A flap is described for recreation of the labia majora. The flap was designed for a young woman who developed vulvar squamous cell carcinoma in-situ after immunosuppression for treatment of juvenile rheumatoid arthritis. The patient underwent removal of the labia majora, and was reconstructed with a bi-lobed abdominal flap tunneled through the mons pubis. The flap produced a normal genital contour and has functioned well to seven years follow-up.

INTRODUÇÃO: O papilomavírus humano (HPV) é o agente mais frequentemente encontrado em doenças sexualmente transmissíveis e é responsável por cerca de 40% dos cânceres vulvo-vaginais. Esse trabalho abordou a resposta imune em lesões vulvares, considerando-se as células dendríticas CD1a+, FXIIIa+ e S-100+, citocinas TNF-, IFN- e IL-10 e a molécula de adesão E-caderina. MÉTODOS: Foram utilizadas 49 lesões de vulva pelo HPV (condiloma acuminado, NIV-I, NIV-II e NIV-III) e 11 bióspias com diagnóstico de vulvite crônica inespecífica. Foram constituídos quatro grupos: lesões de baixo grau (condiloma e NIV I), lesões de alto grau (NIV II e III), vulvites inespecíficas e pele normal. A detecção das células, citocinas e E-caderina foi feita através de método imuno-histoquímico. RESULTADOS: As células de Langerhans (CD1a+) estavam distribuídas em todo o epitélio, sobretudo nas camadas suprabasal e espinhosa. Não diferiram entre os grupos de lesões HPV+, mas estavam diminuídas em número e tamanho quando comparadas à pele normal (p<0.0001). As células S-100+ ou FXIIIa+ estavam localizadas em toda a extensão do estroma, sem diferença estatística entre as lesões pelo HPV. Embora os DDFXIIIa+ estivessem aumentados em tamanho nas lesões de vulva, seu número não diferiu da pele normal. Não se observou diferenças numéricas das células S-100+ entre os grupos de lesão e pele normal. Foi possível detectar maior número de DDFXIIIa+ sobre as células S-100+ no grupo de lesões de baixo grau (p = 0,0008) e de alto grau (p = 0,0031). As citocinas foram detectadas em pequenas quantidades nos grupos de lesões, porém sem diferença estatística. Para a análise da expressão de e-caderina, o grupo de vulvites crônicas inespecíficas foi utilizado como controle. Em 91.0% das vulvites inespecíficas foi observado padrão homogêneo e difuso da expressão de e-caderina na camada espinhosa baixa e média. Ambos os grupos de lesões HPV+ exibiram padrões semelhantes de expressão de e-caderina, com marcação difusa ou focal na camada espinhosa baixa e média. Não houve imuno-reatividade nas áreas de displasias. Como resultado da reação de dupla-marcação, feita através da utilização da hibridização in situ para detecção do DNA do HPV e imunohistoquímica para DDFXIIIa+, foi possível identificar antígenos virais no citoplasma dessas células. CONCLUSÕES: o HPV interfere na expressão das células de Langerhans, pois estas estavam diminuídas, com morfologia alterada em relação à pele normal; os DDFXIIIa+ apresentam-se aumentados em número sobre as células S-100+, o que poderia refletir um mecanismo local compensatório contra o HPV; as lesões de baixo e alto grau não apresentam diferenças significativas quanto à densidade de células expressando TNF-, IFN- e IL-10, embora TNF- predomine entre as três citocinas; há uma correlação positiva entre os DDFXIIIa+ e a expressão de TNF-, o que poderia ser explicado por sua capacidade em produzir tal citocina a partir de um provável estímulo desencadeado pelo HPV; o HPV influencia na expressão de E-caderina na vulva, com destaque para a ausência de expressão nas áreas de displasia; o DNA do HPV encontrado no interior dos DDFXIIIa+ aliado às alterações na morfologia celular, a sobreposição destas sobre as células S-100+ e a relação encontrada com a citocina TNF-, nos permitem sugerir que os DDFXIIIa+ têm um papel importante como células apresentadoras de antígeno frente à infecção pelo HPV. / INTRODUCTION: The human papillomavirus (HPV) is the most frequent agent in sexually transmitted diseases and is responsible for almost 40% of vulvovaginal cancer. We studied the immune response in vulvar lesions, considering the CD1a+, FXIIIa+ and S-100+ dendritic cells, TNF-, IFN- and IL-10 cytokines and the adhesion molecule E-cadherin. METHODS: We used 49 vulvar lesions mediated by HPV (condylomata acuminata, VIN-I, VIN-II e VIN-III) and 11 biopsies diagnosed as chronic non-specific vulvitis. Four groups were formed: low-grade lesions (condylomata and VIN-I), high-grade lesions (VIN-II and III), non-specific vulvitis and normal skin. The detection of cells, cytokines and e-cadherin was performed by immunohistochemistry reaction. RESULTS: Langerhans cells (CD1a+) were distributed through epithelia, mainly in suprabasal and spinous layer. They did not differ between HPV groups, but were decreased in number and size when compared to normal skin (p<0.0001). The S-100+ ou FXIIIa+ cells were distributed through stroma and did not differ between HPV lesions. Although the FXIIIa+DD were increased in size in vulvar lesions, their number did not differ from normal skin. The S-100+ cells did not differ in number between the groups of lesions and normal skin. We detected an increased number of FXIIIa+DD over S-100+ cells in the group of low-grade (p = 0.0008) and high-grade lesions (p = 0.0031). The cytokines were detected in small quantities in both the lesions groups, with no statistical difference. The group of chronic non-specific vulvitis was used as control group to analyse the expression of e-cadherin. 91.0% of non-specific vulvitis presented a homogeneous and diffuse pattern of expression in spinous layer Both the HPV+ groups of lesions presented similar patterns of e-cadherin expression, with a focal or diffuse localization in spinous layer. The dysplastic epithelium did not present immunoreactivity. As a result of the double-staining, using in situ hibridization to detect DNA of HPV and immunohistochemistry to FXIIIa+DD, it was possible to observe viral antigens in the cytoplasm of such cells. CONCLUSIONS: The HPV interfere with the expression of Langerhans cells, since they were decreased when compared to the normal skin; the FXIIIa+DD were increased in number over S-100+ cells, suggesting a local compensatory mechanism against the HPV; the low and high grade lesions did not differ in the number of cells expressing TNF-, IFN- and IL-10, although TNF- predominate among the three cytokines; there is a positive correlation between the FXIIIa+DD and the expression of TNF- that could be explained by their role as TNF-producing cells following a stimulus of HPV; the HPV changes the expression of E-cadherin in vulvar lesions, mainly in dysplastic epithelium; HPV DNA visualized in the cytoplasm of FXIIIa+DD and the cellular morphological changes, the increased number over S-100+ cells and the correlation with TNF-, allow us to suggest that FXIIIa+DD play an important role as antigen presenting cells in the infection by HPV.

INTRODUÇÃO: O papilomavírus humano (HPV) é o agente mais frequentemente encontrado em doenças sexualmente transmissíveis e é responsável por cerca de 40% dos cânceres vulvo-vaginais. Esse trabalho abordou a resposta imune em lesões vulvares, considerando-se as células dendríticas CD1a+, FXIIIa+ e S-100+, citocinas TNF-, IFN- e IL-10 e a molécula de adesão E-caderina. MÉTODOS: Foram utilizadas 49 lesões de vulva pelo HPV (condiloma acuminado, NIV-I, NIV-II e NIV-III) e 11 bióspias com diagnóstico de vulvite crônica inespecífica. Foram constituídos quatro grupos: lesões de baixo grau (condiloma e NIV I), lesões de alto grau (NIV II e III), vulvites inespecíficas e pele normal. A detecção das células, citocinas e E-caderina foi feita através de método imuno-histoquímico. RESULTADOS: As células de Langerhans (CD1a+) estavam distribuídas em todo o epitélio, sobretudo nas camadas suprabasal e espinhosa. Não diferiram entre os grupos de lesões HPV+, mas estavam diminuídas em número e tamanho quando comparadas à pele normal (p<0.0001). As células S-100+ ou FXIIIa+ estavam localizadas em toda a extensão do estroma, sem diferença estatística entre as lesões pelo HPV. Embora os DDFXIIIa+ estivessem aumentados em tamanho nas lesões de vulva, seu número não diferiu da pele normal. Não se observou diferenças numéricas das células S-100+ entre os grupos de lesão e pele normal. Foi possível detectar maior número de DDFXIIIa+ sobre as células S-100+ no grupo de lesões de baixo grau (p = 0,0008) e de alto grau (p = 0,0031). As citocinas foram detectadas em pequenas quantidades nos grupos de lesões, porém sem diferença estatística. Para a análise da expressão de e-caderina, o grupo de vulvites crônicas inespecíficas foi utilizado como controle. Em 91.0% das vulvites inespecíficas foi observado padrão homogêneo e difuso da expressão de e-caderina na camada espinhosa baixa e média. Ambos os grupos de lesões HPV+ exibiram padrões semelhantes de expressão de e-caderina, com marcação difusa ou focal na camada espinhosa baixa e média. Não houve imuno-reatividade nas áreas de displasias. Como resultado da reação de dupla-marcação, feita através da utilização da hibridização in situ para detecção do DNA do HPV e imunohistoquímica para DDFXIIIa+, foi possível identificar antígenos virais no citoplasma dessas células. CONCLUSÕES: o HPV interfere na expressão das células de Langerhans, pois estas estavam diminuídas, com morfologia alterada em relação à pele normal; os DDFXIIIa+ apresentam-se aumentados em número sobre as células S-100+, o que poderia refletir um mecanismo local compensatório contra o HPV; as lesões de baixo e alto grau não apresentam diferenças significativas quanto à densidade de células expressando TNF-, IFN- e IL-10, embora TNF- predomine entre as três citocinas; há uma correlação positiva entre os DDFXIIIa+ e a expressão de TNF-, o que poderia ser explicado por sua capacidade em produzir tal citocina a partir de um provável estímulo desencadeado pelo HPV; o HPV influencia na expressão de E-caderina na vulva, com destaque para a ausência de expressão nas áreas de displasia; o DNA do HPV encontrado no interior dos DDFXIIIa+ aliado às alterações na morfologia celular, a sobreposição destas sobre as células S-100+ e a relação encontrada com a citocina TNF-, nos permitem sugerir que os DDFXIIIa+ têm um papel importante como células apresentadoras de antígeno frente à infecção pelo HPV. / INTRODUCTION: The human papillomavirus (HPV) is the most frequent agent in sexually transmitted diseases and is responsible for almost 40% of vulvovaginal cancer. We studied the immune response in vulvar lesions, considering the CD1a+, FXIIIa+ and S-100+ dendritic cells, TNF-, IFN- and IL-10 cytokines and the adhesion molecule E-cadherin. METHODS: We used 49 vulvar lesions mediated by HPV (condylomata acuminata, VIN-I, VIN-II e VIN-III) and 11 biopsies diagnosed as chronic non-specific vulvitis. Four groups were formed: low-grade lesions (condylomata and VIN-I), high-grade lesions (VIN-II and III), non-specific vulvitis and normal skin. The detection of cells, cytokines and e-cadherin was performed by immunohistochemistry reaction. RESULTS: Langerhans cells (CD1a+) were distributed through epithelia, mainly in suprabasal and spinous layer. They did not differ between HPV groups, but were decreased in number and size when compared to normal skin (p<0.0001). The S-100+ ou FXIIIa+ cells were distributed through stroma and did not differ between HPV lesions. Although the FXIIIa+DD were increased in size in vulvar lesions, their number did not differ from normal skin. The S-100+ cells did not differ in number between the groups of lesions and normal skin. We detected an increased number of FXIIIa+DD over S-100+ cells in the group of low-grade (p = 0.0008) and high-grade lesions (p = 0.0031). The cytokines were detected in small quantities in both the lesions groups, with no statistical difference. The group of chronic non-specific vulvitis was used as control group to analyse the expression of e-cadherin. 91.0% of non-specific vulvitis presented a homogeneous and diffuse pattern of expression in spinous layer Both the HPV+ groups of lesions presented similar patterns of e-cadherin expression, with a focal or diffuse localization in spinous layer. The dysplastic epithelium did not present immunoreactivity. As a result of the double-staining, using in situ hibridization to detect DNA of HPV and immunohistochemistry to FXIIIa+DD, it was possible to observe viral antigens in the cytoplasm of such cells. CONCLUSIONS: The HPV interfere with the expression of Langerhans cells, since they were decreased when compared to the normal skin; the FXIIIa+DD were increased in number over S-100+ cells, suggesting a local compensatory mechanism against the HPV; the low and high grade lesions did not differ in the number of cells expressing TNF-, IFN- and IL-10, although TNF- predominate among the three cytokines; there is a positive correlation between the FXIIIa+DD and the expression of TNF- that could be explained by their role as TNF-producing cells following a stimulus of HPV; the HPV changes the expression of E-cadherin in vulvar lesions, mainly in dysplastic epithelium; HPV DNA visualized in the cytoplasm of FXIIIa+DD and the cellular morphological changes, the increased number over S-100+ cells and the correlation with TNF-, allow us to suggest that FXIIIa+DD play an important role as antigen presenting cells in the infection by HPV.

BACKGROUND White vulva! skin lesions may be due to various conditions, including benign and non-benign causes. The dilemma faced by the clinician with such a patient is the aetiology of the lesion, as well as the approach to management. AIM To establish the aetiology of white vulva! skin lesions in patients attending the gynaecology clinic and to evaluate the role of Collin's test and vulvoscopy. SETTING R. K. Khan Hospital, which is a secondary level hospital in Durban, KwaZulu Natal. METHOD Sixty-two patients with white vulva! skin lesions whom consented to the study were recruited. The investigations consisted of Pap smear, colposcopy of the vulva [Vulvoscopy], perineum and where appropriate, vaginoscopy and colposcopy; Collin's test and biopsy of all abnormal areas detected by these tests. RESULTS Pruritus vulvae was the commonest presenting symptom [70%1. No vulvoscopic abnormalities were detected in 97% of patients, whilst 3% had acetowhite areas indicative of Human papilloma virus infection. Collin's test was positive in 40% of patients, although, histologically these areas were benign. All patients in the study had benign lesions on histology. CONCLUSION All patients in this study had benign causes of white vulval skin lesions. However, this cannot lead us to conclude that there is no role for doing Vulvoscopy and Collin's test, as premalignant and malignant lesions should be detected by these tests had they been present. / Thesis (M.Med.)-University of Natal, Durban, 1998.

Made available in DSpace on 2014-06-11T19:29:52Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-05-27Bitstream added on 2014-06-13T19:59:58Z : No. of bitstreams: 1 ferreira_apm_me_botfm.pdf: 237424 bytes, checksum: 9a7f1664374ee98c2c2d1ea822cfc82f (MD5) / Identificar as repercussões estruturais, funcionais e na qualidade de vida de mulheres submetidas à vulvectomia e linfadenectomia inguinal para tratamento cirúrgico do câncer de vulva. Estudo observacional, prospectivo, transversal. Foram avaliadas 28 mulheres submetidas ao tratamento cirúrgico para câncer de vulva e 28 mulheres saudáveis (grupo controle), pareadas por idade. Os dados demográficos e clínicos referentes ao câncer de vulva foram obtidos por meio de análise de registros médicos, entrevista, exame físico e dos questionários: European Organization for Reseach and Treatment of Cancer Quality-of-Life Questionnaire (EORTC QLQ-C30), para qualidade de vida, International Consultation on Incontinence Questionnare – Short Form (ICIQ-SF), para avaliação da função urinária e o The Female Sexual Function Index (FSFI), para avaliar a função sexual. Os testes estatísticos utilizados foram qui-quadrado, t de Student, Spearman e Mann Whitney-U. A ocorrência de linfedema foi maior nas pacientes com câncer de vulva em comparação ao controles (p<0,05). O linfedema foi mais grave nas pacientes tratadas para câncer de vulva em comparação ao controle (p=0,003). Não houve diferença entre a gravidade do linfedema e as variáveis: estadiamento, tratamento adjuvante, lateralidade do linfedema e complicações. Houve associação entre gravidade do linfedema e as variáveis idade (p=0,04) e IMC (p=0,04). As escalas de qualidade de vida, definidas pelos domínios: físico, cognição, emocional, social, fadiga, dor, sono, e questões financeiras; se associaram com a gravidade do linfedema (p<0,05). Não houve influência das variáveis: estado civil, escolaridade, menopausa e câncer de vulva na qualidade de vida sexual. Houve associação entre qualidade de vida sexual com a idade (p=0,01) e parceiro estável (p=0,01). As variáveis: IMC, menopausa e câncer de vulva... / To identify the impact structural, functional and quality of life of women before vulvectomy and inguinal lymphadenectomy for surgical treatment of cancer of the vulva. Observational, prospective, cross. We evaluated 28 women undergoing surgical treatment for cancer of the vulva and 28 healthy women (control group), matched for age. The demographic and clinical data relating to cancer of the vulva were obtained through analysis of medical records, interview, physical examination and questionnaires: European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire (EORTC QLQ-C30) for quality of life, International Consultation on Incontinence Questionnaire - Short Form (SF-ICIQ) for assessment of urinary function and The Female Sexual Function Index (FSFI) to assess sexual function. Statistical tests used were chi-square, t Student, Spearman and Mann-Whitney-U. The incidence of lymphedema was higher in patients with cancer of the vulva as compared to controls (p <0.05). The lymphedema was more severe in patients treated for cancer of the vulva as compared to control (p = 0003). There was no difference between the severity of lymphedema and the variables: stage, adjuvant treatment, laterality and complications of lymphedema. There was an association between severity of lymphedema and the variables age (p = 0.04) and BMI (p = 0.04). The scales of quality of life, defined by domains: physical, cognitive, emotional, social, fatigue, pain, sleep, and financial issues, became associated with the severity of lymphedema (p<0.05). There was no influence of variables: marital status, educational level, menopause and cancer of the vulva in the quality of sexual life. There was an association between sexual quality of life with age (p = 0.01) and stable partner (p = 0.01). The variables: BMI, menopause and cancer of the vulva did not influence... (Complete abstract click electronic access below)

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Orientador : Jose Aristodemo Pinotti / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-07-16T04:44:03Z (GMT). No. of bitstreams: 1 Rudge_MarilzaVieiraCunha_D.pdf: 2163842 bytes, checksum: 47e9248992ae7f1e9bbe925f43c81b57 (MD5) Previous issue date: 1976 / Resumo: Não informado / Abstract: Not informed / Doutorado / Doutor em Ciências Médicas

The LIN-12/Notch signaling pathway is highly conserved in all animals, and is crucial for proper development. It is a key pathway in specifying cell fate in many cellular contexts, and dysregulation of the pathway can have deleterious consequences. Therefore, understanding how LIN-12/Notch signaling is regulated in different contexts has been a main area of interest in the field. Previous studies in different model organisms have identified many modes of regulation of the signaling pathway, one of which is endocytosis of the ligand and receptor. Here, I further investigated the role of endocytosis in LIN-12/Notch signaling in multiple developmental contexts in Caenorhabditis elegans. Work in Drosophila and vertebrates had previously established that ligand-mediated activation of Notch requires ubiquitination of the intracellular domain of the transmembrane ligand and the activity of the endocytic adaptor Epsin in the signaling cell. The consensus in the field is that Epsin-mediated endocytosis of mono-ubiquitinated ligand generates a pulling force that exposes a cleavage site in Notch for an ADAM protease, a critical step in signal transduction. In contrast, in this thesis, I examined two different transmembrane ligands in several different cell contexts and found that activation of LIN-12/Notch and the paralogous GLP-1/Notch in C. elegans does not require either Epsin-mediated endocytosis or ubiquitination of the intracellular domain of the ligand. Results obtained by a collaborator indicate that C. elegans ligand and receptor interactions are tuned to a lower force threshold than are Drosophila ligand and receptor interactions, potentially accounting for these differences. I also looked at the role of endocytosis in regulating LIN-12 signaling in the context of vulval development. The cell fate pattern of six vulval precursor cells (VPCs) is mediated by EGFR and LIN-12/Notch signaling. Previous work using multicopy transgenes in fixed specimens indicated that LIN-12 is post-translationally downregulated via endocytosis in response to EGFR activation in the VPC named P6.p, an event that appeared essential for ligands to activate LIN-12/Notch in neighboring VPCs. In this thesis, I manipulate the endogenous lin-12 gene and examine live specimens to show that LIN-12 appears to be regulated transcriptionally in P6.p and evidence that there may be additional potential endocytic motifs that may regulate LIN-12 in this context.

Quiescent adult stem cells are important for both tissue maintenance and for responding to stress. C. elegans provides an ideal context to dissect pathways involved in the maintenance of long-term cellular quiescence. In favorable environmental conditions, larvae develop continuously into reproductive adults. In adverse environmental conditions, larvae can undergo an alternative life history and enter dauer diapause, a long-lived state with characteristics that promote survival and dispersal. Animals that enter dauer can survive for months, many times the normal life span of an animal that develops continuously. Entry into dauer interrupts the development of the vulva and is associated with a reprogramming-like event that ensures that Vulval Precursor Cells (VPCs) remain multipotent and quiescent until conditions improve. In this work, I aim to understand how the pathways that regulate dauer entry dictate cellular outcomes that oppose VPC fate acquisition and cell division.VPC specification is initiated when an inductive EGF signal from the somatic gonad activates EGFR-Ras-ERK signaling in the nearest VPC, P6.p. Using an ERK activity biosensor, we found that EGFR signal transduction is activated in P6.p prior to dauer entry. However, during the molt into dauer, EGFR signal transduction itself is downregulated and ERK activity remains low in P6.p throughout dauer. To understand how the VPCs are maintained as multipotent precursors in dauer larvae, we investigated the level at which negative regulation of EGFR signaling occurs. We found that dauer VPCs are desensitized to both endogenous and ectopic expression of EGF despite the presence and correct localization of the EGFR. A constitutively active allele of Ras, but not the EGFR, was sufficient to increase ERK activity in the VPCs. This suggests that during dauer, regulation of EGFR signal transduction occurs at or above the level of Ras. We conclude that EGFR signaling is opposed within the VPCs themselves at the level of membrane associated events. Entry into dauer is regulated by Insulin (IIS), TGF-β and Nuclear Hormone Receptor (NHR) signaling pathways. To understand how these pathways might act to block VPC specification and cell division, we characterized mutants acting in either the IIS or NHR pathway that show inappropriate VPC developmental progression in dauer larvae. We found that the phosphatase DAF-18/PTEN, a modulator of IIS, is required to maintain VPC quiescence during dauer. We created an endogenously floxed daf-18 allele and used tissue-specific Cre recombinase drivers to determine the cellular focus of DAF-18/PTEN in regulating VPCs. Our data is consistent with DAF-18/PTEN acting nonautonomously to prevent VPC division and to maintain competence in dauer. DAF-16/FOXO, the major downstream effector of IIS, and DIN-1S/SHARP, which acts in NHR signaling, were previously implicated in regulation of the VPCs during dauer. We looked at null mutants over time in dauer life history and found that each transcription factor opposes VPC division during distinct stages in dauer development. While DIN-1S/SHARP appears to be required to maintain quiescence at the end of the L2d-dauer molt, DAF-16/FOXO is required to maintain quiescence in dauer itself. This suggests that regulation of the VPCs during dauer life history is dynamic and occurs in phases with each stage having distinct regulatory mechanisms, which is like what has been described for dauer exit. Our research provides insights into robust protective mechanisms that maintain multipotency and quiescence over long periods of time. While the pathways required to enact the dauer program are well defined, the downstream consequences of these pathways on individual or groups of cells are less understood. Future work will aim to link dauer regulating pathways to the downregulation of EGFR signaling in the VPCs.

Cell fate specification is a crucial mechanism for generating different cell types in complex multicellular organisms. In the larval somatic gonad of C. elegans hermaphrodites, the anchor cell (AC) is a terminally differentiated cell that coordinates uterine and vulval development. Four cells in the proximal lineage of Z1 and Z4 precursor cells, Z1.ppa, Z1.ppp, Z4.aaa, and Z4.aap, are born with the competence for AC fate. The two distal cells, the β cells (Z1.ppa and Z4.aap), invariably assume the ventral uterine precursor (VU) fate. The two proximal cells, the α cells (Z1.ppp and Z4.aaa), undergo the AC/VU decision mechanism to determine which one becomes the AC and the other the third VU. The E protein HLH-2 plays key and sequential roles in this process. First, HLH-2 endows the α and β cells with the potential for AC fate. Second, it orchestrates the decision mechanism that determines which of the α cells become the AC and the third VU. HLH-2 is required for the expression of the Notch gene lin-12 and its ligand lag-2/DSL, and the interaction of LIN-12 and LAG-2 amplifies lin-12 in one α cell that becomes the VU whereas the other α cell becomes the AC. In the VUs, HLH-2 is degraded post-translationally by a ubiquitination-dependent mechanism, whereas it is maintained in the AC and required for AC functions. I first tested the hypothesis that lin-12 regulates degradation of HLH-2. I found that in a lin-12(0) background, in which the AC/VU decision does not occur and both α cells become ACs, HLH-2 expression is greater in the ACs than in the wild type AC, and greater in lin-12(0) β cells compared to wild type β cells. My results suggest that lin-12 contributes to degradation of HLH-2 in all four α and β cells. I then focused on hlh-2 transcription in the proximal gonad. Previous work had established that HLH-2 begins to be expressed in the parents of α and β cells, Z1.pp and Z4.aa, and that which parent cell visibly expresses HLH-2 first is predictive of the outcome of the AC/VU decision; the α cell daughter of the first parent cell to express HLH-2 is biased towards VU fate. Therefore, the initial activation of hlh-2 transcription early on in the parents of α and β cells has crucial downstream implications for the AC/VU outcome. I identified early activation elements (EAEs) required for initial transcription of hlh-2 and mutated them in the endogenous gene, and showed that it disrupts initial HLH-2 expression in α and β cells and their parents and induces phenotypes consistent with defective AC function. I also showed that similar sequence elements previously identified in another gene, nhr-67, which is also expressed in α and β cells and plays a role in the AC/VU decision, is required for transcription of nhr-67 in α and β cells and that mutation of those sequences in endogenous contexts disrupts its initial expression in α and β cells and their parents. I also performed an RNAi screen and identified several candidate transcription factors that may regulate the initial transcription of both hlh-2 and nhr-67 in the proximal gonad. Hlh-2 transcription, which occurs in α and β cells initially, is diminished in β cells and maintained in the α cells over time. I tested the hypothesis from earlier studies that the difference between α and β cells in part reflects activity of the Wnt/β-catenin asymmetry pathway. I found that endogenous POP-1 is present at asymmetric levels in α and β cell nuclei and that depletion of its regulator LIT-1, which abolishes the wild type asymmetric pattern of POP-1 accumulation, results in maintenance of hlh-2 transcription and elevated HLH-2 expression in the β cells while not transforming them to AC fate. Finally, I identified regions in hlh-2prox that appear to regulate the continued maintenance of hlh-2 transcription after initial expression and lsy-12 to likely be involved in that role. Thus, my experiments provide greater context into the regulation of hlh-2 transcription in the proximal somatic gonad from initial onset in the parents of α and β cells to later patterning in α and β cells.