Shannon MacLaughlan

Current state of biomarker development for clinical application in epithelial ovarian cancer

Each year in the United States over 15,000 women die of epithelial ovarian cancer (EOC) and 22,000 are diagnosed with the disease. The incidence of ovarian cancer has remained stable over the past decade however, survival rates have improved steadily. Increases in survival rates can be attributed to the advances in surgical management, development of effective cytotoxic drugs and the route of administration of chemotherapy. Ovarian cancer survival rates could also be improved through screening and early detection. Disappointingly, effective screening methods have not been established and continue to be elusive. Historically the goal of a screening test was to achieve a positive predictive value (PPV) greater than 10% in order be considered cost effective and have an acceptable risk for the population being screened. Despite the inability of currently available screening algorithms to achieve the desired PPV there may be an advantage in producing a stage migration to lower stages at the time of diagnoses, thereby resulting in improved survival. Equally important recent studies have demonstrated that women who have their initial surgery performed by gynecologic oncologists, and women who have their surgeries at centers experienced in the treatment of ovarian cancer have higher survival rates. For these reasons it is essential that all women at high risk for ovarian cancer receive their initial care by gynecologic oncologists and at centers with multidisciplinary teams experienced in the optimal care of ovarian cancer patients. With this in mind, methods that facilitate the accurate triage of women who will ultimately be diagnosed with ovarian cancer could play a significant role in improving survival rates for these patients. This review article will examine the current state of biomarker use in ovarian cancer screening, risk assessment and for monitoring ovarian cancer patients.

Identification of Ovarian Cancer Metastatic miRNAs

Serous epithelial ovarian cancer (EOC) patients often succumb to aggressive metastatic disease, yet little is known about the behavior and genetics of ovarian cancer metastasis. Here, we aim to understand how omental metastases differ from primary tumors and how these differences may influence chemotherapy. We analyzed the miRNA expression profiles of primary EOC tumors and their respective omental metastases from 9 patients using miRNA Taqman qPCR arrays. We find 17 miRNAs with differential expression in omental lesions compared to primary tumors. miR-21, miR-150, and miR-146a have low expression in most primary tumors with significantly increased expression in omental lesions, with concomitant decreased expression of predicted mRNA targets based on mRNA expression. We find that miR-150 and miR-146a mediate spheroid size. Both miR-146a and miR-150 increase the number of residual surviving cells by 2–4 fold when challenged with lethal cisplatin concentrations. These observations suggest that at least two of the miRNAs, miR-146a and miR-150, up-regulated in omental lesions, stimulate survival and increase drug tolerance. Our observations suggest that cancer cells in omental tumors express key miRNAs differently than primary tumors, and that at least some of these microRNAs may be critical regulators of the emergence of drug resistant disease.

Current clinical use of biomarkers for epithelial ovarian cancer.

Purpose of review The majority of women diagnosed with epithelial ovarian cancer (EOC) will be diagnosed with advanced stage disease, a stage that is fundamentally incurable. Survival rates for this deadly disease have improved over the last 25 years secondarily to the advances in surgery and chemotherapeutics. Effective screening protocols are not currently available, and risk assessment protocols for the presence of EOC in women with an ovarian cyst need improvement. Earlier diagnosis may result in stage migration and decreased morbidity for women diagnosed with EOC. Better risk assessment will allow the triage of women to centers of excellence in the treatment and management of ovarian cancer with improved outcomes and survival rates. This review will focus on new biomarkers and algorithms for screening and risk assessment for ovarian cancer. Recent findings The use of multiple biomarkers and statistical algorithms has been shown to be an accurate method for assessing the risk of ovarian cancer in women with ovarian cysts/masses preoperatively. Newer algorithms employing biomarkers to trigger ultrasound imaging for screening also show promise. The addition of novel biomarkers such as human epididymis protein 4 to the use of CA125 improves the sensitivity and specificity over that of either biomarker alone for the management of EOC. Summary For more than 25 years CA125 has been the main biomarker for the management of women with EOC. Recently, novel biomarkers have become available clinically that improve upon the use of CA125 for the risk assessment and management of women with ovarian cancer.

HE4 (WFDC2) gene overexpression promotes ovarian tumor growth

Selective overexpression of Human epididymal secretory protein E4 (HE4) points to a role in ovarian cancer tumorigenesis but little is known about the role the HE4 gene or the gene product plays. Here we show that elevated HE4 serum levels correlate with chemoresistance and decreased survival rates in EOC patients. HE4 overexpression promoted xenograft tumor growth and chemoresistance against cisplatin in an animal model resulting in reduced survival rates. HE4 displayed responses to tumor microenvironment constituents and presented increased expression as well as nuclear translocation upon EGF, VEGF and Insulin treatment and nucleolar localization with Insulin treatment. HE4 interacts with EGFR, IGF1R, and transcription factor HIF1α. Constructs of antisense phosphorothio-oligonucleotides targeting HE4 arrested tumor growth in nude mice. Collectively these findings implicate increased HE4 expression as a molecular factor in ovarian cancer tumorigenesis. Selective targeting directed towards the HE4 protein demonstrates therapeutic benefits for the treatment of ovarian cancer.

Expression profiling of primary and metastatic ovarian tumors reveals differences indicative of aggressive disease.

The behavior and genetics of serous epithelial ovarian cancer (EOC) metastasis, the form of the disease lethal to patients, is poorly understood. The unique properties of metastases are critical to understand to improve treatments of the disease that remains in patients after debulking surgery. We sought to identify the genetic and phenotypic landscape of metastatic progression of EOC to understand how metastases compare to primary tumors. DNA copy number and mRNA expression differences between matched primary human tumors and omental metastases, collected at the same time during debulking surgery before chemotherapy, were measured using microarrays. qPCR and immunohistochemistry validated findings. Pathway analysis of mRNA expression revealed metastatic cancer cells are more proliferative and less apoptotic than primary tumors, perhaps explaining the aggressive nature of these lesions. Most cases had copy number aberrations (CNAs) that differed between primary and metastatic tumors, but we did not detect CNAs that are recurrent across cases. A six gene expression signature distinguishes primary from metastatic tumors and predicts overall survival in independent datasets. The genetic differences between primary and metastatic tumors, yet common expression changes, suggest that the major clone in metastases is not the same as in primary tumors, but the cancer cells adapt to the omentum similarly. Together, these data highlight how ovarian tumors develop into a distinct, more aggressive metastatic state that should be considered for therapy development.

PT19c, Another Nonhypercalcemic Vitamin D2 Derivative, Demonstrates Antitumor Efficacy in Epithelial Ovarian and Endometrial Cancer Models

Hypercalcemia remains a major impediment to the clinical use of vitamin D in cancer treatment. Approaches to remove hypercalcemia and development of nonhypercalcemic agents can lead to the development of vitamin D-based therapies for treatment of various cancers. In this report, in vitro and in vivo anticancer efficacy, safety, and details of vitamin D receptor (VDR) interactions of PT19c, a novel nonhypercalcemic vitamin D derived anticancer agent, are described. PT19c was synthesized by bromoacetylation of PTAD-ergocalciferol adduct. Broader growth inhibitory potential of PT19c was evaluated in a panel of chemoresistant breast, renal, ovarian, lung, colon, leukemia, prostate, melanoma, and central nervous system cancers cell line types of NCI60 cell line panel. Interactions of PT19c with VDR were determined by a VDR transactivation assay in a VDR overexpressing VDR-UAS-bla-HEK293 cells, in vitro VDR-coregulator binding, and molecular docking with VDR-ligand binding domain (VDR-LBD) in comparison with calcitriol. Acute toxicity of PT19c was determined in nontumored mice. In vivo antitumor efficacy of PT19c was determined via ovarian and endometrial cancer xenograft experiments. Effect of PT19c on actin filament organization and focal adhesion formation was examined by microscopy. PT19c treatment inhibited growth of chemoresistant NCI60 cell lines (log10GI50 ~ -4.05 to -6.73). PT19c (10 mg/kg, 35 days) reduced growth of ovarian and endometrial xenograft tumor without hypercalcemia. PT19c exerted no acute toxicity up to 400 mg/kg (QDx1) in animals. PT19c showed weak VDR antagonism, lack of VDR binding, and inverted spatial accommodation in VDR-LBD. PT19c caused actin filament dysfunction and inhibited focal adhesion in SKOV-3 cells. PT19c is a VDR independent nonhypercalcemic vitamin D-derived agent that showed noteworthy safety and efficacy in ovarian and endometrial cancer animal models and inhibited actin organization and focal adhesion in ovarian cancer cells.

Correction: Identification of Ovarian Cancer Metastatic miRNAs

Lauren Comisar was erroneously omitted from the author list. Her affiliation is: Department of Molecular Biology, Cell Biology, and Biochemistry, Brown University. The updated author list is: Souriya Vang, Hsin-Ta Wu, Andrew Fischer, Daniel H. Miller, Shannon MacLaughlan, Elijah Douglass, Lauren Comisar, Margaret Steinhoff, Colin Collins,Peter J. S. Smith, Laurent Brard, Alexander S. Brodsky The updated author contributions are: Pathology and tissue analysis: MS. Funding and intellectual support: CC PJS. Conceived and designed the experiments: ASB LB. Performed the experiments: SV AF DHM ED LC. Analyzed the data: HTW ASB. Contributed reagents/materials/analysis tools: SM. Wrote the paper: ASB.

Necrotizing infection of the breast after core needle biopsy.

An 80-year-old white female was transferred to our Emergency Room from an outside hospital where she presented complaining of left breast swelling and spreading redness 4 days after undergoing a core needle biopsy. The patient had been diagnosed with endometrial adenocarcinoma during a recent hospitalization for postmenopausal vaginal bleeding. During this hospitalization, the patient was also found to have a left-sided breast mass that had been present for several years. An ultrasound of the breast was performed that revealed a complex appearing breast mass (Fig. 1). Upon discharge, the patient underwent further workup with a CT scan of the chest, abdomen and pelvis that showed multiple nodules within the lung (Fig. 2). She also had lesions in several vertebral bodies as well as two densities seen in the liver; all of which was consistent with metastatic disease. Because of these findings and the unclear primary source, the patient underwent a fine needle aspiration of the left breast mass. Unfortunately, the biopsy yielded only fluid with no evidence of malignancy. Subsequently, the patient underwent a core needle biopsy at an outside institution that revealed invasive ductal carcinoma. On admission, the patient had signs of sepsis including tachypnea, leukocytosis with bandemia, and laboratory values consistent with end-organ damage. The left breast was swollen and cool to the touch. There was skin desquamation and blistering Figure 1. Ultrasound showing features of a complex appearing breast mass.

Evaluation and Management of Women Presenting with a Pelvic Mass

Management of women with a pelvic mass is a very common scenario for gynecologists. Often these are benign masses that can either be observed or managed with straightforward laparoscopic surgery, but complex, potentially malignant masses require careful consideration and triaging for appropriate care. This article aims to outline the presentation, management, and triage guidelines for women presenting with an ovarian cyst or pelvic mass. We discuss data surrounding the use of triage guidelines, as well as the role of promising biomarkers that can assist in better predicting benign versus malignant pathology.