international papers and two thesis have been published. The main subjects of publications were: IVF and risk of menopause age, IVF and risk of caner in offspring, IVF and risk of benign gynaecological disease, IVF and hypospadia and IVF and cancer risk review. (for updated information see:

Future plans: special goals and approach

A. The endometrium (in collaboration with Prof.dr. R. Fodde, Pathology, EMC)

  • Using conditional knockout mouse-models in which we can induce Wnt signalling early in uterine development and later during puberty we will investigate the role of Wnt signalling during initiation of the myometrial layer and during carcinogenesis in the endometrial layer (KWF-grant).
  • Using an inducible Histon2B-GFP mouse-model we will investigate label retaining cells in order to identify stem cells of the endometrium and of endometrial cancer (ErasmusMC-grant).
  • Using endometrial cell lines progesterone signalling via the PRA, the PRB or PRA/B will be investigated. We will produce expression profiles and we will establish a number of protein partners for the different progesterone receptor isoforms (ErasmusMC-grant).
  • The role of Wnt signaling in endometriosis. This project is currently starting-up and ran by CW Wensveen.

B. Vulvar disorders (in collaboration with Dermatology&Venereology (WI van der Meijden), Pulmonary Disease (A Kleinjan) and Obstetrics & Gynaecology (M van Beurden, AVL, Amsterdam)

Disorders of the vulvae are a burdon to the patient and are complicated to treat. The end-point of some of these disorders is vulvar cancer and it is therefore important to study molecular mechanisms which lead to carcinogenesis. There are several lines of research which are followed:

  • Usual type VIN (Vulvar Intraepithelial Neoplasia) is caused by a persistent high-risk HPV infection and may develop into vulvar cancer. Condylomata are also caused by a persistent HPV infection, but this time a low-risk HPV type. Condylomata will not proceed into vulvar cancer. We are currently investigating the difference in signal transduction between high- and low-risk HPV types (NWO-AGIKO).
  • Usual type VIN and differentiated type VIN are caused by different precursor lesions (persistent HPV infection or lichen sclerosus/lichen planus). It is our intention to determine the molecular similarities and differences between the precursor lesions that ultimately result in carcinogenesis.
  • Imiquimod is an immunomodifier which is used in the treatment of HPV-related VIN. Van Seters indicated that imiquimod is acting as a curative drug in a certain subset of patients. Continuing on this the following research is initiated
          I.            The role of the immune systen in the development and treatment of HPV-related VIN).
         II.            Conduct a new clinical trial to improve patient outcome by combining imiquimod with vaccination

C. Ovarian stimulation and the risk of gynaecological and breast malignancies (in collaboration with OMEGA projectgroup members

From 2008-2010 the primary cohort of 26.000 will be extended to 38.000 women by identification of the extended cohort. This extra cohort is needede to increase the number of patients with relatively rare diseases. Using our almost 38.000 women-cohord, collected DNA will enable us to assess future genetic predisposition for subfertility-treatment-related risks of several types of cancer. Furthermore, data will be collected from questionnaires and medical records.  Especially focus is given on dose-response relationships and effects after very long follow-up (> 20 years). Finally, we will evaluate genetic predisposition for fertility-related adverse effects by analysing genetic polymorphism profiles of the participants. Results will be available in 2011-1-2013. The location of DNA analysis is yet to be determined (NKI or Erasmus MC, department of Obstetrics and Gynaecology). More grants will be necessary to analyse this databank of DNA. Preferentially the analysis will take place in the lab of dr. LJ Blok because of his expertise in this field. Clinical and epidemiological data will be further analyses in collaboration with Netherlands Cancer Institute (prof dr FE van Leeuwen).

Most recent publications
  1. Wang Y, Hanifi-Moghaddam P, Hanekamp EE, Kloosterboer HJ, Franken P, Veldscholte J, Van Doorn HC, Ewing PC, Kim JJ, Grootegoed JA, Burger CW, Fodde R, Blok LJ. Progesterone inhibition of Wnt/β-catenin signaling in normal endometrium and endometrial cancer. 2009; Accepted Clin Cancer Res
  2. Bais AG, Eijkemans MJ, Rebolj M, Snijders PJ, Verheijen RH, van Ballegooijen M, Meijer CJ, Helmerhorst TJ. Post-treatment CIN: randomised clinical trial using hrHPV testing for prediction of residual/recurrent disease. Int J Cancer. 2009;124:889-95.
  3. van Seters M, van Beurden M, ten Kate FJ, Beckmann I, Ewing PC, Eijkemans MJ, Kagie MJ, Meijer CJ, Aaronson NK, Kleinjan A, Heijmans-Antonissen C, Zijlstra FJ, Burger MP, Helmerhorst TJ. Treatment of vulvar intraepithelial neoplasia with topical imiquimod. N Engl J Med. 2008; 358:1465-73.
  4. Santegoets LAM,  Van Seters M, Heijmans-Antonissen C,  KleinJan A, Van Beurden M, Ewing PC, Khne ECM Ilse Beckmann1, Burger CW, Helmerhorst TJM, Blok LJ. Reduced local immunity in HPV related VIN: expression of chemokines and involvement of immunocompetent cells. Int J Cancer. 2008; 123:616-22
  5. Hanifi-Moghaddam P, Boers-Sijmons B,  Klaassens AHA, Van Wijk FH, Den Bakker MA Ott MC, Shipley GL, Verheul HA, Kloosterboer HJ, Burger CW, Blok LJ. Molecular analysis of human endometrium: short-term tibolone signaling differs significantly from estrogen and estrogen + progestagen signaling. J Mol Med 2007;85:471-80
  6. Hanifi-Moghaddam P,  Gielen SCJP, Kloosterboer HJ, De Gooyer ME, Sijvers AM, van Gool AJ, Smid M, Morehouse M, Van Wijk FH, Burger CW, Blok LJ. Molecular portrait of the estrogenic and progestagenic actions of tibolone: Behavior of biological networks in response to tibolone. J Clin Endocrinol Metab 2005;90:973-83
  7. Gielen SC, Khne LC, Ewing PC, Blok LJ, Burger CW. Tamoxifen treatment for breast cancer enforces a distinct gene-expression profile on the human endometrium: an exploratory study. Endocr Relat Cancer. 2005;12:1037-49.
  8. Hanekamp EE, Gielen SCJP, Smid-Koopman E, Khne ECM, de Ruiter PE, Chadha-Ajwani S, Brinkmann AO, Grootegoed JA, Burger CW, Huikeshoven FJ, Blok LJ. Concequences of loss of progesterone receptor expression in development of metastatic endometrial cancer. Clin Cancer Res 2003;9:4190-4199
  9. Klip H, Verloop J, van Gool JD, Koster ME, Burger CW, van Leeuwen FE; OMEGA Project Group. Hypospadias in sons of women exposed to diethylstilbestrol in utero: a cohort study. Lancet. 2002;359:1102-7.
  10. Klip H, Burger CW, de Kraker J, van Leeuwen FE; OMEGA-project group. Risk of cancer in the offspring of women who underwent ovarian stimulation for IVF. Hum Reprod. 2001 Nov;16(11):2451-2458.