{"paper_id":"5f8087fc-5602-4636-bd7b-c887229ca58c","body_text":"Inoue et al. Cell Death and Disease          (2020) 11:347 \nhttps://doi.org/10.1038/s41419-020-2559-0 Cell Death & Disease\nEDITORIAL Open Access\nKRAS mutations in uterine endometrium are\nassociated with gravidity and parity\nSatoshi Inoue 1, Emiko Yoshida2, Yamato Fukui3, Toshihide Ueno1, Masahito Kawazu1, Reina Takeyama1,\nMasako Ikemura4, Yutaka Osuga3,Y a s u h i s aT e r a o2,Y a s u s h iH i r o t a3 and Hiroyuki Mano 1\nRecent genomic analyses have shown that, despite\nappearing histologically normal, many tissues bear\nsomatic mutations. Somatic clones with genomic altera-\ntions can expand in such normal tissues due not only to\naging but also to exposure to exogenous stresses or sti-\nmuli\n1. Benign disorders such as colitis can also stem from\nsuch genomic changes 2. The uterus is the only organ\nexperiencing menstruation, gestation and birth, and so\nthe normal endometrium (NE) is exposed to unique\nstresses capable of inducing somatic genomic alterations.\nExternal physical/mechanical factors such as caesarean\nsection can induce reactions that trigger genomic altera-\ntions in NE. Notably, recurrent mutations affecting KRAS\nand PIK3CA have been reported in NE\n3–6. Increased age,\nhigh body mass index and parity may be associated with a\nburden of mutations in NE 4,5.\nAdenomyosis is a common benign gynecological dis-\norder in women of reproductive age that reduce the\nquality-of-life of affected women. Endometrium-like epi-\nthelial cells that ectopically proliferate in normal myo-\nmetrium (NM). Mutation of KRAS and/or PIK3CA in NE\nis the earliest events in the molecular pathogenesis of\nadenomyosis\n3. It has been shown that parity, spontaneous\nabortion and smoking could be risk factors for adeno-\nmyosis7,8. In this study, we investigated whether particular\nclinical characteristics of individuals are associated with\nthe presence of KRAS, PIK3CA and PPP2R1A\nalterations in NE.\nIn a previous study, we performed mutational analyses\nof NE from 56 individuals\n3. Here, we collected additional\n42 uterine tissue samples, enabling us to examine KRAS,\nPIK3CA and PPP2R1A alterations in NE samples from a\ntotal of 98 women (Supplementary Tables S1 and S2).\nAfter enrichment of NE and NM by macro-dissection,\ngenomic DNA from NE and NM (control) for each\nindividual was subjected to targeted deep sequencings to\nassess mutations in the genomic hotspots KRAS p.G12/\nG13, PIK3CA p.H1047 and PPP2R1A p.P179/R182−R183\n(Table 1, Supplementary Tables S3 −S9), all of which have\npreviously been reported as undergoing mutations in NE\n3.\nConsistent with recent publications 3–6, we commonly\nobserved mutations in KRAS p.G12/G13 (58/98 =\n59.18%), PIK3CA p.H1047 (19/98 = 19.39%) and\nPPP2R1A p. P179/R182 −R183 (15/98 = 15.31%) in the\nNE of individuals (Table 1, Supplementary Tables\nS10–S12). Most of clinical characteristics were not asso-\nciated with any of these genetic alterations, and PIK3CA\nand PPP2R1A mutations were not linked to any\nspecific clinical features (Table 1, Supplementary Tables\nS10–S12). However, mutations in KRAS p.G12/G13 were\nfrequently detected in NE of individuals with vaginal\ndelivery, gravidity and parity (Table 1, Supplelmentary\nTable S10). As KRAS p.G12/G13-mutated clones are\nknown to be signi ficantly expanded in NE of adenomyosis\npatients\n3, our observations raise the possibility that\nstresses during pregnancy and parity could induce\nmutations in KRAS in NE, providing a putative mechan-\nism to explain why parity is a risk factor for adenomyosis.\nIn contrast to vaginal delivery, no association between\nfrequency of mutations in KRAS p.G12/G13 in NE and\nindividuals with caesarean section were observed (Table 1,\nSupplementary Table S10), raising a possibility uterine\ncontraction during vaginal delivery affect on the genomic\nalterations. Validation of our results in a larger patient\ncohort is obviously required, but if our findings are con-\nfirmed, they would support our hypothesis that gravidity\n© The Author(s) 2020\nOpen AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution andreproduction\nin any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a lin kt ot h eC r e a t i v eCommons license,and indicate if\nchanges were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicatedotherwise in a credit line to the material. If\nmaterial is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain\npermission directly from the copyright holder. To view a copy of this license, visithttp://creativecommons.org/licenses/by/4.0/.\nCorrespondence: Satoshi Inoue ( satoshiinouencc4@gmail.com)\n1Division of Cellular Signaling, National Cancer Center Research Institute, Tokyo\n104-0045, Japan\n2Department of Obstetrics and Gynecology, Juntendo University Faculty of\nMedicine, Tokyo 113-8421, Japan\nFull list of author information is available at the end of the article\nThese authors contributed equally: Satoshi Inoue, Emiko Yoshida, Yamato Fukui\nOfficial journal of the Cell Death Differentiation Association\n1234567890():,;1234567890():,;\n1234567890():,;\n1234567890():,;\n\nand parity may drive adenomyosis pathogenesis, poten-\ntially explaining the increased frequency of KRAS-muta-\nted clones in NE of these individuals.\nOur work may have signi ficant clinical implications.\nIdentification of KRAS-mutated clones in NE of parous\nwomen may allow clinicians to choose an alternative\nprotocol that might prevent or mitigate adenomyosis\ndevelopment, perhaps maintaining a better quality-of life\nfor these women. In addition, our genomic analyses of NE\nhave yielded novel biological insights that could lead to\nthe identi fication of new therapeutic strategies to elim-\ninate KRAS-mutated clones in NE and prevent gravidity/\nparity-associated adenomyosis.\nAuthor details\n1Division of Cellular Signaling, National Cancer Center Research Institute, Tokyo\n104-0045, Japan. 2Department of Obstetrics and Gynecology, Juntendo\nUniversity Faculty of Medicine, Tokyo 113-8421, Japan. 3Department of\nObstetrics and Gynecology, The University of Tokyo, Tokyo 113-0033, Japan.\n4Department of Pathology, Graduate School of Medicine, The University of\nTokyo, Tokyo 113-0033, Japan\nConflict of interest\nThe authors declare that they have no con flict of interest.\nPublisher’s note\nSpringer Nature remains neutral with regard to jurisdictional claims in\npublished maps and institutional af filiations.\nSupplementary Information accompanies this paper at ( https://doi.org/\n10.1038/s41419-020-2559-0).\nReceived: 1 April 2020 Revised: 24 April 2020 Accepted: 24 April 2020\nReferences\n1. Yokoyama, A. et al. Age-related rem odelling of oesophageal epithelia by\nmutated cancer drivers.Nature 565,3 1 2–317 (2019).\n2. Kakiuchi, N. et al. Frequent mutations that converge on the NFKBIZ pathway in\nulcerative colitis.Nature 577,2 6 0–265 (2020).\n3. Inoue, S. et al. Uterine adenomyosis is a n oligoclonal disorder associated with\nKRAS mutations. Nat. Commun. 10, 5785 (2019).\n4. Lac, V. et al. Oncogenic mutations in h istologically normal endometrium: the\nnew normal? J. Pathol. 249,1 7 3–181 (2019).\n5. Moore, L. et al. The mutational landscape of normal human endometrial epi-\nthelium. Nature 580, 640–646 (2020).\n6. Suda, K. et al. Clonal expansion and diversi fication of cancer-associated muta-\ntions in endometriosis and normal endometrium. Cell Rep. 24,1 7 7 7–1789\n(2018).\n7. Parazzini, F. et al. Risk factors for adenomyosis. Hum. Reprod. 12,1 2 7 5–1279\n(1997).\n8. Templeman, C. et al. Adenomyosis and endometriosis in the California Teachers\nStudy. Fertil. Steril.90,4 1 5–424 (2008).\nTable 1 Relationship between individual characteristics\nand KRAS mutation status.\nValue (%)\nKRAS\nwild type\nKRAS\nmutated\nCharacteristics ( N = 40) ( N = 58) Statistics\nMedian age at operation\n(range), years\n46 (35 –87) 45 (33 –65)\nGravidity, n (%) ≥1 12/40 (30.00) 38/58 (65.52) 0.001\n0 28/40 (70.00) 20/58 (34.48)\n1 5/40 (12.50) 16/58 (27.59)\n2 5/40 (12.50) 11/58 (18.97)\n≥3 2/40 (5.00) 11/58 (18.97)\nParity, n (%) ≥1 11/40 (27.50) 33/58 (56.90) 0.007\n0 29/40 (72.50) 25/58 (43.10)\n1 5/40 (12.50) 15/58 (25.86)\n2 5/40 (12.50) 10/58 (17.24)\n≥3 1/40 (2.50) 8/58 (13.79)\nAbortion or stillborn,\nn (%)\n≥1 3/40 (7.50) 11/58 (18.97) n.s.\n0 37/40 (92.50) 47/58 (81.03)\n1 2/40 (5.00) 7/58 (12.07)\n2 1/40 (2.50) 3/58 (5.17)\n≥3 0/40 (0.00) 1/58 (1.72)\nCaesarean section,\nn (%)\n≥1 6/40 (15.00) 5/58 (8.62) n.s.\n0 34/40 (85.00) 53/58 (91.38)\n1 4/40 (10.00) 2/58 (3.45)\n2 2/40 (5.00) 1/58 (1.72)\n≥3 0/40 (0.00) 2/58 (3.45)\nVaginal delivery, n (%) ≥1 7/40 (17.50) 28/58 (48.28) 0.003\n0 33/40 (82.50) 30/58 (51.72)\n1 4/40 (10.00) 13/58 (22.41)\n2 3/40 (7.50) 10/58 (17.24)\n≥3 0/40 (0.00) 5/58 (8.62)\nSmoking history, n (%) 8/40 (20.00) 5/58 (8.62) n.s.\nn.s. not signi ficant assessed by Fisher ’s exact test.\nInoue et al. Cell Death and Disease          (2020) 11:347 Page 2 of 2\nOfficial journal of the Cell Death Differentiation Association","source_license":"CC-BY-4.0","license_restricted":false}