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Background: Hormonal therapies are commonly prescribed to patients with metastatic granulosa cell tumours (GCT), based on high response rates in small retrospective studies. Aromatase inhibitors (AIs) are reported to have high response rates and an accepted treatment option. We report the results of a phase 2 trial of an AI in recurrent/metastatic GCTs., Methods: 41 patients with recurrent ER/PR + ve GCT received anastrozole 1 mg daily until progression or unacceptable toxicity. The primary endpoint was clinical benefit rate (CBR) at 12 weeks, evaluated by RECIST1.1 criteria. Secondary endpoints included progression-free survival (PFS), CBR duration, quality of life and toxicity., Results: The CBR at 12 weeks in 38 evaluable patients was 78.9%, which included one (2.6%; 95% CI: 0.5-13.5%) partial response and 76.3% stable disease. Two additional patients without measurable disease were stable, based on inhibin. Median PFS was 8.6 m (95% CI 5.5-13.5 m). There were delayed responses observed after 12 weeks with a total of 4 pts. (10.5%; 95% CI 4.2%-24.1%) with a RECIST partial response; 23 (59%) patients were progression-free at 6 months. The adverse effects were predominantly low grade., Conclusions: This is the first prospective trial of hormonal therapy in GCTs. Although there was a high CBR, the objective response rate to anastrozole was much lower than the pooled response rates of >70% to AIs reported in most retrospective series and case reports. PARAGON demonstrates the importance of prospective trials in rare cancers and the need to reconsider the role of AIs as single agents in GCTs., Competing Interests: Declaration of Competing Interest SB: Institutional grants from Astrazeneca, Tesaro, GSK. Personal fees for advisory boards/lectures: Amgen, Astrazeneca, Clovis, Genmab, GSK, Immunogen, Mersana, MSD, Merck Sereno, Mersana, Oncxerna, Pfizer, Roche, Takeda, Tesaro, outside the submitted work. KS: Research funding to institution, Bayer and Amgen. Personal fees from Merck, Amgen, Servier, BMS, IPSEN, Competitive Drug Development, outside the submitted work. AC: Grants from Cancer Research UK and Astrazeneca, personal fees from AstraZeneca, GSK, Tesaro, Clovis Oncology, Eisai, outside the submitted work. RL: Personal fees from Tesaro and Roche outside the submitted work. MH: Research funding to institution Merck, BMS, Clovis Oncology. Honoraria for Advisory Boards/ Lectures: Amgen, AZ, Clovis Oncology, GSK, MSD, Roche outside the submitted work. CG: Research funding to institution: AstraZeneca, Novartis, Aprea, Nucana, Tesaro, BerGen Bio. Honorary for advisory boards/lectures: Roche, AstraZeneca, MSD, GSK, Tesaro, Nucana, Clovis, Foundation One, Sierra Oncology, Cor2Ed, Takeda. PS: Grant from University of Sydney. RE: Personal fees from Arquer Diagnostics, GSK, Clovis oncology outside submitted work. MF: personal fees from Astra Zeneca, MSD, GSK, Tesaro, Lilly, Takeda and Novartis; institutional grants from Astra Zeneca, Novartis and Beigene, other from Abbvie and ACT Genomics outside the submitted work. All other authors (MT, ROC, DM, SN, VMM, TB, JCG, PTG, OM, LA, CK, KC, LD, NB) report no disclosures of interest., (Copyright © 2021. Published by Elsevier Inc.)

Objective: Indoleamine 2,3-dioxygenase-1 (IDO1) is a key regulator of immune tolerance in ovarian cancer. This study investigated efficacy and safety of the IDO1 enzyme inhibitor epacadostat versus tamoxifen in patients with biochemical-only recurrence (CA-125 elevation) following complete remission after first-line chemotherapy for advanced epithelial ovarian, primary peritoneal, or fallopian tube cancer., Methods: In this open-label, phase 2 study (NCT01685255), patients were randomised 1:1 to epacadostat 600mg or tamoxifen 20mg twice daily for successive 28-day cycles and stratified by time since completion of first-line chemotherapy to first CA-125 elevation (3 to <12 or ≥12months). The primary endpoint was investigator-assessed progression-free survival (PFS; RECIST v1.1). Secondary endpoints included CA-125 response (Gynecologic Cancer InterGroup criteria), overall survival, safety, and tolerability., Results: The study was terminated primarily due to slow accrual and lack of evidence of superiority. Median PFS was 3.75months for epacadostat (n=22) versus 5.56months for tamoxifen (n=20; HR, 1.34 [95% CI, 0.58-3.14]; P=0.54). Of evaluable patients, 1 (5.0%) epacadostat and 3 (15.8%) tamoxifen patients had confirmed CA-125 responses. The most common treatment-emergent adverse event was fatigue (epacadostat, 36.4%; tamoxifen, 40.0%). Immune-related adverse events, observed with epacadostat only, were primarily rash (18.2%) and pruritus (9.1%). Epacadostat pharmacokinetics/pharmacodynamics were consistent with its known mechanism of action. IDO1 expression was observed in 94% of archival tumour samples., Conclusions: This first report of immunotherapy evaluation in biochemical-only relapse ovarian cancer and of IDO1 inhibitor monotherapy in ovarian cancer found no significant difference in efficacy between epacadostat and tamoxifen. Epacadostat was generally well tolerated., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Our aim was to study the expression of L1CAM in endometrioid and clear cell ovarian carcinomas and to evaluate its correlation with clinical parameters and patient prognosis., Methods: Tissue microarray -based immunohistochemical analysis of L1CAM expression was performed in 249 endometrioid and 140 clear cell ovarian carcinomas. Concurrent endometrial carcinoma was found in 57 of these patients., Results: L1CAM expression was found in 15% of endometrioid and 23% of clear cell ovarian carcinomas. L1CAM expression was strongly associated with poor disease-specific overall survival and poor disease-free survival in endometrioid (p<0.0001, p=0.0005), but not in clear cell ovarian carcinomas. Significant association of L1CAM expression with poor overall survival was observed in grade 1-2 carcinomas (p<0.0001), but not in grade 3 tumors. In endometrioid ovarian carcinomas, L1CAM expression was associated with aggressive tumor characteristics, such as higher grade and stage, and incomplete response to primary therapy. However, L1CAM expression was not an independent prognostic factor for overall or disease-free survival. Of the 57 patients with concurrent endometrial carcinoma L1CAM positivity was found in 4 cases both in the ovarian and endometrial tumors, and in 3 cases only in the endometrial tumor. All these seven patients with L1CAM positive tumors had poor outcome., Conclusions: L1CAM expression could serve as a biomarker for predicting clinical outcome and response to therapy in patients with endometrioid ovarian carcinoma, but not in clear cell carcinomas. L1CAM positivity also predicts poor outcome in patients with concurrent endometrioid ovarian and endometrial carcinomas., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Steroid hormones promote epithelial ovarian cancer (EOC) growth and their receptor expression is associated with disease outcome. Hormone therapy is frequently used in pretreated EOC, but the magnitude of activity overall and by specific agents or tumor characteristics is unknown., Methods: Clinical Benefit Rates (CBR) and deaths from clinical trials of endocrine agents were meta-analyzed. Summary estimates of CBR (SCBR) and Odd Ratio for death (SOR) were calculated according with type of drug, ER and PgR status, platinum resistance, line of therapy, tumor grade and tamoxifen dose., Results: Fifty-three trials in 2490 patients were analyzed. Overall, SCBR was 41% (95%CI, 0.34-0.48) for any endocrine treatment, 43% (95%CI, 0.30-0.56) for tamoxifen, 39% (95%CI, 0.29-0.50) for aromatase inhibitors and 37% (95%CI, 0.26-0.48) for progestins. The SCBR for ER+ and/or PgR+ tumors was 46% (95%CI, 0.34-0.57) versus 37% (95%CI, 0.27-0.48) in tumors with unknown receptors and 55% in platinum sensitive (95%CI, 0.28-0.80) versus 40% (95%CI, 0.29-0.51) in platinum resistant tumors The SOR for death calculated from 6 out of 9 randomized clinical trials (RCTs) showed a reduced mortality with endocrine therapy (SOR=0.69, 95%CI, 0.50-0.97), with a possible tendency for a greater effect in first line and low grade tumors. The overall quality of the RCTs was low., Conclusions: The activity of endocrine therapy in advanced EOC is worth considering and seems to support large properly designed randomized trials in the first treatment of hormone sensitive EOC., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Ovarian clear cell carcinoma (OCCC) frequently presents at an early stage. In stage I OCCC, the prognosis differs according to substage. In particular, predictive biomarkers and new treatment strategies are needed for stage IC2/IC3 disease. We investigated tumor biology and prognostic factors for stage I OCCC from a clinicopathological perspective, including the expression of ARID1A and IL-6, which are considered critical for OCCC carcinogenesis., Methods: A retrospective cohort study of 192 patients with stage I OCCC treated at a single institution was performed. We calculated overall survival (OS) with respect to 12 clinicopathological parameters that included the unique and diverse histological features of OCCC., Results: The estimated 5-year OS rate in patients with all stage I OCCC was 88.9% during a median of 91months of follow-up. The multivariate analysis indicated that substage classification and IL-6 expression status were associated with poor OS (p=0.010 and p=0.027, respectively). Loss of ARID1A expression had no impact on survival; however, it was associated with substage (p=0.001), capsule rupture status (p=0.011), and ascites cytology (p=0.016). No clear association was found between ARID1A and IL-6 expressions. Histological findings, including the presence of endometriosis, adenofibroma, architectural pattern, and tumor cell type, showed no prognostic effects., Conclusions: Both substage classification and IL-6 expression status may be independent prognostic factors in stage I OCCC. Therefore, IL-6 molecular stratification may be crucial in optimizing therapeutic strategies for early stage OCCC to improve survival., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: The CD47 "don't eat me" signal allows tumor immune evasion. We tested the association of CD47 expression with outcomes in EOC., Methods: CD47 expression was examined within the TCGA database for ovarian carcinoma. For validation, IHC was performed on a TMA consisting of specimens from 265 patients with EOC. The medical records of the patients were also retrospectively reviewed to correlate demographic and survival data., Results: CD47 was amplified in 15/316 (5%) ovarian serous cancers in TCGA. In the validation cohort, the majority of patients had stage III/IV disease (208/265, 78.4%). CD47 expression was seen in 210/265 (79.2%). Patients were categorized into CD47hi (129/265; 48.7%) versus CD47lo (136/265; 51.3%). Patients with CD47lo tumors were more likely to have a complete response to adjuvant therapy than CD47hi (65% vs 50%, p=0.026). Although there was a trend towards an increase in median OS (37.64 vs 45.26months, p=0.92) in the CD47lo group compared with CD47hi, the difference was not significant., Conclusions: CD47 is expressed at high frequency in EOC. Patients with CD47lo EOC had a better treatment response to standard therapy, and trended towards improved OS. This demonstrates that while CD47 may be an immunologic shield that may be considered for targeted therapies, it is likely that it operates in concert with other mechanisms of immune evasion. Future studies to evaluate CD47 expression with other known mechanisms of immune escape in the tumor microenvironment may help further define its role., Competing Interests: The authors have no conflicts of interest., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Homologous recombination (HR) proficient ovarian cancers, including CCNE1 (cyclin E)-amplified tumors, are resistant to poly (ADP-ribose) polymerase inhibitors (PARPi). Histone deacetylase inhibitors (HDACi) are effective in overcoming tumor resistance to DNA damaging drugs. Our goal was to determine whether panobinostat, a newly FDA-approved HDACi, can sensitize cyclin E, HR-proficient ovarian cancer cells to the PARPi olaparib., Methods: Expression levels of CCNE1 (cyclin E), BRCA1, RAD51 and E2F1 in ovarian tumors and cell lines were extracted from The Cancer Genome Atlas (TCGA) and Broad-Novartis Cancer Cell Line Encyclopedia (CCLE). In HR-proficient ovarian cancer cell line models (OVCAR-3, OVCAR-4, SKOV-3, and UWB1.289+BRCA1 wild-type), cell growth and viability were assessed by sulforhodamine B and xenograft assays. DNA damage and repair (pH2AX and RAD51 co-localization and DRGFP reporter activity) and apoptosis (cleaved PARP and cleaved caspase-3) were assessed by immunofluorescence and Western blot assays., Results: TCGA and CCLE data revealed positive correlations (Spearman) between cyclin E E2F1, and E2F1 gene targets related to DNA repair (BRCA1 and RAD51). Panobinostat downregulated cyclin E and HR repair pathway genes, and reduced HR efficiency in cyclin E-amplified OVCAR-3 cells. Further, panobinostat synergized with olaparib in reducing cell growth and viability in HR-proficient cells. Similar co-operative effects were observed in xenografts, and on pharmacodynamic markers of HR repair, DNA damage and apoptosis., Conclusions: These results provide preclinical rationale for using HDACi to reduce HR in cyclin E-overexpressing and other types of HR-proficient ovarian cancer as a means of enhancing PARPi activity., Competing Interests: DK received olaparib from AstraZeneca and is a co-investigator for a clinical trial of olaparib. MAC is the local principal investigator for a clinical trial of olaparib., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Integral membrane protein 2A (ITM2A) is a type 2 transmembrane protein of unknown function. The aim of this study was to investigate its expression pattern, clinical significance, and biological function in epithelial ovarian cancer., Methods: ITM2A expression in 35 normal, 20 adenoma, 11 borderline and 90 cancerous ovarian tissues was measured by immunohistochemistry. Clinicopathological parameters were obtained from medical records. Survival data was analyzed using Kaplan-Meier estimates and multivariate analysis using the Cox-regression method. Anti-tumor activities of ITM2A were explored by cell proliferation and colony formation assays, flow cytometry, Western blots and animal studies using ovarian cancer cell lines. Chemoresponsiveness was evaluated by measuring IC50 and confirmed by animal studies using an intraperitoneal orthotropic model., Results: ITM2A was significantly downregulated in invasive carcinomas compared to normal, adenoma and borderline tumor tissues. ITM2A loss occurred in 45.6% (41 of 90) of invasive carcinomas and was significantly associated with FIGO stage, type II tumors, suboptimal debulking operation, recurrence and chemoresistance. ITM2A loss and higher FIGO stage were independent factors for poor prognosis. Expression of ITM2A inhibited growth and induced G2/M cell cycle arrest by attenuating cdc2, cyclin B1, cdc25c and p-cdc2 (Thr 161). In vitro and in vivo experiments showed that ITM2A expression significantly reduced the paclitaxel and carboplatin IC50 and tumor mass after paclitaxel treatment., Conclusion: ITM2A is a new biomarker of poor prognosis in ovarian cancer. It is a novel tumor suppressor that induces cell cycle arrest, acts as a chemosensitizer, and has therapeutic potential for ovarian cancer., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Aims: Wilms tumor protein 1 (WT1) expression is used in gynecological pathology as a diagnostic marker of serous differentiation, and is frequently co-expressed with ER-α. Early phase studies on WT1 vaccine in gynecological cancers are ongoing. In this study we aimed to determine the prognostic value of WT1 in high-grade serous ovarian carcinoma., Methods: WT1 protein expression was determined by immunohistochemistry in a cohort of 207 primary high-grade serous ovarian carcinomas. WT1 mRNA expression was evaluated in a cohort of 1137 ovarian carcinomas from publically available gene expression datasets., Results: High WT1 expression was a significant positive prognostic factor in primary high-grade serous ovarian carcinoma regarding overall survival (OS, p=0.008) and progression free survival (PFS, p=0.015), which was independent of age, stage, and residual tumor (OS: p=0.024, PFS: p=0.047). The prognostic significance of immunohistochemical WT1 expression could be reproduced in an independent cohort of 72 patients. On the mRNA level the prognostic significance was validated in silico in publically available gene expression datasets including TCGA data (OS: p=0.002, PFS: p=0.011). WT1 expression was significantly linked to ER-α expression (p=0.001), and tumors that co-expressed both markers (WT1+/ER-α+) had a longer survival time than tumors of all other marker combinations (OS: p=0.002, PFS: p=0.013)., Conclusion: We present WT1 as a robust prognostic marker in high-grade serous ovarian carcinoma, which adds prognostic information to ER-α. This should be kept in mind when WT1 is used as a biomarker in the context of WT1-targeting therapies., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Platinum resistance is a dominant cause of poor outcomes in advanced ovarian cancer (OC). A mechanism of platinum resistance is the inhibition of apoptosis through phosphatidylinositol 3 kinase (PI3K) pathway activation. The role of phosphatase and tensin homolog (PTEN), a negative regulator of this pathway, as a tumor biomarker is unclear. Quantitative analysis of PTEN expression as an alternative to immunohistochemistry has not been considered., Patients and Methods: In 238 patient tumors from the NCIC-CTG trial OV.16, PTEN protein expression was quantified by Automated QUantitative Analysis (AQUA). Cox model was used to study the association between PTEN expression and clinical outcomes using a minimum p-value approach in univariate analysis. Multivariate analysis was used to adjust for clinical and pathological parameters., Results: PTEN scores (range 13.9-192.3) of the 202 samples that passed quality control were analyzed. In univariate analysis, there was a trend suggesting an association between PTEN expression by AQUA as a binary variable (low ≤61 vs high >61) and progression free survival (HR=0.77, p=0.083), and in multivariate analysis, this association approached significance (HR=0.74, p=0.059). The relationship between quantitative PTEN expression and PFS differed (p=0.01 for interaction) by the extent of surgical debulking (residual disease (RD) <1cm or ≥1cm), with a numerically superior PFS in patients with high PTEN (23.5 vs 14.9m) only when RD<1cm (p=0.19). There was no association between PTEN levels and overall survival., Conclusions: AQUA is a novel method to measure PTEN expression. Further study of PTEN as a biomarker in OC is warranted., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: This study investigated the relationship between 13 proteins involved in DNA damage and the outcomes of patients with recurrent ovarian cancer (ROC)., Patients and Methods: Immunohistochemistry staining was performed in 114 diagnostic samples from patients with serous ROC who participated in the OVA-301 study, which compared pegylated liposomal doxorubicin (PLD) with a combination of trabectedin plus PLD. Percentage of positive cells for every marker was calculated and correlated with overall response rate (ORR), progression-free survival (PFS) and overall survival (OS)., Results: A statistically significant correlation between high levels of nibrin and lower ORR (P=0.03), shorter PFS (P=0.007) and shorter OS (P=0.01) was observed. After stratification, in patients with platinum-sensitive disease treated with the combination of trabectedin plus PLD, high levels of nibrin correlated with lower ORR (P=0.01) and shorter PFS (P=0.02). A better clinical outcome (ORR, PFS and OS) was also associated to low levels of CHK2 in trabectedin plus PLD treated patients. No correlations were found in PLD-treated patients. According to the results of a multivariate analysis, there was a statistically significant correlation between high nibrin (P=0.001) and low BRCA2 levels (P=0.03) and a worse PFS, and between high nibrin levels and a worse OS (P=0.006)., Conclusion: Our results indicate that high nibrin expression seems to be associated with a worse clinical outcome in serous ROC, particularly in patients treated with the combination trabectedin plus PLD. Prospective studies to determine clinical usefulness of nibrin as a possible biomarker in other series of patients with ROC are warranted., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: Platelet-derived growth factor receptor alpha (PDGFRα) is believed to be associated with cell survival. We examined (i) whether PDGFRα blockade enhances the antitumor activity of taxanes in ovarian carcinoma and (ii) potential biomarkers of response to anti-PDGFRα therapy., Methods: PDGFRα expression in 176 ovarian carcinomas was evaluated with tissue microarray and correlated to survival outcome. Human-specific monoclonal antibody to PDGFRα (IMC-3G3) was used for in vitro and in vivo experiments with or without docetaxel. Gene microarrays and reverse-phase protein arrays with pathway analyses were performed to identify potential predictive biomarkers., Results: When compared to low or no PDGFRα expression, increased PDGFRα expression was associated with significantly poorer overall survival of patients with ovarian cancer (P=0.014). Although treatment with IMC-3G3 alone did not affect cell viability or increase apoptosis, concurrent use of IMC-3G3 with docetaxel significantly enhanced sensitization to docetaxel and apoptosis. In an orthotopic mouse model, IMC-3G3 monotherapy had no significant antitumor effects in SKOV3-ip1 (low PDGFRα expression), but showed significant antitumor effects in HeyA8-MDR (high PDGFRα expression). Concurrent use of IMC-3G3 with docetaxel, compared with use of docetaxel alone, significantly reduced tumor weight in all tested cell lines. In protein ontology, the EGFR and AKT pathways were downregulated by IMC-3G3 therapy. MAPK and CCNB1 were downregulated only in the HeyA8-MDR model., Conclusion: These data identify IMC-3G3 as an attractive therapeutic strategy and identify potential predictive markers for further development., (© 2013.)

Objectives: Abelson tyrosine kinase (c-Abl) has been shown to promote solid tumor invasion and metastasis. However, little is known regarding whether c-Abl contributes to the development or progression of epithelial ovarian cancer (EOC). The aims of this study are to determine the expression of c-Abl and investigate a possible relationship between c-Abl and prognosis in EOC., Methods: c-Abl protein level was evaluated in 137 EOC specimens by immunohistochemical staining and 32 EOC specimens by Western blot analysis. Expression of c-Abl in ovarian cancer cell lines was measured by Western blot analysis and immunofluorescence. Survival analysis was performed to assess the correlation between c-Abl expression and survival., Results: Immunohistochemical staining and Western blot analysis revealed that c-Abl was overexpressed in EOC compared with samples from a non-invasive ovarian tumor and normal ovaries (P<0.05). Furthermore, expression of c-Abl was significantly associated with advanced FIGO stage, poor grade, serum Ca-125 and residual tumor size (P<0.05). By Western blot analysis, c-Abl expression was examined in four ovarian cancer cell lines. Meanwhile, immunofluorescence was performed to show c-Abl expression in SKOV3 and 3AO cell lines. Survival analysis demonstrated that patients with low c-Abl staining had a significantly better survival compared to patients with high c-Abl staining (P<0.05). In multivariate analysis, c-Abl overexpression, poor grade, advanced stage and suboptimal surgical debulking were independent prognostic factors of poor survival., Conclusions: Our present study finds that c-Abl overexpression is associated with an unfavorable outcome. c-Abl may be a crucial predictor for EOC metastasis., (© 2013.)

Objective: The presence of Six1 mRNA gene portends a poor prognosis in ovarian cancer. We describe validation of a Six1 specific antibody and evaluate its association with tumorigenicity and prognosis in ovarian cancer., Methods: A Six1 antibody (Six1cTerm) was raised to residues downstream of the Six1 homeodomain, representing its unique C-terminus as compared to other Six family members. Cells were transfected with Six1-Six6 and Western blot was performed to demonstrate Six1 specificity. Ovarian cancer cell lines were analyzed for Six1 mRNA and Six1cTerm and tumorigenicity was evaluated. Ovarian cancer tissue microarrays (OTMA) were analyzed for Six1cTerm by immunohistochemistry and scored by two blinded observers. The metastatic tumors of 15 stage IIIC high grade serous ovarian cancers were analyzed with Six1 mRNA and Six1cTerm and expression was compared to clinical factors and survival., Results: The Six1cTerm antibody is specific for Six1. Cell line tumorigenicity in SCID mice correlates with Six1 levels both by mRNA(p=0.001, Mann-Whitney U test) and by protein (presence vs. absence, p=0.05 Fischer's Exact test). Six1 protein was present in up to 54% of OTMA specimens. Six1 protein expression in omental/peritoneal metastases correlated with worsened survival in a sample (n=15) of high grade serous stage IIIC ovarian cancers (p=0.001)., Conclusions: The Six1cTerm antibody is specific and able to detect Six1 in cell lines and tumor tissue. Six1 protein detection is common in ovarian cancer and is associated with tumorigenicity and poor prognosis in this group of patient samples. Six1cTerm antibody should be further validated as prognostic tool., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: The role of molecular markers in ovarian cancer is still a matter of debate. Angiogenesis is a necessary condition for tumor growth. Hypoxia induces angiogenesis, and cyclooxygenase-2 (COX-2), p53 and HER2 are involved in cancer proliferation and angiogenesis regulation. The aims of this study were to evaluate the relationship between intratumoral microvessel density (IMD) and the expression of molecular markers that affect angiogenesis (COX-2, p53 and HER2) in advanced epithelial ovarian cancer (EOC), to analyze their prognostic and predictive value and their association with clinicopathological features, such as serum hemoglobin level at diagnosis (Hb)., Methods: Immunohistochemical staining with CD34 (for IMD), COX-2, p53 and HER2 antibodies was performed in 113 patients with advanced EOC who had undergone primary surgery. Clinicopathological data were collected and statistical analyses were performed., Results: Neither IMD, COX-2 nor HER2 had any predictive or prognostic value in EOC. A relationship that approached statistical significance was found between p53 expression and a complete response to treatment (p=0.05). p53 expression and tumor grade were inversely associated (p=0.012). Hb<12g/dl had predictive value (p=0.02)., Conclusions: In our series IMD, COX-2 and HER2 had neither prognostic nor predictive value in advanced EOC. p53 and Hb may be predictive factors. The results and clinical usefulness of immunohistochemistry are controversial. Further evaluations are required to determine whether the serum levels of molecular markers correlate with the results of immunohistochemical assays and whether they offer any prognostic and/or predictive value. Targeted therapy remains the ultimate goal of these studies., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: Current intraperitoneal (IP) regimens for the treatment of ovarian cancer rely on cisplatin (DDP) whereas intravenous regimens rely on carboplatin (CBDCA). A major question in the field is whether CBDCA can replace DDP for IP treatment. We compared the uptake of IP administered DDP and CBDCA into human ovarian carcinoma nodules of various sizes growing on the peritoneal surface of nu/nu mice., Methods: Human 2008 cells expressing GFP were inoculated IP in nu/nu mice. When small tumor nodules became visible by external imaging, a maximum tolerated dose of DDP, or either an equimolar or equitoxic dose of CBDCA, was injected IP. Platinum (Pt) concentration in tumor nodules was measured by inductively coupled plasma mass spectrometry., Results: A total of 749 tumors harvested from 33 mice were analyzed for Pt concentration. DDP produced a 3.4-fold higher level of Pt in tumor nodules when compared to an equimolar dose of CBDCA (p=0.02). However, when DDP and CBDCA were injected at doses that were equitoxic to the mice, tumor Pt levels were equivalent (p=0.63). Although Pt concentrations of equal-sized nodules were highly variable, tumor Pt content (ng Pt/mg tumor) decreased with increasing nodule size following IP DDP, an effect not seen with IP administration of equitoxic doses of CBDCA (p<0.001)., Conclusions: These results suggest that IP CBDCA has comparable or better drug penetration when compared to DDP given at equitoxic doses, and thus provide support for replacing DDP with CBDCA in the IP treatment of patients with ovarian cancer.

Objective: In the last decade several studies have been published using proteomics to unravel molecular pathways and to find biomarkers which can be used for diagnosis and/or prognostication in ovarian cancer. This review gives an overview of proteomic studies performed in ovarian cancer focusing on the nature of samples that have been used., Methods: Recent literature regarding the role of proteomic studies in ovarian cancer has been reviewed., Results: Most studies have focused on finding biomarkers for early diagnosis of ovarian cancer using blood samples though proteins identified until now are mainly acute phase reactants. Studies regarding platinum sensitivity have only been performed on cell culture models and need confirmation in tissue samples. Proteomic studies using ovarian cancer tissue are sparse and mostly contain a low number of samples., Conclusion: To date no biomarkers for early diagnosis or prognostication in ovarian cancer have been found using proteomics. We speculate that it would be interesting to investigate the tissue proteome in an attempt to overcome acute phase reactants and to facilitate the discovery of real tumor-specific biomarkers instead of the identification of secondary protein changes.

Objectives: The objectives of this study were to evaluate the diagnostic value for ovarian cancer using proteomic pattern established by surface-enhanced laser desorption/ionization (SELDI-TOF-MS) profiling of plasma proteins coupled with support vector machine (SVM) data analysis, and to investigate whether the proteomic pattern established by advanced ovarian cancer could be used for diagnosis of early-stage ovarian cancer patients., Methods: The study included 44 ovarian cancer patients (11 early-stage and 33 advanced ovarian cancer patients) and 31 age-matched non-cancer controls. SELDI-TOF-MS coupled with SVM analysis was performed to establish a proteomic pattern to discriminate 33 advanced ovarian cancer patients from 31 non-cancer controls. A blind test, including 11 early-stage ovarian cancer cases, was performed to investigate whether proteomic pattern established by advanced ovarian cancer could be used for diagnosis of early-stage ovarian cancer patients., Results: A seven-peak proteomic pattern was established which discriminated 33 advanced ovarian cancer patients from 31 non-cancer controls effectively. A sensitivity of 93.94% (31/33) and a specificity of 93.55% (29/31) were yielded from the proteomic pattern. Among the 7 protein peaks, 5 with mass charge ratio (m/z) 4099 Da, 5488 Da, 4144 Da, 4479 Da and 3940 Da were up-regulated, while 2 peaks, with m/z 13 783 Da and 8588 Da were down-regulated in the advanced ovarian cancer group compared with non-cancer control group. After blind test, 9 of 11 early-stage ovarian cancer patients were successfully diagnosed with the accuracy of 81.82% (9/11)., Conclusions: This study demonstrated that SELDI-TOF-MS coupled with SVM is effective in distinguishing protein expression between ovarian cancer and non-cancer plasma and it may be feasible to diagnose early-stage ovarian cancer using proteomic pattern established by advanced ovarian cancer. The gained and lost protein peaks in plasma may exist in both early-stage and advanced ovarian cancer plasma. Further studies should be performed using larger sample numbers.

Objective: The plasminogen activator system (PA) plays an important role in invasion and metastasis of solid tumors. The PA Inhibitor type 1 (PAI-1) is the main physiologic regulator of plasminogen activation. A recently characterized protein, PAI-RBP1 (PAI-1 mRNA Binding Protein 1), appears to regulate the stability of PAI-1 mRNA. Expression of PAI-RBP1 (the new, approved gene symbol is SERBP1) has not been previously analyzed in human tumors. We present herein for the first time expression analysis of PAI-RBP1 in epithelial ovarian cancer., Methods: PAI-RBP1 was identified as gene overexpressed in ovarian cancer by an in silico approach using EST database mining. A thorough expression analysis of PAI-RBP1 and PAI-1 was performed in normal ovary (n=4), benign (n=6) and malignant (n=42) ovarian lesions using non-radioactive RNA in situ hybridization and immunohistochemistry, respectively., Results: PAI-RBP1 mRNA and PAI-1 were significantly overexpressed in tumor epithelial cells as compared to benign and normal ovarian tissue. A significant correlation between PAI-RBP1 expression and advanced disease stage (FIGO) was found (p=0.042)., Conclusion: In ovarian cancer, PAI-RBP1 is significantly overexpressed in tumor epithelial cells, suggesting a biological role in tumor invasion and metastasis. Its expression is higher in advanced disease, thus the prognostic significance of PAI-RBP1 in ovarian cancer remains to be evaluated in further studies.

Objective: The objective of this study was to determine the relationship between multidrug resistance and sensitivity to paclitaxel (PTX) in ovarian cancer., Methods: We used human ovarian adenocarcinoma cell lines, KF, a PTX-resistant cell line (KFTx), SK-OV-3, and KOC7c. Additionally, 27 patients with ovarian cancer who had residual disease were examined. All patients underwent postoperative chemotherapy consisting of 175 mg/m(2) PTX and area under curve (AUC) 5 carboplatin. The sensitivity of the cells to PTX or cisplatin (CDDP) was determined by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. mRNA expression of multidrug resistance gene-1 (MDR-1) and multidrug resistance-associated protein-1 (MRP-1) and MRP-2 was determined by reverse transcription-polymerase chain reaction. beta-Tubulin polymerization and Bcl-2 phosphorylation were examined by Western blot analysis., Results: Compared with KF, the IC(50) to PTX was 5.5-fold higher for KFTx, 0.3-fold for SK-OV-3, and 52.1-fold for KOC7c. The IC(50) to CDDP was 0.7-, 4.2-, and 5.8-fold, respectively. Expression of the MDR-1 gene was clearly observed in KFTx and KOC7c. Expression of MRP-1 was observed in SK-OV-3 and KOC7c. Expression of MRP-2 was detected only in KOC7c. CDDP enhanced beta-tubulin polymerization induced by PTX in CDDP-sensitive cells. Bcl-2 phosphorylation appeared after exposure to IC(50) PTX in all cells. Twenty-one patients responded to chemotherapy and six did not. Expression of the MDR-1 gene for nonresponders was significantly higher than that for responders (260.0 +/- 191.6 vs 9.3 +/- 21.8). With the cutoff value of MDR-1 expression at 100, the predictive value for chemoresponse was 96%. Expression of the MRP-1 and MRP-2 genes did not differ between nonresponders and responders., Conclusion: MDR-1 gene expression may be a useful predictor for PTX-based chemotherapy.

Objectives: Theprognostic value of p53 expression in epithelial ovarian cancer remains unresolved. We hypothesized that prognosis may relate more to expression of p21(waf1/cip1), the major downstream effector of p53, which can also be induced through p53-independent mechanisms. We therefore studied the relationship of p53 and p21(waf1/cip1) expression in epithelial ovarian cancers to clinicopathological variables and prognosis., Methods: Fixed, embedded tumors from 85 patients with untreated, primary epithelial ovarian cancer were immunostained with antibodies to p53 and p21(waf1/cip1). Expression was correlated with clinicopathological features and prognosis. Survival curves were calculated by the Kaplan-Meier method and compared using the log-rank test for p53, p21(waf1/cip1), and all combinations of expression of the two markers., Results: Sixty-two percent of tumors expressed p53, and 42% expressed p21(waf1/cip1). There was no correlation between p53 and p21(waf1/cip1) expression. Advanced stage, grade, age >/=50, and p53 expression were associated with worse disease-free survival. Patients whose tumors were p53(+)/waf1(-), however, had a particularly strong association with poorer disease-free survival when compared with other combinations of p53 and p21(waf1/cip1) expression (P = 0.003). Neither p53, nor p21(waf1/cip1), nor combinations of expression were independently related to survival when histology, age, stage, and differentiation were considered., Conclusions: p53 expression in the absence of p21(waf1/cip1) expression is a better marker of poor prognosis than either p53 or p21(waf1/cip1) expression status alone in univariate analysis. Absence of independent prognostic significance may be related to the paucity of early stage cases in the current study., (Copyright 1999 Academic Press.)

Objective: Gelatinase A (MMP-2) is a member of the matrix metalloproteinase family and it degrades the major component of the basement membrane, type IV collagen. MMP-2 has been linked to invasion in different types of cancer., Method: We have studied the localization of MMP-2 in 18 benign, 3 borderline, and 33 malignant ovarian lesions by immunohistochemical stainings using a monoclonal antibody against MMP-2., Results: MMP-2-immunoreactive protein was localized in epithelial cells and in fibroblasts. Two types of cytoplasmic staining were observed, a diffuse and a granular pattern. The diffuse staining model was found more often. In 19% of the cases, both staining patterns were present in epithelial cells. Granular staining was found in epithelial cells in cystadenomas and in ovarian cancer cells. The pattern of MMP-2 positivity in fibroblasts was diffuse. MMP-2 positivity in cancer cells was associated with recurrent disease (P < 0.05) in ovarian cancers. MMP-2 negativity in fibroblasts correlated to Grade 3 (P < 0.01), Stage III-IV (P < 0.001), recurrency (P < 0.05), and refractory disease (P < 0.05) in ovarian cancer. The relative survival rate was 32% in patients with an MMP-2-positive ovarian cancer, 57% in patients with an MMP-2-negative ovarian cancer, and 19% in patients with MMP-2 positivity in cancer cells and concomitant negativity in stromal fibroblasts. The disease-free 5-year survival rates were 25, 57, and 12.5%, respectively., Conclusions: These data suggest that MMP-2 may contribute to poor prognosis of ovarian cancer., (Copyright 1999 Academic Press.)

Objectives: The aim of this study was to detect polycyclic aromatic hydrocarbon-DNA (PAH-DNA) adducts in single cervical cells collected during a routine Papanicolaou smear and to relate this carcinogen exposure dose marker to smoking habit., Methods: An immunohistochemical assay, using a polyclonal antiserum raised against benzo[a]pyrene diol epoxide-DNA adducts, was performed to evaluate PAH-DNA adducts in cervical cells collected from 16 volunteers who smoked at least 20 cigarettes/day and 16 nonsmokers., Results: The mean adduct level, determined as relative staining intensity by an optical density image analyzer, was significantly higher in smokers compared to nonsmokers (AOD x 1000 +/- SD = 98 +/- 32 and 73 +/- 25, respectively) (P = 0.04)., Conclusions: These results demonstrate that this immunohistochemical assay, much simpler than other methodologies used to evaluate PAH-DNA adducts in cervical tissue, is sufficiently sensitive for quantitative adduct evaluation in single epithelial cervical cells, as already verified for other exfoliated material. This work thus confirms that tobacco smoke is a risk factor for genotoxic damage generation in cervical cells and indicates a procedure likely adaptable to a large population screening., (Copyright 1999 Academic Press.)

A case of ovarian carcinoma with thrombopoietin production is reported. A 49-year-old Japanese woman had serous cystadenocarcinoma of the right ovary with peritoneal spread. The platelet count was elevated to 432 x 10(9)/L. Enzyme-linked immunosorbent assay of the serum demonstrated remarkably high levels of thrombopoietin (2.96 fmol/ml). Immunohistochemical examination using an antibody specific for thrombopoietin revealed positive staining in the carcinoma cells, confirming thrombopoietin production., (Copyright 1999 Academic Press.)

Although the coexistence of mucinous ovarian neoplasms and Brenner tumors is well established, the histogenesis and developmental relationship between the two remain unknown. We used comparative genomic hybridization to analyze two such tumors occurring simultaneously, one in each ovary, in a patient. Amplification of 12q14-21 sequences was found in both tumors; in addition, both tumors also had other, different changes, four identified in the Brenner tumor and six in the mucinous carcinoma. The occurrence of the same genetic alteration in both tumors in this woman suggests that the mucinous carcinoma and Brenner tumor may be clonally related, i.e., one arose from the other by means of metastatic spreading of transformed cells from one ovary to the other. An alternative explanation is that some unknown, putative tumorigenic agent induced similar and synchronous pathogenetic changes in the epithelium of both ovaries. The phenotypic differences between the tumors are presumably attributable to the other unique genetic abnormalities identified in both tumor types., (Copyright 1999 Academic Press.)

Objectives: In this study we evaluated changes in serum Müllerian inhibiting substance (MIS) concentration in a large number of patients with granulosa cell tumors (GCT) to determine whether MIS is elevated at the time of presentation and whether MIS is an index of successful surgical resection and management of recurrences., Methods: We retrospectively reviewed MIS levels from 17 subjects prior to tumor resection and studied serial MIS samples from 56 subjects following initial tumor resection. Clinical follow-up information was available for 36 of those with postoperative MIS values. Serum MIS was measured by an ELISA. MIS values were compared to a combination of normative values previously established in our laboratory and from more recently obtained samples from older pre- and postmenopausal women, using this assay., Results: Serum MIS was elevated pre-operatively in 6 of 8 (75%) subjects with juvenile GCTs and in 7 of 9 (78%) of those with adult GCTs relative to age-matched controls (76% for both types combined). Post-operative clinical correlation was available for 36 patients. There was no clinical recurrence in 21 subjects with normal or undetectable postoperative values, and incompletely resectable tumor or recurrence was identified in 6 of 15 patients with elevated postoperative values., Conclusions: The results of this study demonstrate that postoperative serum MIS concentrations may be used to evaluate the completeness of tumor removal following initial surgery and that serial MIS determinations may allow the detection of recurrences., (Copyright 1999 Academic Press.)

Due to the difficulties in separating malignant and benign ovarian cysts by transvaginal ultrasound and other techniques, there is a need for biochemical markers in serum or cyst fluids. In the present study we have evaluated the levels of the chemokine interleukin-8 (IL-8) in ovarian cysts. IL-8 is known to be expressed in the normal ovary and to influence proliferation and angiogenesis of several nonovarian types of tumors. Cyst fluids from benign (n = 15) and malignant (n = 13) ovarian tumors were analyzed. The levels of IL-8 were found to be significantly (13-fold) higher in cyst fluids from malignant tumors (18.1 +/- 7.5 ng/ml; mean +/- SE) compared to benign cysts (1.3 +/- 0.7 ng/ml). The plasma levels of IL-8 were considerably lower (2.9 and 0.3% of levels in benign and malignant cyst fluids, respectively) than in cyst fluids. No difference in the plasma levels of patients with benign or malignant tumor could be detected. In contrast, the levels of CA 125 were significantly higher in plasma of patients with malignant disease with the inverse relation in cyst fluids. In conclusion, the levels of IL-8 are markedly elevated in cyst fluid from malignant tumors compared to benign. This specific increase indicates a role for this cytokine in ovarian tumor biology., (Copyright 1998 Academic Press.)

Objective: CD44 is a surface glycoprotein widely distributed among different tissues. Malignant tumors may show a more complex pattern of CD44 expression, indicating a loss of splice control. The aim of our study is to investigate the expression of CD44 splice variants (CD44v) and its metastatic potential in clear cell carcinoma of the ovary., Methods: Twenty-two cases of clear cell carcinoma of the ovary were evaluated for CD44 standard form (CD44s) and splice variants: -4v, -6v, and -9v expression by immunocytochemistry., Results: Twenty-one primary ovarian tumors and 23 metastatic sites were available for evaluation. Eighteen of 21 (86%) of ovarian sections studied expressed CD44s; 15/21 (71%) expressed CD44-4v; 14/21 (67%) expressed CD44-6v; and 12/21 (57%) expressed CD44-9v. Of 23 metastatic sites evaluated, 87% expressed CD44s. In contrast, only 5 (22%) metastases had CD44-4v and CD44-6v expression and 8 (35%) had CD44-9v immunoreactivity. None of 10 normal contralateral ovaries expressed CD44s or any splice variants. In 2 cases we had tumor available from the primary surgery, and subsequent recurrences. Both recurrences showed decreased expression of CD44-4v and CD44-6v., Conclusions: Clear cell carcinoma of the ovary shows an abnormal pattern of CD44s expression and mRNA splicing when compared to the contralateral normal ovary in the same patient. Metastases of clear cell carcinoma show a downregulation in expression of some splice variants. Furthermore, we have data that suggest that as the tumors recur, CD44s and its isoforms are downregulated. Our results suggest that alternative mRNA splicing of CD44 may be important in the development of metastases from clear cell carcinoma of the ovary., (Copyright 1998 Academic Press.)

Objective: Drug resistance represents a complex problem for the treatment of ovarian cancer. This study was undertaken to assess several putative resistance parameters (DRP) in parallel in cancer tissue from newly diagnosed patients with ovarian cancer in order to establish possible correlations to known clinical factors and prognosis., Material and Methods: Tumor and adjacent tumor free ovarian tissue samples from 39 consecutive, untreated female patients with ovarian cancer were obtained and as potential DRPs, the level of glutathione (GSH), the activities of glutathione S-transferase (GST), glutathione-peroxidase (GPx), O6-alkylguanine-DNA alkyltransferase (Atase), and topoisomerase II (TOPO) were assessed biochemically, and P-glycoprotein (Pgp) was assessed by Western blotting., Results: Interindividual variations were high and each patient exhibited an individual profile of resistance factor expression. Levels of GSH were increased with stage (linear trend: P < 0.002), and GST, GPx, and Atase showed a similar tendency. With few exceptions no correlation was found between the DRPs and other prognostic characteristics. All tested DRPs except Pgp showed significantly higher levels/activities in tumor tissues than in the surrounding tumor free tissues (P < 0.05). The tested DRPs were found not to influence response to treatment., Conclusions: It is concluded that elevated DRPs reflect an intrinsic pattern of components of the detoxifying system in the tumor tissue. This pattern differs between patients and may partly explain the difficulty to assess the clinical importance of individual DRPs in order to translate them into recommendations for specific therapies., (Copyright 1998 Academic Press.)

Progress has been made in identifying the molecular changes that occur in ovarian carcinoma; still our understanding of these changes and their interactions remains incomplete. In the present study the authors examined the expression of retinoblastoma protein, a tumor suppressor protein, in a spectrum of ovarian epithelial tumors including cystadenomas, low-malignant-potential tumors, and carcinomas. A heterogeneous pattern of reactivity was observed in all of the cystadenomas, in all of the low-malignant-potential tumors, and in a majority (27/34) of the carcinomas. The remaining carcinomas showed either a complete absence of reactivity or a pattern of altered reactivity characterized by areas of tumor with intact reactivity adjacent to zones of tumor with a complete absence of reactivity. There was no significant association between grade or stage and absent/altered reactivity. We conclude that alterations of retinoblastoma protein expression are uncommon in ovarian carcinoma.

Objective: Heat shock protein 27 (HSP27) is produced in response to pathophysiologic stress in animal cells. The purpose of this study was to determine prospectively whether HSP27 was associated with known prognostic factors as well as survival in patients with epithelial ovarian carcinoma., Methods: Ninety-nine patients with epithelial ovarian carcinoma were studied. Slides were prepared from fresh tissue. Patient records were examined for FIGO stage, grade, histology, level of cytoreduction, and survival., Results: Immunohistochemical staining for HSP27 was not related to histologic grade, level of cytoreduction or histologic subtype. A statistically significant difference in HSP27 staining was found in relation to FIGO stage (P = 0.013). HSP27 staining was found to be an independent predictor of 2-year survival in these patients (P = 0.041)., Conclusion: The level of HSP27 significantly decreases as the FIGO stage increases and is an independent prognostic indicator of survival in patients with epithelial ovarian carcinoma.

Objectives: Inhibins and activins are related gonadal peptides with opposing biologic actions on gonadotropin regulation, cell differentiation, and proliferation. The previous study of activin in ovarian cancer cell lines suggests that activin may promote growth of ovarian cancer. Elevated serum inhibin levels were also found in ovarian cancer patients; however, the source of elevated inhibin is unknown. This study is designed to examine the expression of inhibin and activin subunits as well as activin receptor in primary ovarian epithelial tumors to explore their role in the process of ovarian epithelial tumorigenesis., Methods: The protein and mRNA expression of alpha and betaA subunits of inhibin/activin as well as of activin receptor mRNA were examined with immunohistochemistry (IHC) and reverse transcription-polymerase chain reaction (RT-PCR) in 112 ovarian carcinomas. Cases included 59 serous, 23 endometrioid, 16 mucinous, 9 clear cell, and 5 undifferentiated carcinomas. We also tested normal ovary and benign and borderline ovarian tumors for comparison. These included 17 ovarian surface epithelial samples, 6 serous and 5 mucinous cystadenomas, and 9 serous and 7 mucinous tumors of low malignant potential. A total of 139 ovarian tumors were analyzed by IHC and a total of 63 ovarian tumor samples were tested by RT-PCR., Results: Inhibin alpha subunit expression was found in 47% of ovarian surface epithelia and focal alpha immunoreactivity was seen in tumor stroma, but was not found in the epithelial component of ovarian cystadenomas, tumors of low malignant potential (LMP), or carcinomas. Activin betaA subunit was expressed in 93% of surface epithelia, in the epithelial component of all cystadenomas, in 81% of LMP tumors, and in 72% of carcinomas, but not in tumor stroma. Activin expression did not correlate with histologic grades, tumor types, and surgical stages. Activin receptor type I and II mRNA-amplified products were found in virtually all the surface epithelial samples and ovarian tumors., Conclusions: The data suggest that imbalanced expression of inhibin and activin subunits in ovarian surface epithelium may represent an early event which leads to epithelial proliferation. Unopposed betaA and activin receptor expression in epithelial compartment of ovarian tumors suggest that activin may be available as autocrine and/or paracrine factors in ovarian epithelial tumors. But exact roles of inhibin and activin in ovarian epithelial tumors remain to be defined.

Objective: The perceived function of wild-type p53 is suppression of cell proliferation. An alteration in the p53 tumor suppressor gene is a common defect in human malignancies. The purpose of this study was to prospectively determine whether p53 expression, as quantified by image analysis, was related to traditional prognostic indicators as well as survival in patients epithelial ovarian cancer., Methods: Eighty-three consecutive patients with epithelial ovarian cancer had their p53 expression studied by immunohistochemical staining and quantified by image analysis. Unless otherwise noted, p53 expression was reported as the percentage positive nuclear area staining., Results: The mean follow-up was 37 months (median, 30 months; range 24-55 months). In patients with serous carcinomas of the ovary, the mean p53 expression was 29.4%, whereas in patients with other histologies, the mean was 10.5% (P < 0.001). The tumors of patients with stage III or IV tumors stained significantly higher (mean 28. 7%) than the tumors of patients with stage I or II disease (mean 8. 36%) (P < 0.001). The tumors of patients with disease which could be optimally cytoreduced stained significantly lower (mean 23.0%) than the tumors of patients whose disease was unable to be optimally cytoreduced (mean 28.6%) (P = 0.041). Utilizing survival as the endpoint for multivariate analysis, FIGO stage (P = 0.006), p53 expression (P = 0.046), and the level of cytoreduction (P < 0.001) were independent prognostic indicators., Conclusion: Image analysis allows quantitative measurements of p53 staining. p53 staining is significantly higher in advanced-stage, high-grade tumors which are unable to be cytoreduced than in early-stage, low-grade tumors which can be optimally cytoreduced. p53 expression is an independent prognostic indicator of survival in patients with epithelial ovarian carcinomas., (Copyright 1997 Academic Press.)

The majority of human ovarian cancers originate from the surface epithelial (OSE) cells that surround the ovary. The incidence of OSE cancer is correlated with the number of ovulations that occur during fertile life. OSE cells remain quiescent but undergo rapid mitotic activity after ovulation to repair the wound. This increase in mitotic activity following each ovulation may give rise to mutations that make the OSE susceptible to malignant transformation. Steroidogenesis-inducing protein (SIP), a protein isolated from human follicular fluid obtained from hyperstimulated ovaries, is a potent mitogen for several gonadal cells. To investigate the possibility that SIP may be involved in the proliferation of OSE cells, we have studied its effects on DNA synthesis in seven cell lines derived from OSE carcinomas (HEY, MLS, SKA, OW-1, SAU, NIH:OVCAR-3, and Caov-3). The cells were cultured in serum-free medium in the presence of SIP for 18 hr, followed by incubation with [3H]thymidine for 4 hr. The radioactivity incorporated into the DNA was measured. SIP stimulated DNA synthesis in six of the cell lines. HEY, SKA, MLS, and OVCAR3 were most responsive to SIP. Interactions between SIP and other growth factors and cytokines known to be present in follicular fluid (EGF/TGFalpha, TGFbeta, FGF, IGF-1, IL-1beta, and TNFalpha) were also investigated in HEY and SKA cells. EGF/TGFalpha and IGF-1 potentiated the effects of SIP. TGFbeta had no effect on SIP, and/or EGF/TGFalpha stimulated DNA synthesis. Other growth factors which were tested in this study had no effect on DNA synthesis in SKA cells. Dibutyryl cyclic-AMP blocked the effects of SIP on DNA synthesis. We conclude that SIP is a potent mitogen for OSE cell lines and together with TGFalpha and IGF-1 may be involved in the proliferation of normal OSE cells after ovulation. Since SIP is obtained from the preovulatory follicle, it may represent a link between the number of ovulations and the increased incidence of OSE cancers., (Copyright 1997 Academic Press.)

Objective: The purpose of the study was to investigate the significance of p53 expression for the prognosis in patients with ovarian granulosa cell tumors (GCT)., Methods: The records of 30 patients operated on for GCT at Tampere University Hospital, Finland, were reviewed. The mean age at the time of the diagnosis was 55 years. Twenty-one of the tumors were of FIGO stage I, three were of stage II, three were of stage III, and three were of stage IV. Paraffin-embedded tumor specimens were analyzed by immunohistochemistry for expression of mutated p53 protein and by flow cytometry., Results: Eleven tumors were positive for p53 and 19 were negative. The median crude survival of p53-negative patients was 10 times that of p53-positive ones (210 months vs 21 months, P = 0.037, log-rank test). The association between p53 immunoreactivity and stage was statistically significant (P = 0.026 Pearson chi2 test), while there was no association between p53 expression and DNA ploidy or S-phase fraction., Conclusion: Although the results should be considered as preliminary, expression of mutated p53 in ovarian granulosa cell tumors seems to be associated with unfavorable prognosis., (Copyright 1997 Academic Press.)

The apoptotic index (apoptotic cells/1000 tumor cells, AI) was evaluated in 71 ovarian carcinomas, all surgically resected. Apoptosis was examined by modified terminal deoxynucleotidyltransferase-mediated deoxyuridine triphosphate-biotin nick end-labeling (TUNEL) method in histologic sections. High AI (>/=2.8) significantly correlated with high mitotic index (P = 0.05), high histologic grade of the tumor (P = 0. 018), and short overall survival (P = 0.017). An inverse relationship between AI and bcl-2 protein expression was also observed (P = 0.007). In addition, AI was assessed in 5 ovarian epithelial tumors of borderline malignancy, and all were categorized as low AI (<2.8). No significant correlation was found between AI and other clinicopathologic factors, such as age, clinical stage, lymph node metastasis, tumor size, histology of the tumor, and expression of p53 protein. Multivariate survival analysis showed that only clinical stage (P = 0.0395) and mitotic index (P = 0.0387) had independent prognostic value, whereas AI did not. Our results suggest that counting apoptosis can be useful for predicting the patient survival in ovarian carcinoma, although AI is not an independent prognostic factor. It is also suggested that bcl-2 protein is an important regulator of apoptosis in ovarian carcinoma., (Copyright 1997 Academic Press.)

Objective: Cisplatin- and Taxol-induced apoptosis was studied in four human ovarian cancer cell lines to evaluate apoptosis as a measure of chemosensitivity., Methods: In vitro sensitivities of OVCAR-3, SKOV-3, UL-1, and UL-2 cells to cisplatin or Taxol were determined by the sulforhodamine B assay. Induction of apoptosis was studied by DNA fragmentation following treatment with cisplatin and/or Taxol after 24- and 48-hr exposure. DNA fragmentation was further quantitated by the diphenylamine assay and the proportion of cells in the G1, G2/M, and S phase of the cell cycle was determined by flow cytometry. Presence of the p53 gene product was examined by Western blotting., Results: The four cell lines represent various sensitivities to cisplatin and Taxol (LD50 range for cisplatin, 5-30 microg/ml; Taxol, 30-1000 nM). UL-2 represents a resistant cell line which was 10-30 times resistant to Taxol and 6 times resistant to cisplatin when compared to the others. Demonstration of apoptosis correlated with the sensitivity of the cell lines to both cisplatin and Taxol for OVCAR-3 and UL-2. DNA fragmentation of OVCAR-3 was uniformly present when treated with cisplatin or Taxol, at 24 or 48 hr. UL-2 demonstrated no apoptosis after 24 or 48 hr of treatment with either cisplatin or Taxol. When sequencing experiments were performed with cisplatin and Taxol, DNA fragmentation correlated with the cytotoxicity assays, except in UL-1 cells where no significant difference was observed in different interactions of cisplatin and Taxol. Pretreatment with Taxol generally resulted in enhanced cytotoxicity in a schedule-dependent manner, and increased fragmentation was demonstrated; cisplatin pretreatment consistently resulted in decreased fragmentation. Quantitation of the fragmented DNA correlated with that seen on gel electrophoresis. OVCAR-3 and UL-1 demonstrated the greatest change from baseline at 24 hr (3.8 and 3.7 times baseline, respectively), whereas UL-2 had little change from the baseline following treatment. G1 arrest occurred more readily in OVCAR-3 and SKOV-3 cells. UL-2 cells had very little change in the proportion of cells entering G1 arrest, but had a significant increase in the G2/M proportion. In OVCAR-3, UL-1, and UL-2 cells, we demonstrated the presence of an aberrantly expressed p53 gene product, while no p53 was detected in the SKOV-3 cells., Conclusions: Our findings indicate that the ability to achieve significant cytotoxicity by cisplatin and Taxol may be directly related to the induction of apoptosis; however, cellular and genetic characteristics determine the eventual outcome of these treatments.

The expression of different genes potentially involved in DNA repair and in cell responses to chemotherapy was evaluated in 33 previously untreated ovarian cancer patients. In biopsies of the same patients the expression of repair genes O6-methylguanine DNA methyltransferase (MGMT), 3-methyladenine DNA glycosylase (MAG), ERCC1, MDR-1, DNA topoisomerase I, DNA topoisomerase IIalpha, and glutathione S-transferase-pi (GST-pi) was assessed by Northern blot analysis. No direct statistical correlation was found between the expression of these genes and the response to chemotherapy (mainly platinum-based with or without doxorubicin and cyclophosphamide). Univariate analysis showed a weak negative correlation (P = 0.037) between the expression of ERCC1 and mortality, whereas no statistically significant correlation was found for other parameters. The MDR-1 gene encoding for the P-glycoprotein P-170 was mostly undetectable in these patients (as assessed by Northern blotting), whereas relatively high levels of MAG and MGMT were found in the majority of patients. A statistically significant correlation was found between the expression of DNA topoisomerase I and the expression of either ERCC1 (P = 0.0026) or GST-pi (P = 0.0279).

Ten serous neoplasms of low malignant potential (LMP) resected during pregnancy were found in the files of the University of Texas M. D. Anderson Cancer Center (UTMDACC). Microscopically, all tumors had marked epithelial proliferation with abundant eosinophilic cells, and eight had intraluminal mucin. Multiple areas of microinvasion were found in eight cases. Additional unusual features were found in three cases. One patient presented with a serous LMP tumor in a supraclavicular lymph node. After resection of an ovarian serous LMP tumor, she was treated with chemotherapy and is without evidence of disease after 21 years. One patient had tumor resected at 24 weeks of gestation and at 2 months postpartum. Marked regression of the epithelial proliferation, the number of eosinophilic cells, and the amount of mucin was seen in the second specimen. Another patient had multiple peritoneal nodules at cesarean section, one of which was biopsied and diagnosed as a primary serous LMP of the peritoneum with multiple areas of microinvasion. Two months later a diagnostic laparoscopy was performed and no residual disease was found. All patients are alive with no evidence of disease. In summary, serous LMP tumors during pregnancy have microscopic and clinical features suggesting aggressive behavior; however, these features appear to regress at the termination of the pregnancy.

The epidermal growth factor receptor (EGFR) system has been implicated in the etiology of numerous cancers, including that of ovarian cancer. Elevated levels of EGFR are associated with poor patient prognosis. Moreover, a significant number of ovarian cancers express both the receptor and one of its ligands, suggesting an autocrine mechanism for autonomous tumor growth. Because of the implicated role of the EGFR system in neoplasia, a greater understanding of the factors involved in this system is necessary. We have recently characterized a truncated EGFR-like protein (TEGFR) in human placenta, and we now extend this investigation to ovarian cancer. We report that TEGFR is expressed in ovarian cancer and its level correlates to that of EGFR. Moreover, the level of TEGFR is reduced in metastatic compared to primary tumors. These results suggest that TEGFR may play a role in the EGFR system.

Glutathione, glutathione S-transferases alpha and pi, and aldehyde dehydrogenase are associated with resistance to carboplatin and/or cyclophosphamide in cell lines. Therefore, we examined whether the expression of these factors in ovarian cancer tissue specimens is associated with resistance of the patients to combination chemotherapy with cyclophosphamide/carboplatin. Ovarian cancer tissue specimens were taken intraoperatively from 139 patients and frozen in liquid nitrogen, and the contents of glutathione S-transferases alpha and pi, total glutathione, and aldehyde dehydrogenase activity were determined. No association between the levels of glutathione S-transferases alpha and pi or aldehyde dehydrogenase activity in tumor tissue and the survival time was observed in patients with primary ovarian cancer. Significantly higher levels of aldehyde dehydrogenase were observed in FIGO stage I and II compared to FIGO stage III and IV tumors (P = 0.019, Wilcoxon test, two sided). The median survival time was significantly longer in patients with primary ovarian cancer with a tumor glutathione content of <4.9 microg/mg protein compared to patients with a tumor glutathione content of > or =4.9 microg/mg protein (P = 0.047). However, glutathione was not an independent prognostic factor, but was significantly associated with FIGO stage resulting in higher levels in FIGO stage III and IV tumors than in FIGO stage I and II tumors (P = 0.0094, Wilcoxon test, two sided). In conclusion the glutathione content was associated with progression of ovarian carcinomas but neither glutathione nor glutathione S-transferases alpha and pi or aldehyde dehydrogenase were independent factors of resistance to cyclophosphamide/carboplatin.

Normal ovarian and ovarian cancer tissues from 35 patients were tested for LDH-A-ras protein complex formation, as well as for the expression of ras and LDH-A genes. By immunodetection of the immunoprecipitates, LDH-A-ras protein complexes are present in the homogenates of human ovarian tissues (benign and malignant). Two bands of 21 and 36 kDa were demonstrated in affinity-purified LDH active fractions by Western blot analysis, and these two proteins were proved to be ras p21 and LDH-A by immunodetection. By Northern blot analysis, elevated levels of c-Ki-ras and LDH-A mRNA transcripts were noted in 49% (17/35) and 40% (14/35) of ovarian cancers, respectively. Concurrent high expression of both genes was demonstrated in 11 cases (31%). Tyrosylphosphorylation of LDH-A was demonstrated in normal and malignant ovarian tissues, and the extent of phosphorylation was correlated with the stage of ovarian cancer. The concurrent elevated expression of ras and LDH-A in the same ovarian tissue may imply that the increased synthesis of LDH-A is due to increased or amplified signaling of the ras-cascade pathway. The possible biochemical role of the tyrosylphosphorylated LDH-A complexed with ras p21 in cell transformation and progression of human ovarian cancer is worthy of further investigation.

A 58-year-old postmenopausal woman with primary ovarian serous carcinoma presented with the syndrome of inappropriate antidiuresis (SIAD). Preoperative workup showed serum sodium level of 110 mEq/liter and antidiuretic hormone level of 3.3 pg/ml. The serum and urine osmolarity were 239 and 371, respectively. Antidiuretic hormone was demonstrated in tumor cells by immunohistochemistry. To the best of the authors' knowledge, this represents the first case of SIAD due to primary ovarian tumor.

In an extension of a previous in vitro study [Carreiras et al., Int. J. Cancer 63, 530-536 (1995)] and in an effort to understand the adhesive interactions mediated by integrins within epithelial ovarian tumors, the presence of the alpha v and beta 3 subunits and that of vitronectin (Vn) in ovarian carcinomas at various stages of differentiation and in normal ovarian epithelium were comparatively investigated. The study was performed on material from 34 patients. By immunofluorescence, cryostat sections were analyzed for their expression of alpha v (34 cases), beta 3 (19 cases), and Vn (29 cases). alpha v was expressed in normal epithelium and in highly differentiated tumors as well as in a majority of moderately and poorly differentiated carcinomas with identical staining pattern. beta 3 subunit and Vn were also expressed in normal cases and highly differentiated carcinomas. However, they were lacking in most of the less differentiated tumors. The analysis of cases which were simultaneously tested for the presence of alpha v, beta 3, and Vn revealed that a large proportion of normal ovarian epithelium and highly differentiated tumors simultaneously expressed alpha v, beta 3, and Vn; in contrast, in all moderately and poorly differentiated carcinomas either beta 3 or Vn was absent. The potential role of the alpha v beta 3/Vn system in ovarian epithelium functions is discussed. It is also speculated that modifications of this system in ovarian carcinomas might contribute to tumor progression.

The complete clinical course of a case of ovarian clear cell carcinoma expressing luteinizing hormone (LH)/human chorionic gonadotropin (hCG) receptor arising from endometriosis in a pregnant woman is presented. A 31-year-old woman visited a private clinic in May 1993 for screening tests for infertility. Transvaginal ultrasonography revealed no abnormal findings in the uterus or ovaries. Her menstrual cycle was regular; however, a slight luteal insufficiency was noted. She had been treated with clomiphene, and soon became pregnant. She was diagnosed to be at 5 weeks gestation in June, and at the same time, an ovarian tumor with the diameter of 5 cm was identified. Since the tumor had grown rapidly and was 9 cm in diameter 1 week later, she was referred to our hospital. When she was admitted to our hospital at 9 weeks gestation, the tumor diameter was 14 cm and we found the solid portion within the ovarian tumor. The levels of the tumor markers CA125 and CA19-9 were 106 and 51 U/ml, respectively. The crown-rump length of the fetus (24 mm) was compatible with the gestational age, and fetal heartbeat was confirmed. Under the diagnosis of ovarian carcinoma, right salpingo-oophorectomy was performed at 10 weeks of gestation. Postoperative histological examination revealed a clear cell carcinoma and endometriosis of the right ovary. Immunohistochemically, the clear cell carcinoma stained positively for LH/hCG receptors and estrogen receptors, but not progesterone receptor. No malignant cells were detected by ascitic cytology. Exploratory specimens obtained at the time of operation from the left ovary and pelvic lymph nodes exhibited no malignant cells. Based on these findings, the pregnancy was allowed to proceed, and she delivered a 3010-g male baby at 39 weeks of gestation. She had no signs of recurrence for 2 years after the operation.

The oncogene specific mRNA of c-erbB-2 was detected by the S1 nuclease protection assay in 95 ovarian cancer specimens. In 79 primary carcinomas, we found 16 (20%) with strong expression, 13 (17%) with weak expression, 4 (5%) with very weak expression, and 46 (58%) with no expression. In 3 of 16 recurrencies (19%) a strong expression of c-erbB-2 mRNA was detected, in 2 (12%) weak expression was detected, and in 11 (69%) no expression of c-erbB-2 mRNA was detected. Kaplan-Meier analysis revealed no significant association between strong expression of c-erbB-2 mRNA and survival of the 79 patients with primary cancer. However, in the subgroup of patients with FIGO (International Federation of Gynecology and Obstetrics) stages III and IV (n = 60) a shorter median survival time (12 months) was obtained for patients with strong c-erbB-2 mRNA expression compared to patients with no, very weak, and weak c-erbB-2 mRNA expression (25 months, P = 0.04). In addition, strong expression of c-erbB-2 mRNA did not depend on histologic grade, histologic type, and FIGO stage. Adverse prognostic factors include histologic type (serous carcinoma), high grade, high stage (FIGO stages III and IV), and residual of tumor after surgery. From our results we conclude that for all patients (FIGO stages I-IV) strong expression of c-erbB-2 mRNA is not a prognostic parameter, but in the subpopulation of patients with FIGO stage III and IV only, an association between strong c-erbB-2 mRNA expression and shorter median survival time was found, although statistical significance was weak (P = 0.04).

A 62-year-old female presented with a pelvic mass and ascites. The Papanicolaou vaginal smear showed an unusual maturation, maturation index being 0/80/20. The serum level of estradiol was 48.7 pg/ml. The preoperative checkup suggested a pelvic malignancy with a differential diagnosis of hormone-secreting ovarian tumor. On surgical exploration, she had a hemangioma of the ovary without malignant cytology in the ascitic fluid. Histologically, this tumor was associated with stromal luteinization. This is the first case, reported in the literature, possessing ovarian hemangioma with stromal luteinization accompanying massive ascites. It should be noted that an ovarian hemangioma can be associated with stromal luteinization and ascites, and that MR imaging is sometimes of value for making a preoperative diagnosis of ovarian hemangioma.

Image analysis has rarely been used to quantitate the DNA content of intact cells derived from peritoneal fluid in patients with ovarian malignancy. An average of 118 (range 100-208) of the most atypical, visually selected Feulgen-stained cells in peritoneal fluid obtained from 46 patients undergoing primary cytoreductive surgery for histologically proven ovarian tumors of low malignant potential and truly invasive ovarian cancer were evaluated retrospectively using the SAMBA-4000 Image analysis system. The patients were stratified into 3 groups: 16 with ovarian tumors of low malignant potential (LMP), 14 with low-stage disease (LSD) (FIGO I and II), and 16 with advanced-stage (ASD) (FIGO III and IV). A pattern of high-degree aneuploidy with negative balance (means: LMP, 3.3; LSD, 20.5; ASD, 32.0), increased proliferative index (LMP, 11.2; LSD, 16.1; ASD, 13.9), and percentage of cells with DNA content greater than 5C (LMP, 6.7; LSD, 6.5; ASD, 9.5) was demonstrated in the peritoneal fluid of 8 of 16 patients with LMP (50%), 8 of 14 patients with LSD (57%), and 13 of 16 with ASD (81%). The median disease-free interval for patients with invasive epithelial ovarian cancer with peritoneal DNA diploid tumor cells was 57 months and for those with DNA aneuploid tumor cells 28 months, while in patients with LMP it was 65 and 54 months, respectively. In total, 19 patients developed a recurrence (LMP, 2; LSD, 5; ASD, 12) of which 17 were shown to have DNA aneuploid cells in the peritoneal fluid. Multivariate analysis, however, did not identify aneuploid population in the fluid, ploidy balance, proliferation indices, or degree of hyperploidy as an independently significant variable for predicting recurrence. It did appear, however, that tumor cells in peritoneal fluid with a degree of hyperploidy greater than 8 had a strong correlation for development of recurrence, although not statistically significant. Interactive image analysis of tumor cells in peritoneal fluid proved to be a valuable adjunct to cytodiagnosis. Seven of 28 patients (25%) who were underdiagnosed by cytology alone (LMP, 2; LSD, 3; ASD, 2) were shown to have malignant cells in their peritoneal fluid, while 2 of 18 patients (11%) who were called positive by cytology (LMP, 1; LSD, 1) showed diploid pattern histograms and upon review were interpreted as reactive mesothelial cells.

Purpose: The presence of estrogen receptor (ER) and its therapeutic significance in ovarian borderline tumors (OBT) have not been established. We recently observed a response to tamoxifen therapy given empirically to a patient with unresectable, recurrent serous borderline tumor (SBT). In view of this observation the present study was undertaken to assess ER expression in 51 cases of OBT., Materials and Methods: ER expression was determined retrospectively, using an immunohistochemical method on formalin-fixed, paraffin-embedded specimens, from 35 cases of SBTs, 6 cases of mucinous mullerian (MMBT), and 10 cases of mucinous intestinal borderline tumors (MIBT). ER was considered positive if > 5% of tumor epithelial cell nuclei were immunostained. Both SBTs and mucinous borderline tumors (MBTs) were included to determine the influence of histologic type on ER expression., Results: The patients ranged in age from 25 to 77 years (median 43 years for SBTs, 36 years for MMBTs, and 37 years for MIBTs). The stage distribution for the SBTs was stage I in 27 patients (77%), stage II in 4 patients (11.5%), and stage III in 4 patients (11.5%). All patients with MBTs were stage I. ER expression was observed in the majority of cases and correlated with histologic type: 94% (33/35) of SBTs and 100% (6/6) of MMBTs were ER positive compared to 0% (0/10) of MIBTs (P < 0.01). In the SBT category the presence of ER did not correlate significantly with stage or age. In addition, ER was positive in all four SBT implants (including one involved lymph node) and two recurrent SBTs analyzed., Conclusion: ER expression is a common feature of SBT and MMBT, but not MIBT. The relevance of ER expression in the pathogenesis and treatment of OBTs requires further investigation.

The density and affinity of tamoxifen (TAM) binding sites in isolated plasma membrane fractions from human ovarian tissue and ovarian tumors was measured. TAM binding in both membrane preparations was specific, saturable, and had a high affinity (KD < 1 nM). The density of TAM binding sites in the tumors was at least three times higher than that in the normal ovaries, whereas the affinity of TAM binding sites in the tumors was lower than in normal ovaries. The relatively large number of TAM binding sites that are distinct from estrogen receptors in ovarian tumors suggest that TAM alone and in combination with other chemotherapy could be used with advantage in ovarian cancer.