Adam C. ElNaggar

HO-3867, a Safe STAT3 Inhibitor, Is Selectively Cytotoxic to Ovarian Cancer

STAT3 is well corroborated preclinically as a cancer therapeutic target, but tractable translational strategies for its blockade by small molecule inhibitors have remained elusive. In this study, we report the development of a novel class of bifunctional STAT3 inhibitors, based on conjugation of a diarylidenyl-piperidone (DAP) backbone to an N-hydroxypyrroline (-NOH) group, which exhibits minimal toxicity against normal cells and good oral bioavailability. Molecular modeling studies of this class suggested direct interaction with the STAT3 DNA binding domain. In particular, the DAP compound HO-3867 selectively inhibited STAT3 phosphorylation, transcription, and DNA binding without affecting the expression of other active STATs. HO-3867 exhibited minimal toxicity toward noncancerous cells and tissues but induced apoptosis in ovarian cancer cells. Pharmacologic analysis revealed greater bioabsorption and bioavailability of the active (cytotoxic) metabolites in cancer cells compared with normal cells. The selective cytotoxicity of HO-3867 seemed to be multifaceted, eliciting differential activation of the Akt pathway in normal versus cancer cells. RNAi attenuation experiments confirmed the requirement of STAT3 for HO-3867-mediated apoptosis in ovarian cancer cells. In vivo testing showed that HO-3867 could block xenograft tumor growth without toxic side effects. Furthermore, in primary human ovarian cancer cells isolated from patient ascites, HO-3867 inhibited cell migration/invasion and survival. Our results offer preclinical proof-of-concept for HO-3867 as a selective STAT3 inhibitor to treat ovarian cancer and other solid tumors where STAT3 is widely upregulated.

Perioperative Outcomes for Laparotomy Compared to Robotic Surgical Staging of Endometrial Cancer in the Elderly: A Retrospective Cohort.

Objective This study aimed to compare outcomes of endometrial cancer (EMCA) staging in elderly patients performed either robotically or via laparotomy. Methods A retrospective, multi-institutional chart review was conducted of all robotic and laparotomy staging surgeries for EMCA between 2003 and 2009. Charts were reviewed for intraoperative and postoperative complications and morbidities. Results Seven hundred forty-six women were identified who had undergone EMCA staging either robotically or via laparotomy; 89 and 93 patients 70 years or older underwent staging for EMCA via robotic and laparotomy, respectively. Both groups had similar age and body mass index. Among elderly patients being staged robotically, a higher incidence of pelvic lymphadenectomy, and decreased blood loss, incidence of blood transfusion, and overall complications were seen compared to laparotomy. Postoperatively, elderly patients staged robotically had a shorter median hospital stay (1 vs 4 days, P < 0.001), with no increase in readmission or return to the operating theater. No vessel, bowel, or genitourinary injuries occurred. Vaginal cuff dehiscence after robotic surgery was not significantly different, but wound and fascial complications were significantly increased in patients undergoing laparotomy. Thromboembolism rates were similar between both groups. Conclusions Elderly patients can safely undergo robotic EMCA staging with improved outcomes compared to laparotomy. The benefits of robotic staging include higher incidence of completion of lymphadenectomy, decreased hospital stay (without an increase in readmissions or reoperations), decreased transfusions, and decreased wound and fascial complications.

Anticancer potential of diarylidenyl piperidone derivatives, HO-4200 and H-4318, in cisplatin resistant primary ovarian cancer

ABSTRACT We have previously developed a novel class of bi-functional compounds based on a diarylidenyl-piperidone (DAP) backbone conjugated to an N-hydroxypyrroline (-NOH; a nitroxide precursor) group capable of selectively inhibiting STAT3 activation, translocation, and DNA binding activity. HO-4200 and H-4318 are 2 such derivatives capable of inducing apoptosis in ovarian cancer cells through this mechanism and demonstrated efficacy in platinum resistant primary ovarian cancer cell populations and tumor tissues. The improved absorption and cellular uptake of HO-4200 by cancer cells was determined using optical and electron paramagnetic resonance spectrometry. Treatment of ovarian cancer cells with HO-4200 and H-4318 resulted in cleavage of caspase proteins 3, 7, and 9, as well as PARP and inhibition of the pro-survival protein, Bcl-xL, resulting in significantly decreased cell survival and increased apoptosis. HO-4200 and H-4318 significantly inhibit fatty acid synthase (FAS) and pSTAT3 and decreased the expression of STAT3 target proteins: Survivin, c-myc, Bcl-xl, Bcl-2, cyclin D1/D2, and VEGF were suppressed as analyzed using quantitative real time PCR. In addition, HO-4200 and H-4318 significantly inhibited migration/invasion, in primary ovarian cancer cell populations isolated from primary and recurrent ovarian cancer patients. Treatment of freshly collected human ovarian tumor sections with HO-4200 demonstrated significant suppression of pSTAT3 Tyr 705, angiogenesis (VEFG), and markers of proliferation (Ki-67) in ex vivo models. We have shown, for the first time, that the DAP compounds, HO-4200 and H-4318, inhibit cell migration/invasion and induce apoptosis by targeting FAS/STAT3 in human ovarian cancer cells, including primary ovarian cancer cell populations and tumor tissues. Therefore, our results highlight the clinical anti-cancer potential of HO-4200 and H-4318.

Setting the bar: compliance with ovarian cancer quality indicators at a National Cancer Institute-designated Comprehensive Cancer Center.

OBJECTIVES Ovarian cancer quality measures are being developed to improve health care delivery and outcomes. Our objective is to evaluate compliance with 8 quality indicators proposed by the Society of Gynecologic Oncology. METHODS A review of 123 ovarian cancer patients who underwent primary surgical staging/cytoreduction and chemotherapy from 2010-2012 was undertaken. Medical records were reviewed, and descriptive statistics were performed to determine compliance. RESULTS A timely operative report documenting residual disease was dictated for 121/123 (98.4%) patients. Complete surgical staging was performed in 33/55 (60.0%) stage I-IIIB patients, with lymphadenectomy most frequently omitted. For optimally debulked stage III patients, 52/56 (92.9%) were offered intraperitoneal chemotherapy. Ultimately, 29/56 (51.8%) received this route and 19/56 (33.9%) within 42 days (range 18-48, median 40 days). Clinical trial randomization and co-morbidities accounted for most cases of non-compliance. All 105 patients for whom chemotherapy was indicated received platin/taxane therapy, and 79/105 (75.2%) within 42 days (range 4-82, median 37days). Venous thromboembolism prophylaxis was provided mechanically in 122/123 (99.2%) and pharmacologically in 99/123 (80.5%) patients within 24h of surgery. Prophylactic parenteral antibiotics were administered within 60 min of cytoreduction in 119/123 (96.7%) and discontinued within 24h after surgery in 120/123 (97.6%) cases. CONCLUSIONS Compliance with strict definitions of ovarian cancer quality indicators varies depending on the care delivered and documentation of that care. Increased attention to comprehensive surgical staging and timely initiation of chemotherapy appears warranted. With the move toward value-based payment models, quality indicators will play a significant role in health care delivery.

Addition of Everolimus Post VEGFR Inhibition Treatment Failure in Advanced Sarcoma Patients Who Previously Benefited from VEGFR Inhibition: A Case Series

Background Patients with metastatic sarcoma who progress on vascular endothelial growth factor receptor inhibitors (VEGFRi) have limited treatment options. Upregulation of the mTOR pathway has been demonstrated to be a means of resistance to targeted VEGFRi in metastatic sarcoma. Patients and methods Retrospective cohort study to evaluate the clinical benefit at four months of combining mTOR inhibition (mTORi) via everolimus with VEGFRi in patients who have derived benefit from single-agent VEGFRi but have progressed. Patients with recurrent, metastatic soft tissue or bone sarcomas who progressed after deriving clinical benefit to VEGFRi beyond 12 weeks were continued on VEGFRi with the addition of everolimus (5 mg daily). Progression free survival was measured from start of VEGFRi to disease progression on single agent VEGFRi as well as from the addition of everolimus therapy to disease progression or drug discontinuation due to toxicity. Clinical benefit was defined as stable disease or partial response at 4 months. Results Nine patients were evaluated. Two patients did not tolerate therapy due to GI toxicity and one elected to discontinue therapy. Of the remaining six patients, the clinical benefit rate at four months was 50%. Progression free survival (PFS) for these patients was 3.1 months ranging from 0.5 to 7.2 months with one patient remaining on combination therapy. Conclusion In this heavily pre-treated, advanced sarcoma population, the addition of mTOR inhibition to VEGFRi based therapy resulted in a clinical benefit for a subset of patients. Prospective studies will be needed to verify these results.

Guided outcomes in learned efficiency model in clinical medical education: a randomized controlled trial of self-regulated learning

OBJECTIVE The guided outcomes in learned efficiency (GOLE) model emphasizes the use of evidence-based resources to understand the diagnosis, treatment, follow-up, and prevention of disease. We seek to determine whether presentations created using the GOLE model are superior to an unstructured approach in achieving Accreditation Council for Graduate Medical Education (ACGME) Core Competencies. STUDY DESIGN Consenting medical students were randomized to GOLE or control groups to individually research a self-selected clinical topic. A validated survey instrument was used prepresentation and postpresentation to assess perceived improvement in knowledge. Subjects completed self-evaluations at enrollment and after presentation of their chosen clinical topic. Other students, residents, and a faculty member also completed evaluations after each student presentation. Standard statistical methods (analysis of variance, 2-tailed t test) were used to determine if a statistically significant difference existed between intervention and control groups. RESULTS Self-assessments were similar in the GOLE and control groups. Externally perceived presentation scores were greater in the GOLE group (ACGME global P < .0001, presentation global P = .07), which demonstrated a significant improvement in 5 core competencies. Time spent preparing the presentation and resources utilized did not differ between groups. CONCLUSION The presentations prepared using the GOLE model were rated higher by observers than those prepared using traditional techniques.

Recurrent low grade serous ovarian cancer in a 20 year old woman: A case from the Ohio State University College of Medicine

A 20 year old with recurrent low-grade serous carcinoma (LGSC) is discussed. The differential diagnosis, pathology, epidemiology, treatment options are discussed. Focus on the molecular pathways of LGSC and the implications of the diagnosis on fertility are highlighted.

Incidence and contributing factors to termination of the patient-physician relationship.

Purpose Identify the incidence and factors contributing to the termination of gynecologic patient-physician relationships. Methods All patients terminated from the practice between January 2008 and December 2012 were identified. Charts were reviewed for demographic information, termination reason, and cancer diagnosis. Results In the five year study period, 8851 new patients presented to the division of gynecologic oncology. Within this cohort, 123 patient-physician relationships were terminated. Among terminated patients, missed appointments (63.4%), noncompliance to treatment (23.6%), disruptive behavior (10.6%), and drug abuse behavior (2.4%) were the key reasons for termination. While no patients were terminated for financial reason, statistical differences were found for those with Medicaid insurance (OR = 5; 95% CI: 3.4–7.1). Terminated patients were more likely to be younger, African American/Black, and have a diagnosis of GTD or cancer, particularly cervical cancer, when compared against all retained patients. Conclusion The prevalence of patient-physician relationship termination was low at 1.4% (123/8851). However, the finding that the 52% of terminated patients had a diagnosis of cancer is concerning; 73% of which had stage III or greater disease, or were unstaged. We hope that the identification and quantification of reasons for termination and those at risk for termination, as well as the introduction of patient-navigators, will lead to improved methods to ensure patient compliance and retention.

Abstract LB-036: Elevated STAT3 expression in ovarian tumor ascites regulates invasion and metastasis: a promising therapeutic target

Objectives: Although, the ovarian cancer patient ascites is a recognized source of metastasis, the expression of oncogenic proteins in ascites and their effects on the tumor metastatic microenvironment still remain poorly understood. In this study, we investigate the role of STAT3 in primary ovarian cancer ascites and STAT3 as a potential target for ovarian tumor therapy in a preclinical animal model using our novel and safe STAT3 inhibitor of HO-3867. Methods: We start with culturing the primary cancer cell lines from various human ascites and confirming the status of STAT3 signaling. The exact role that STAT3 plays in ovarian cancer was addressed using STAT3 knocked down and STAT3 overexpression cell lines. These were further used to develop an orthotopic mouse model of ovarian cancer. In vivo antitumor activity of STAT3 inhibitor of HO-3867 assessment was done by oral administration of HO-3867 in orthotopic tumor mice. using histopathological analysis, RPPA, TUNEL and angiogenesis assays. In vivo bio-absorption of HO-3867 compounds in tumors by EPR and LCMS analysis. Results: We have found that pSTAT3 Tyr705 is constitutively expressed in the patient ascites derived cancer cells (ADCCs) and the range of expression could be very high to low. Subsequent in vivo transplantation of ADCCs with higher pSTAT3 expression injected into mice resulted in a large primary tumor and widespread metastases; while the mice with cells with STAT3 Knocked out had a smaller tumor and no metastases. We further demonstrate that the cytokines secreted into the culture medium can activate the JAK/STAT pathway in the STAT3 Ko cells thereby making up for the absence of inherent STAT3 in the cells. Once we proved the importance of STAT3 in ovarian cancer progression and metastases, we moved on to targeting STAT3 using our novel STAT3 inhibitor and pre-clinical orthotopic tumor model. Treatment with HO-3867 (100 ppm) significantly suppressed ovarian tumor growth and metastasis. A substantial amount of HO-3867 was detected in the ovarian tumor tissues. Suppression of STAT3 and its downstream target proteins were confirmed with reverse phase protein array. In vivo Matrigel assay showed that HO-3867 treated samples had significantly reduced vessel formation (∼4 times) when compared to untreated control. HO-3867 was also found to have cytotoxic effects in ex vivo culture of freshly collected human tumor samples, including patients with chemotherapy-resistant disease. Conclusions: Our study has concluded that constitutive expression of STAT3 in patient ascites is a significant contributor in ovarian tumor invasion and metastasis. STAT3-selective targeting agent HO-3867 in orthotopic ovarian tumor and ex vivo tumor tissue culture, results in inhibition of tumor growth and induction of apoptosis both in vivo and ex vivo, suggesting that HO-3867 is an exciting new cytotoxic agent acting through targeting STAT3; which could have a considerable role in the future treatment of ovarian cancer. Citation Format: Uksha Saini, Shan Naidu, Adam C. ElNaggar, Hemant K. Bid, John Wallbillich, Ross Wanner, Kristin Bixel, Maria Riley, Chelsea Bolyard, Adrian A. Suarez, Balveen Kaur, Periannan Kuppusamy, John Hays, Paul Goodfellow, David E. Cohn, Karuppaiyah Selvendiran. Elevated STAT3 expression in ovarian tumor ascites regulates invasion and metastasis: a promising therapeutic target. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-036.

Abstract POSTER-THER-1413: Targeting constitutively-activated STAT3 in hypoxic ovarian cancer

Abstracts: 10th Biennial Ovarian Cancer Research Symposium; September 8-9, 2014; Seattle, WA Background: Tumor hypoxia, a feature of many solid tumors including ovarian cancer, is associated with resistance to therapies. We previously demonstrated that hypoxic exposure results in increased expression of phosphorylated signal transducer and activator of transcription 3 (pSTAT3). We hypothesized that the activation of STAT3 could lead to chemotherapeutic resistance in ovarian cancer cells in hypoxic conditions. Methods: The increase of pSTAT3 Tyr705 in the hypoxic regions of human epithelial ovarian cancer (EOC) specimens was determined by HIF-1α and CD-31 staining. In vitro mutagenesis studies of pSTAT3 Tyr705 were used to demonstrate the necessity for cell survival and proliferation under hypoxic conditions. In addition, S1PR1, a regulator of STAT3 transcription via the JAK/STAT pathway, is highly expressed in hypoxic ovarian cancer cells (HOCCs). This association was evaluated with knock down of S1PR1 in HOCCs. HOCCs were treated with our novel STAT3 inhibitor, HO-3867. Results: pSTAT3 Tyr705 is increased in the hypoxic regions of EOC specimens. In vitro mutagenesis studies proved that pSTAT3 Tyr705 is necessary for cell survival and proliferation under hypoxic conditions. Knock down of S1PR1 in HOCCs reduced pSTAT3 Tyr705 levels and was associated with decreased cell survival. Treatment of HOCCs with the STAT3 inhibitor HO-3867 resulted in a rapid and dramatic decrease in pSTAT3 Tyr705 levels as a result of ubiquitin proteasome degradation. There was decreased expression of the STAT3-target proteins Bcl-xL, cyclin D2, and VEGF in all HO-3867 treated cells. Conclusions: These findings suggest that activation of STAT3 Tyr705 promotes cell survival and proliferation in HOCCs, and that S1PR1 is involved in the initiation of STAT3 activation. Therefore, targeting hypoxia-mediated STAT3 activation represents a therapeutic option for ovarian cancer and other solid tumors. Citation Format: Georgia A McCann, MD, Adam ElNaggar, MD, Shan Naidu, MS; Kellie S Rath, MD; Brent J Tierney, MD; Adrian Suarez, MD; David E Cohn, MD; Karuppaiyah Selvendiran, PhD. Targeting constitutively-activated STAT3 in hypoxic ovarian cancer [abstract]. In: Proceedings of the 10th Biennial Ovarian Cancer Research Symposium; Sep 8-9, 2014; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2015;21(16 Suppl):Abstract nr POSTER-THER-1413.