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Mysona DP, Purohit S, Richardson KP, Suhner J, Brzezinska B, Rungruang B, Hopkins D, Bearden G, Higgins R, Johnson M, Bin Satter K, McIndoe R, Ghamande S. Ovarian recurrence risk assessment using machine learning, clinical information, and serum protein levels to predict survival in high grade ovarian cancer. Sci Rep 2023; 13:20933. [PMID: 38016985 PMCID: PMC10684567 DOI: 10.1038/s41598-023-47983-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023] Open
Abstract
In ovarian cancer, there is no current method to accurately predict recurrence after a complete response to chemotherapy. Here, we develop a machine learning risk score using serum proteomics for the prediction of early recurrence of ovarian cancer after initial treatment. The developed risk score was validated in an independent cohort with serum collected prospectively during the remission period. In the discovery cohort, patients scored as low-risk had a median time to recurrence (TTR) that was not reached at 10 years compared to 10.5 months (HR 4.66, p < 0.001) in high-risk patients. In the validation cohort, low-risk patients had a median TTR which was not reached compared to 4.7 months in high-risk patients (HR 4.67, p = 0.009). In advanced-stage patients with a CA125 < 10, low-risk patients had a median TTR of 68 months compared to 6 months in high-risk patients (HR 2.91, p = 0.02). The developed risk score was capable of distinguishing the duration of remission in ovarian cancer patients. This score may help guide maintenance therapy and develop innovative treatments in patients at risk at high-risk of recurrence.
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Affiliation(s)
- David P Mysona
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA.
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA.
| | - Sharad Purohit
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
- Department of Undergraduate Health Professionals, College of Allied Health Sciences, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Katherine P Richardson
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Jessa Suhner
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Bogna Brzezinska
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Bunja Rungruang
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Diane Hopkins
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Gregory Bearden
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Robert Higgins
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Marian Johnson
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Khaled Bin Satter
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Richard McIndoe
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Sharad Ghamande
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
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Targeting receptor tyrosine kinases in ovarian cancer: Genomic dysregulation, clinical evaluation of inhibitors, and potential for combinatorial therapies. Mol Ther Oncolytics 2023; 28:293-306. [PMID: 36911068 PMCID: PMC9999170 DOI: 10.1016/j.omto.2023.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Epithelial ovarian cancer (EOC) remains one of the leading causes of cancer-related deaths among women worldwide. Receptor tyrosine kinases (RTKs) have long been sought as therapeutic targets for EOC, as they are frequently hyperactivated in primary tumors and drive disease relapse, progression, and metastasis. More recently, these oncogenic drivers have been implicated in EOC response to poly(ADP-ribose) polymerase (PARP) inhibitors and epigenome-interfering agents. This evidence revives RTKs as promising targets for therapeutic intervention of EOC. This review summarizes recent studies on the role of RTKs in EOC malignancy and the use of their inhibitors for clinical treatment. Our focus is on the ERBB family, c-Met, and VEGFR, as they are linked to drug resistance and targetable using commercially available drugs. The importance of these RTKs and their inhibitors is highlighted by their impact on signal transduction and intratumoral heterogeneity in EOC and successful use as maintenance therapy in the clinic through suppression of the VEGF/VEGFR axis. Finally, the therapeutic potential of RTK inhibitors is discussed in the context of combinatorial targeting via co-inhibiting proliferative and anti-apoptotic pathways, epigenomic/transcriptional programs, and harnessing the efficacy of PARP inhibitors and programmed cell death 1/ligand 1 immune checkpoint therapies.
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Functional Analysis of Non-Genetic Resistance to Platinum in Epithelial Ovarian Cancer Reveals a Role for the MBD3-NuRD Complex in Resistance Development. Cancers (Basel) 2021; 13:cancers13153801. [PMID: 34359703 PMCID: PMC8345099 DOI: 10.3390/cancers13153801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/15/2021] [Accepted: 07/23/2021] [Indexed: 01/04/2023] Open
Abstract
Simple Summary Most epithelial ovarian cancer (EOC) patients, although initially responsive to standard treatment with platinum-based chemotherapy, develop platinum resistance over the clinical course and succumb due to drug-resistant metastases. It has long been hypothesized that resistance to platinum develops as a result of epigenetic changes within tumor cells evolving over time. In this study, we investigated epigenomic changes in EOC patient samples, as well as in cell lines, and showed that profound changes at enhancers result in a platinum-resistant phenotype. Through correlation of the epigenomic alterations with changes in the transcriptome, we could identify potential novel prognostic biomarkers for early patient stratification. Furthermore, we applied a combinatorial RNAi screening approach to identify suitable targets that prevent the enhancer remodeling process. Our results advance the molecular understanding of epigenetic mechanisms in EOC and therapy resistance, which will be essential for the further exploration of epigenetic drug targets and combinatorial treatment regimes. Abstract Epithelial ovarian cancer (EOC) is the most lethal disease of the female reproductive tract, and although most patients respond to the initial treatment with platinum (cPt)-based compounds, relapse is very common. We investigated the role of epigenetic changes in cPt-sensitive and -resistant EOC cell lines and found distinct differences in their enhancer landscape. Clinical data revealed that two genes (JAK1 and FGF10), which gained large enhancer clusters in resistant EOC cell lines, could provide novel biomarkers for early patient stratification with statistical independence for JAK1. To modulate the enhancer remodeling process and prevent the acquisition of cPt resistance in EOC cells, we performed a chromatin-focused RNAi screen in the presence of cPt. We identified subunits of the Nucleosome Remodeling and Deacetylase (NuRD) complex as critical factors sensitizing the EOC cell line A2780 to platinum treatment. Suppression of the Methyl-CpG Binding Domain Protein 3 (MBD3) sensitized cells and prevented the establishment of resistance under prolonged cPt exposure through alterations of H3K27ac at enhancer regions, which are differentially regulated in cPt-resistant cells, leading to a less aggressive phenotype. Our work establishes JAK1 as an independent prognostic marker and the NuRD complex as a potential target for combinational therapy.
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Bhatt A, de Hingh I, Van Der Speeten K, Hubner M, Deraco M, Bakrin N, Villeneuve L, Kusamura S, Glehen O. HIPEC Methodology and Regimens: The Need for an Expert Consensus. Ann Surg Oncol 2021; 28:9098-9113. [PMID: 34142293 DOI: 10.1245/s10434-021-10193-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hyperthermic intraperitoneal chemotherapy (HIPEC) is performed with a wide variation in methodology, drugs, and other elements vital to the procedure. Adoption of a limited number of regimens could increase the collective experience of peritoneal oncologists, make comparison between studies more meaningful, and lead to a greater acceptance of results from randomized trials. This study aimed to determine the possibility of standardizing HIPEC methodology and regimens and to identify the best method of performing such a standardization. METHODS A critical review of preclinical and clinical studies evaluating the pharmacokinetic aspects of different HIPEC drugs and drug regimens, the impact of hyperthermia, and the efficacy of various HIPEC regimens as well as studies comparing different regimens was performed. RESULTS The preclinical and clinical data were limited, and studies comparing different regimens were scarce. Many of the regimens were neither supported by preclinical rationale or data nor validated by a dose-escalating formal phase 1 trial. All the regimens were based on pharmacokinetic data and did not take chemosensitivity of peritoneal metastases into account. Personalized medicine approaches such as patient-derived tumor organoids could offer a solution to this problem, although clinical validation is likely to be challenging. CONCLUSIONS Apart from randomized trials, more translational research and phases 1 and 2 studies are needed. While waiting for better preclinical and clinical evidence, the best way to minimize heterogeneity is by an expert consensus that aims to identify and define a limited number of regimens for each indication and primary site. The choice of regimen then can be tailored to the patient profile and its expected toxicity and the methodology according regional factors.
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Affiliation(s)
- Aditi Bhatt
- Department of Surgical Oncology, Zydus Hospital, Ahmedabad, India
| | - Ignace de Hingh
- Department of Surgical Oncology, Catharina Hospital, Eidhoven, The Netherlands
| | | | - Martin Hubner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Marcello Deraco
- Department of Surgical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Naoual Bakrin
- Department of Surgical Oncology, Centre Hospitalier Lyon-sud, Lyon, France
| | - Laurent Villeneuve
- Department of Clinical Research, Hospices Civils de Lyon, Centre Hospitalier Lyon-sud, Lyon, France
| | - Shigeki Kusamura
- Department of Surgical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Olivier Glehen
- Department of Surgical Oncology, Centre Hospitalier Lyon-sud, Lyon, France.
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Immune-Checkpoint Inhibitors in Platinum-Resistant Ovarian Cancer. Cancers (Basel) 2021; 13:cancers13071663. [PMID: 33916221 PMCID: PMC8037571 DOI: 10.3390/cancers13071663] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 12/24/2022] Open
Abstract
Platinum-resistant ovarian cancer (OC) has limited treatment options and is associated with a poor prognosis. There appears to be an overlap between molecular mechanisms responsible for platinum resistance and immunogenicity in OC. Immunotherapy with single agent checkpoint inhibitors has been evaluated in a few clinical trials with disappointing results. This has prompted exploration of immunotherapy combination strategies with chemotherapy, anti-angiogenics, poly (ADP-ribose) polymerase (PARP) inhibitors and other targeted agents. The role of immunotherapy in the treatment of platinum-resistant OC remains undefined. The aim of this review is to describe the immunobiology of OC and likely benefit from immunotherapy, discuss clinical trial data and biomarkers that warrant further exploration, as well as provide an overview of future drug development strategies.
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Saki S, Ali NR, Saki SS, AlRabeea ZS, AlRemeithi FN, Carrick FR, Abdulrahman M. Barriers to healthcare seeking, beliefs about ovarian cancer and the role of socio-economic position. A cross-sectional multilevel study in Dubai, a multicultural society. J Public Health Res 2021; 10. [PMID: 33759446 PMCID: PMC8419630 DOI: 10.4081/jphr.2021.2073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 03/15/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Studies have shown that public awareness of ovarian cancer is weak, and women are often diagnosed at late stages when treatment is difficult. This study aimed to determine the barriers for seeking early medical care and level of knowledge and awareness among women regarding ovarian cancer. Design and methods: A structured questionnaire was designed and adapted from the validated cancer awareness measure. Results: The recognition level of ovarian cancer symptoms among women in this study varied from 12-51%, and the most alarming ones, back pain, eating difficulties, and persistent abdominal pain, were missed by most of the surveyed women. The most recognized ovarian cancer risk factors were never being pregnant, having a history of infertility, and going through menopause, while the least recognized was having personal or family history of breast cancer. Non-UAE nationals women with higher educational levels had better knowledge of ovarian cancer compared to their peers. Conclusions:A change or implementation model is highly recommended in order to improve women’s awareness of ovarian cancer symptoms. Strengthening education among women with regards to risk factors, early symptoms, and the need to seek early medical help should help to increase ovarian cancer awareness and reduce a delay in the diagnosis. Significance for public health In the absence of effective screening, "appropriate clinical suspicion" of the signs and symptoms of the ovarian cancer is currently the best strategy to detect the disease. To reduce the diagnostic interval, several countries have implemented referral guidelines and organizational changes. Most of these guidelines suggest that individuals presenting with symptoms indicative of cancer (alarm symptoms) should be urgently referred to specialized investigative trajectories. However, many studies worldwide have shown that public awareness levels of ovarian cancer are poor, therefore women are often diagnosed at late stages when treatment is difficult. Our findings demonstrate that the overall level of recognition of risk factors and symptoms of ovarian cancer among women in the UAE is indeed low and within a critical level. Thus, strengthening education among women with regards to risk factors, early symptoms, and the need to seek early medical will be helpful in increasing ovarian cancer awareness and reducing the delay in diagnosis.
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Affiliation(s)
- Sallam Saki
- Department of Public Health, Dubai Medical College, Dubai.
| | - Noor Radhi Ali
- Department of Public Health, Dubai Medical College, Dubai.
| | - Safa Sofi Saki
- Department of Public Health, Dubai Medical College, Dubai.
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FOXM1 Inhibition in Ovarian Cancer Tissue Cultures Affects Individual Treatment Susceptibility Ex Vivo. Cancers (Basel) 2021; 13:cancers13050956. [PMID: 33668819 PMCID: PMC7956612 DOI: 10.3390/cancers13050956] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/03/2021] [Accepted: 02/22/2021] [Indexed: 12/16/2022] Open
Abstract
Simple Summary Late diagnosis of ovarian cancer is a major reason for the high mortality rate of this tumor entity. The time to determine tumor susceptibility to treatment is scarce and resistance to therapy occurs very frequently. Here, we aim for a model system that can determine tumor response to (I) study novel drugs and (II) enhance patient stratification. Tissue specimens (n = 10) were acquired from fresh surgical samples. Tissue cultures were cultivated and treated with clinically relevant therapeutics and an FOXM1 inhibitor for 3–6 days. The transcription factor FOXM1 is a key regulator of tumor survival affecting multiple cancerogenic target genes. Gene expression of FOXM1 and its targets BRCA1/2 and RAD51 were investigated together with tumor susceptibility. Tissue cultures successfully demonstrated the individual benefit of FOXM1 inhibition and revealed the potency of the complex model system for oncological research. Abstract Diagnosis in an advanced state is a major hallmark of ovarian cancer and recurrence after first line treatment is common. With upcoming novel therapies, tumor markers that support patient stratification are urgently needed to prevent ineffective therapy. Therefore, the transcription factor FOXM1 is a promising target in ovarian cancer as it is frequently overexpressed and associated with poor prognosis. In this study, fresh tissue specimens of 10 ovarian cancers were collected to investigate tissue cultures in their ability to predict individual treatment susceptibility and to identify the benefit of FOXM1 inhibition. FOXM1 inhibition was induced by thiostrepton (3 µM). Carboplatin (0.2, 2 and 20 µM) and olaparib (10 µM) were applied and tumor susceptibility was analyzed by tumor cell proliferation and apoptosis in immunofluorescence microscopy. Resistance mechanisms were investigated by determining the gene expression of FOXM1 and its targets BRCA1/2 and RAD51. Ovarian cancer tissue was successfully maintained for up to 14 days ex vivo, preserving morphological characteristics of the native specimen. Thiostrepton downregulated FOXM1 expression in tissue culture. Individual responses were observed after combined treatment with carboplatin or olaparib. Thus, we successfully implemented a complex tissue culture model to ovarian cancer and showed potential benefit of combined FOXM1 inhibition.
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Colombo N, Oza AM, Lorusso D, Aghajanian C, Oaknin A, Dean A, Weberpals JI, Clamp AR, Scambia G, Leary A, Holloway RW, Gancedo MA, Fong PC, Goh JC, O'Malley DM, Armstrong DK, Banerjee S, García-Donas J, Swisher EM, Meunier J, Cameron T, Maloney L, Goble S, Bedel J, Ledermann JA, Coleman RL. The effect of age on efficacy, safety and patient-centered outcomes with rucaparib: A post hoc exploratory analysis of ARIEL3, a phase 3, randomized, maintenance study in patients with recurrent ovarian carcinoma. Gynecol Oncol 2020; 159:101-111. [PMID: 32861537 PMCID: PMC8450972 DOI: 10.1016/j.ygyno.2020.05.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/26/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND In the phase 3 trial ARIEL3, maintenance treatment with the poly(ADP-ribose) polymerase (PARP) inhibitor rucaparib provided clinical benefit versus placebo for patients with recurrent, platinum-sensitive ovarian cancer. Here, we evaluate the impact of age on the clinical utility of rucaparib in ARIEL3. METHODS Patients with platinum-sensitive, recurrent ovarian carcinoma with ≥2 prior platinum-based chemotherapies who responded to their last platinum-based therapy were enrolled in ARIEL3 and randomized 2:1 to rucaparib 600 mg twice daily or placebo. Exploratory, post hoc analyses of progression-free survival (PFS), patient-centered outcomes (quality-adjusted PFS [QA-PFS] and quality-adjusted time without symptoms or toxicity [Q-TWiST]), and safety were conducted in three age subgroups (<65 years, 65-74 years, and ≥75 years). RESULTS Investigator-assessed PFS was significantly longer with rucaparib than placebo in patients aged <65 years (rucaparib n = 237 vs placebo n = 117; median, 11.1 vs 5.4 months; hazard ratio [HR]: 0.33 [95% confidence interval (95% CI) 0.25-0.43]; P < 0.0001) and 65-74 years (n = 113 vs n = 64; median, 8.3 vs 5.3 months; HR 0.43 [95% CI 0.29-0.63]; P < 0.0001) and numerically longer in patients aged ≥75 years (n = 25 vs n = 8; median, 9.2 vs 5.5 months; HR 0.47 [95% CI 0.16-1.35]; P = 0.1593). QA-PFS and Q-TWiST were significantly longer with rucaparib than placebo across all age subgroups. Safety of rucaparib was generally similar across the age subgroups. CONCLUSIONS Efficacy, patient-centered outcomes, and safety of rucaparib were similar between age subgroups, indicating that all eligible women with recurrent ovarian cancer should be offered this therapeutic option, irrespective of age. https://clinicaltrials.gov/ct2/show/NCT01968213.
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Affiliation(s)
- Nicoletta Colombo
- Gynecologic Cancer Program, University of Milan-Bicocca and European Institute of Oncology IRCCS, via Ripamonti 435, 20146 Milan, Italy.
| | - Amit M Oza
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, Canada
| | - Domenica Lorusso
- Gynecologic Oncology Unit, Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Carol Aghajanian
- Gynecologic Medical Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Ana Oaknin
- Medical Oncology Department, Vall d'Hebron Institute of Oncology, C/Natzaret, 115-117, 08035 Barcelona, Spain
| | - Andrew Dean
- Department of Medical Oncology, St John of God Hospital Subiaco, 12 Salvado Rd, Subiaco, WA 6008, Australia
| | - Johanne I Weberpals
- Division of Gynecologic Oncology, Ottawa Hospital Research Institute, 501 Smyth Rd, Ottawa, ON K1H 8L6, Canada
| | - Andrew R Clamp
- Department of Medical Oncology, The Christie NHS Foundation Trust and University of Manchester, Manchester M20 4BX, UK
| | - Giovanni Scambia
- Gynecologic Oncology Unit, Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Alexandra Leary
- Gynecological Unit, Gustave Roussy Cancer Center, INSERM U981, and Groupe d'Investigateurs Nationaux pour l'Etude des Cancers Ovariens (GINECO), 98405 Villejuif, France
| | - Robert W Holloway
- Gynecologic Oncology, Advent Health Cancer Institute, 601 East Rollins St, Orlando, FL 32803, USA
| | - Margarita Amenedo Gancedo
- Medical Oncology Department, Oncology Center of Galicia, Rúa Doctor Camilo Veiras, 1, 15009 La Coruña, Spain
| | - Peter C Fong
- Medical Oncology Department, Auckland City Hospital, Grafton, 2 Park Road, Grafton, Auckland 1023, New Zealand
| | - Jeffrey C Goh
- Department of Oncology, Cancer Care Services, Royal Brisbane and Women's Hospital, and University of Queensland, Cnr Butterfield St and Bowen Bridge Rd, Herston, QLD 4029, Australia
| | - David M O'Malley
- Gynecologic Oncology, James Cancer Center, The Ohio State University, Starling-Loving Hall, 320 West 10th Ave, Columbus, OH 43210, USA
| | - Deborah K Armstrong
- Gynecology and Obstetrics, Johns Hopkins University Medical Center, 601 N Caroline St, Baltimore, MD 21287, USA
| | - Susana Banerjee
- Gynaecology Unit, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, Fulham Road, London SW3 6JJ, UK
| | - Jesus García-Donas
- Division of Medical Oncology, HM Hospitales-Centro Integral Oncológico Hospital de Madrid Clara Campal, Calle Oña 10, 28050 Sanchinarro, Madrid, Spain
| | - Elizabeth M Swisher
- Division of Gynecologic Oncology, University of Washington, 1959 NE Pacific Street, Box 356460, Seattle, WA 98195, USA
| | | | - Terri Cameron
- Clinical Science, Clovis Oncology UK Ltd., Granta Centre, Granta Park, Great Abington, Cambridge CB21 6GP, UK
| | - Lara Maloney
- Clinical Development, Clovis Oncology, Inc., 5500 Flatiron Parkway, Boulder, CO 80301, USA
| | - Sandra Goble
- Biostatistics, Clovis Oncology, Inc., 5500 Flatiron Parkway, Boulder, CO 80301, USA
| | - Josh Bedel
- Pricing & Market Access - Europe, Clovis Oncology Switzerland GmBH, Seefeldstrasse 69, 8008 Zurich, Switzerland
| | - Jonathan A Ledermann
- Department of Oncology, UCL Cancer Institute, University College London and UCL Hospitals, 72 Huntley St, London WC1E 6DD, UK
| | - Robert L Coleman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
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Tookman L, Krell J, Nkolobe B, Burley L, McNeish IA. Practical guidance for the management of side effects during rucaparib therapy in a multidisciplinary UK setting. Ther Adv Med Oncol 2020; 12:1758835920921980. [PMID: 32523631 PMCID: PMC7257860 DOI: 10.1177/1758835920921980] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/27/2020] [Indexed: 11/17/2022] Open
Abstract
The use of targeted therapeutics known as poly(adenosine diphosphate-ribose) polymerase (PARP) inhibitors in the management of ovarian cancer is currently transforming clinical practice. The PARP inhibitor rucaparib is indicated in the UK, European Union and the United States for use in the treatment and maintenance settings for patients with relapsed ovarian cancer. Here, we discuss some of the real-world challenges and side effects that we have encountered while prescribing rucaparib, and we provide practical guidance on how the individual members of our multidisciplinary team (MDT), including a clinician, chemotherapy nurse practitioner, and clinical pharmacist, collaborate to manage these side effects. If recognized early, the side effects experienced by patients during rucaparib therapy, which include fatigue, nausea and vomiting, liver enzyme elevations, and anemia, can be easily managed. For example, providing patients with prophylactic antiemetics can help them avoid nausea, and early detection of decreases in hemoglobin levels allows for proactive interventions to alleviate anemia. The MDT should work together with the patient to identify potential side effects early and manage them effectively. The aim of this proactive approach is to maintain patients on rucaparib for optimal clinical benefit, while minimizing the potential negative impact of side effects on patient quality of life.
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Affiliation(s)
- Laura Tookman
- Department of Medical Oncology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Rd, White City, London W12 0HS, UK
| | - Jonathan Krell
- Department of Medical Oncology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Baleseng Nkolobe
- Department of Medical Oncology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Laura Burley
- Department of Pharmacy, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Iain A McNeish
- Department of Medical Oncology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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Lorusso D, García-Donas J, Sehouli J, Joly F. Management of Adverse Events During Rucaparib Treatment for Relapsed Ovarian Cancer: A Review of Published Studies and Practical Guidance. Target Oncol 2020; 15:391-406. [PMID: 32495160 PMCID: PMC7283207 DOI: 10.1007/s11523-020-00715-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The poly(ADP-ribose) polymerase inhibitor rucaparib is approved as monotherapy in the treatment and maintenance settings for women with relapsed ovarian cancer in the European Union and the United States. We review the safety profile of rucaparib in both settings and provide recommendations for the clinical management of the main adverse events (AEs) that may occur during rucaparib treatment. We searched PubMed and congress proceedings for safety data on oral rucaparib monotherapy (600 mg twice daily) from clinical trials involving patients with relapsed ovarian cancer. AE management guidance was developed from clinical trial protocols, rucaparib prescribing information, oncology association guidelines, and author experience. The most frequent any-grade treatment-emergent AEs (TEAEs) included gastrointestinal symptoms, asthenia/fatigue, dysgeusia, anemia/decreased hemoglobin, and increased alanine/aspartate aminotransferase. Across clinical trials, 61.8% of patients had one or more grade 3 or higher TEAEs. Clinicians should employ close follow-up for TEAEs, particularly early in treatment, and educate patients about expected TEAEs and methods for their monitoring and management (e.g., antiemetics for nausea/vomiting, transfusions for hematologic TEAEs, or dose interruptions/reductions for moderate/severe TEAEs). Overall, 16.2% of patients discontinued rucaparib due to TEAEs. Management of AEs that may occur during rucaparib treatment is crucial for patients to obtain optimal clinical benefit by remaining on therapy and to avoid their detrimental impact on quality of life.
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Affiliation(s)
- Domenica Lorusso
- Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Jesús García-Donas
- Medical Oncology Service, HM Hospitales-Centro Integral Oncológico Hospital de Madrid Clara Campal, Madrid, Spain
| | - Jalid Sehouli
- Department of Gynecology and Oncological Surgery, Charité University Medicine of Berlin and NOGGO, Berlin, Germany
| | - Florence Joly
- Medical Oncology Department, Centre François Baclesse, Université Unicaen and GINECO, Caen, France
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Liu Y, Chen S, Sun J, Zhu S, Chen C, Xie W, Zheng J, Zhu Y, Xiao L, Hao L, Wang Z, Chang S. Folate-Targeted and Oxygen/Indocyanine Green-Loaded Lipid Nanoparticles for Dual-Mode Imaging and Photo-sonodynamic/Photothermal Therapy of Ovarian Cancer in Vitro and in Vivo. Mol Pharm 2019; 16:4104-4120. [PMID: 31517495 DOI: 10.1021/acs.molpharmaceut.9b00339] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We have successfully fabricated versatile folate-targeted and oxygen/indocyanine green-loaded lipid nanoparticles (FA-OINPs) for dual-mode imaging-guided therapy in ovarian cancer cells and subcutaneous xenograft models. FA-OINPs were demonstrated to have great potential as superb contrast agents to enhance ultrasound and photoacoustic (US/PA) imaging We have successfully fabricated versatile folate-targeted and oxygen/indocyanine green-loaded lipid nanoparticles (FA-OINPs) for dual-mode imaging-guided therapy in ovarian cancer cells and subcutaneous xenograft models. FA-OINPs were demonstrated to have great potential as superb contrast agents to enhance ultrasound and photoacoustic (US/PA) imaging in vitro and in vivo. Confocal laser scanning microscopy and flow cytometry analysis verified that FA-OINPs could specifically target SKOV3 ovarian cancer cells and be endocytosed with a remarkable efficiency. Compared with other therapeutic options, FA-OINPs exhibited an excellent therapeutic outcome after exposure to laser and ultrasound. The MTT assay and flow cytometry analysis confirmed that cytotoxicity effects and apoptosis/necrosis rates were significantly increased. The fluorescence microscopy and fluorescence microplate reader detection validated that the generation of intracellular reactive oxygen species (ROS) was dramatically improved. Immunohistochemical analyses of tumor tissues demonstrated the enhanced tumor apoptosis, the decreased vascular endothelial growth factor (VEGF) and microvascular density (MVD) expression, and the decreased expression of CD68 after treatment. The presented results suggest that photo-sonodynamic/photothermal mediated FA-OINPs could provide a promising strategy for synergistic therapy in ovarian cancer with the guidance of US/PA dual-mode imaging.
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Affiliation(s)
- Yujiao Liu
- Department of Obstetrics and Gynecology , the Second Affiliated Hospital of Chongqing Medical University , Chongqing 400010 , China
| | - Shuning Chen
- Department of Obstetrics and Gynecology , the Second Affiliated Hospital of Chongqing Medical University , Chongqing 400010 , China
| | - Jiangchuan Sun
- Department of Obstetrics and Gynecology , the Second Affiliated Hospital of Chongqing Medical University , Chongqing 400010 , China
| | - Shenyin Zhu
- Department of Pharmacy , the First Affiliated Hospital of Chongqing Medical University , Chongqing 400016 , China
| | - Chunyan Chen
- Department of Obstetrics and Gynecology , the Second Affiliated Hospital of Chongqing Medical University , Chongqing 400010 , China
| | - Wan Xie
- Department of Obstetrics and Gynecology , the Second Affiliated Hospital of Chongqing Medical University , Chongqing 400010 , China
| | - Jiao Zheng
- Department of Obstetrics and Gynecology , the Second Affiliated Hospital of Chongqing Medical University , Chongqing 400010 , China
| | - Yi Zhu
- Department of Obstetrics and Gynecology , the Second Affiliated Hospital of Chongqing Medical University , Chongqing 400010 , China
| | - Linlin Xiao
- Department of Obstetrics and Gynecology , the Second Affiliated Hospital of Chongqing Medical University , Chongqing 400010 , China
| | - Lan Hao
- Institute of Ultrasound Imaging , the Second Affiliated Hospital of Chongqing Medical University , Chongqing 400010 , China
| | - Zhigang Wang
- Institute of Ultrasound Imaging , the Second Affiliated Hospital of Chongqing Medical University , Chongqing 400010 , China
| | - Shufang Chang
- Department of Obstetrics and Gynecology , the Second Affiliated Hospital of Chongqing Medical University , Chongqing 400010 , China
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12
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Ward Rashidi MR, Mehta P, Bregenzer M, Raghavan S, Fleck EM, Horst EN, Harissa Z, Ravikumar V, Brady S, Bild A, Rao A, Buckanovich RJ, Mehta G. Engineered 3D Model of Cancer Stem Cell Enrichment and Chemoresistance. Neoplasia 2019; 21:822-836. [PMID: 31299607 PMCID: PMC6624324 DOI: 10.1016/j.neo.2019.06.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 06/03/2019] [Accepted: 06/12/2019] [Indexed: 12/14/2022] Open
Abstract
Intraperitoneal dissemination of ovarian cancers is preceded by the development of chemoresistant tumors with malignant ascites. Despite the high levels of chemoresistance and relapse observed in ovarian cancers, there are no in vitro models to understand the development of chemoresistance in situ. Method: We describe a highly integrated approach to establish an in vitro model of chemoresistance and stemness in ovarian cancer, using the 3D hanging drop spheroid platform. The model was established by serially passaging non-adherent spheroids. At each passage, the effectiveness of the model was evaluated via measures of proliferation, response to treatment with cisplatin and a novel ALDH1A inhibitor. Concomitantly, the expression and tumor initiating capacity of cancer stem-like cells (CSCs) was analyzed. RNA-seq was used to establish gene signatures associated with the evolution of tumorigenicity, and chemoresistance. Lastly, a mathematical model was developed to predict the emergence of CSCs during serial passaging of ovarian cancer spheroids. Results: Our serial passage model demonstrated increased cellular proliferation, enriched CSCs, and emergence of a platinum resistant phenotype. In vivo tumor xenograft assays indicated that later passage spheroids were significantly more tumorigenic with higher CSCs, compared to early passage spheroids. RNA-seq revealed several gene signatures supporting the emergence of CSCs, chemoresistance, and malignant phenotypes, with links to poor clinical prognosis. Our mathematical model predicted the emergence of CSC populations within serially passaged spheroids, concurring with experimentally observed data. Conclusion: Our integrated approach illustrates the utility of the serial passage spheroid model for examining the emergence and development of chemoresistance in ovarian cancer in a controllable and reproducible format.
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Affiliation(s)
- Maria R Ward Rashidi
- Department of Materials Science and Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Pooja Mehta
- Department of Materials Science and Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Michael Bregenzer
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Shreya Raghavan
- Department of Materials Science and Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Elyse M Fleck
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Eric N Horst
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Zainab Harissa
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Visweswaran Ravikumar
- Department of Bioinformatics and Computational Biology, Division of Quantitative Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Samuel Brady
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
| | - Andrea Bild
- Division of Molecular Pharmacology, Department of Medical Oncology and Therapeutics, City of Hope Cancer Institute, Duarte, CA, USA
| | - Arvind Rao
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Department of Computational Medicine and Bioinformatics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA; Department of Radiation Oncology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Ronald J Buckanovich
- Director of Ovarian Cancer Research, Magee Womens Research Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Geeta Mehta
- Department of Materials Science and Engineering, University of Michigan, Ann Arbor, MI, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA; Macromolecular Science and Engineering, University of Michigan, Ann Arbor, MI, USA..
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13
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Okunowo AA, Adaramoye VO. Women's Knowledge on Ovarian Cancer Symptoms and Risk Factors in Nigeria: An Institutional-based Study. J Epidemiol Glob Health 2019; 8:34-41. [PMID: 30859785 PMCID: PMC7325817 DOI: 10.2991/j.jegh.2018.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/17/2018] [Indexed: 01/22/2023] Open
Abstract
Ovarian cancer is the 2nd most common and the deadliest gynecological malignancy in Nigeria; yet very little is known about women’s knowledge about the disease in our environment. We evaluated the levels of awareness of ovarian cancer risk factors and symptoms among the Nigerian women, and also determined the factors that predict it. A cross-sectional descriptive study was conducted among 400 women attending out-patient clinics at Lagos University Teaching Hospital, Lagos, Nigeria. Using a structured questionnaire, we assessed their knowledge of ovarian cancer risk factors and symptoms and the factors that influence it. Data were analyzed using SPSS version 20.0. Sixty-three percent of the participants were found to be aware of the disease, whereas only 19.5% and 14.0% demonstrated good knowledge of its symptoms and risk factors, respectively. High level of education and previous conversation with a doctor on ovarian cancer were the only factors that significantly predicted good knowledge of symptoms and risk factors (p < 0.05). The knowledge of ovarian cancer is extremely poor among women in Lagos, Nigeria. Education of the girl child and health education of women about the disease by healthcare providers is important. This will significantly enhance women’s knowledge and encourage early presentation and detection of the disease.
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Affiliation(s)
- Adeyemi Adebola Okunowo
- Department of Obstetrics and Gynecology, College of Medicine, University of Lagos/Lagos University Teaching Hospital, PMB 12003, Lagos, Nigeria
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14
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Zhikhoreva AA, Belashov AV, Bespalov VG, Semenov AL, Semenova IV, Tochilnikov GV, Zhilinskaya NT, Vasyutinskii OS. Morphological changes in the ovarian carcinoma cells of Wistar rats induced by chemotherapy with cisplatin and dioxadet. BIOMEDICAL OPTICS EXPRESS 2018; 9:5817-5827. [PMID: 30460164 PMCID: PMC6238906 DOI: 10.1364/boe.9.005817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/19/2018] [Accepted: 10/19/2018] [Indexed: 06/09/2023]
Abstract
The development of new express methods for the analysis of the efficacy of anti-cancer therapy on the cellular level is highly desirable for the analysis of chemotherapeutic agent performance. In this paper we suggest the use of parameters of cell morphology determined by holographic microscopy and tomography for the effective label free quantitative analysis of cell viability under antitumor chemotherapy and thus of cytostatic agent efficacy. As shown, measured phase shifts and cell morphology change dramatically as a result of chemotherapy and depend strongly on the cell type and agent applied. Experimentally, a comparative analysis of the antitumor efficacy of the two cytostatics, cisplatin and dioxadet, that are commonly used for chemotherapy of disseminated ovarian carcinoma has been performed. The experiments were carried out on the Wistar rat model. An essential difference in the morphology of cells, both normal (erythrocytes) and cancerous, present in ascitic fluid taken from the non-treated group of rats and the groups treated with either dioxadet or cisplatin, has been observed. The results obtained can be interpreted as an indication of the antitumor performance of both cytostatics at the cellular level and as a demonstration of the higher efficacy of therapy with dioxadet as compared to that with cisplatin. Differences in cell morphology are suggested to be applied as quantitative markers of cell viability and cytostatic agent efficacy. The conclusions made are supported by a comparison with the results of recent experiments based on survival rates of laboratory animals treated with these agents..
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Affiliation(s)
- A. A. Zhikhoreva
- Ioffe Institute; 26 Polytekhnicheskaya, St.Petersburg, 194021,
Russia
| | - A. V. Belashov
- Ioffe Institute; 26 Polytekhnicheskaya, St.Petersburg, 194021,
Russia
| | - V. G. Bespalov
- ITMO University; Kronverkskiy pr., 49, St. Petersburg, 197101,
Russia
- N. N. Petrov National Medical Research Center of Oncology, 68, Leningradskaya ul., Pesochnyi, St. Petersburg, 197758,
Russia
| | - A. L. Semenov
- N. N. Petrov National Medical Research Center of Oncology, 68, Leningradskaya ul., Pesochnyi, St. Petersburg, 197758,
Russia
| | - I. V. Semenova
- Ioffe Institute; 26 Polytekhnicheskaya, St.Petersburg, 194021,
Russia
| | - G. V. Tochilnikov
- N. N. Petrov National Medical Research Center of Oncology, 68, Leningradskaya ul., Pesochnyi, St. Petersburg, 197758,
Russia
| | - N. T. Zhilinskaya
- N. N. Petrov National Medical Research Center of Oncology, 68, Leningradskaya ul., Pesochnyi, St. Petersburg, 197758,
Russia
- Peter the Great St.Petersburg Polytechnic University; 29, Polytekhnicheskaya, St. Petersburg, 195251,
Russia
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15
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Dal Molin GZ, Westin SN, Coleman RL. Rucaparib in ovarian cancer: extending the use of PARP inhibitors in the recurrent disease. Future Oncol 2018; 14:3101-3110. [PMID: 30105925 DOI: 10.2217/fon-2018-0215] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rucaparib is a potent inhibitor of poly (ADP-ribose) polymerase (PARP) PARP1, PARP2 and PARP3, and to a lesser extent, PARP4, PARP10, PARP12, PARP15 and PARP16. Study 10 and ARIEL2 evaluated the use of rucaparib as treatment in patients with recurrent high-grade ovarian carcinoma and resulting in approval of rucaparib for patients with both germline and somatic BRCA mutation. Data from the Phase III trial ARIEL3 led to approval in platinum-sensitive disease as maintenance. This article reviews the efficacy, safety, pharmacokinetics and pharmacodynamics of rucaparib as well as future and ongoing trials.
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Affiliation(s)
- Graziela Z Dal Molin
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Shannon N Westin
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Robert L Coleman
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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16
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Efficacy of weekly administration of paclitaxel and carboplatin for advanced ovarian cancer patients with poor performance status. Int J Clin Oncol 2018; 23:698-706. [PMID: 29572761 DOI: 10.1007/s10147-018-1264-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 02/14/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this study was to reveal the efficacy of weekly administration of paclitaxel and carboplatin for advanced ovarian cancer patients with poor performance status (PS). METHODS FIGO stage III/IV ovarian cancer or fallopian tube cancer patients who underwent interval debulking surgery (IDS) followed by neoadjuvant chemotherapy (NAC) were analyzed retrospectively. Patients were divided into two groups based on NAC: weekly paclitaxel and carboplatin (W-TC) and 3 weeks of paclitaxel and carboplatin (TW-TC). Toxicity, efficacy of NAC, surgery outcome, and prognosis were assessed by comparing the two groups. RESULTS Twenty patients treated with W-TC and 18 patients treated with TW-TC were analyzed. All of the W-TC patients were poor PS (PS ≥ 2), and all of the TW-TC patients were good PS (PS ≤ 1). The overall clinical response rates were 70% in W-TC and 83.4% in TW-TC. In the W-TC group, Grade 3/4 anemia and thrombocytopenia and greater than grade 2 neuropathy were significantly reduced compared to TW-TC patients. A frequency of treatment delay greater than 7 and 14 days, G-CSF support, blood transfusion, and dose reduction or regimen change were also significantly reduced in the W-TC group. The rate of IDS, optimal debulking surgery, complications during operation, and blood transfusion were similar between the W-TC and TW-TC groups. Progression-free survival and overall survival were also similar between the two groups. CONCLUSION Our study suggested that NAC with W-TC for poor PS patients with non-treated ovarian cancer reduced the toxicity of chemotherapy and had the same efficacy as TW-TC.
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17
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Targeting estrogen receptor beta (ERβ) for treatment of ovarian cancer: importance of KDM6B and SIRT1 for ERβ expression and functionality. Oncogenesis 2018; 7:15. [PMID: 29422491 PMCID: PMC5833712 DOI: 10.1038/s41389-018-0027-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/21/2017] [Accepted: 12/25/2017] [Indexed: 02/06/2023] Open
Abstract
Estrogen receptor (ER) β has growth inhibitory and chemo drug potentiating effect on ovarian cancer cells. We studied the dependence of ERβ function on the presence of KDM6B and SIRT1 in human ovarian cancer cells in vitro. Activation of ERβ with the subtype-selective agonist KB9520 resulted in significant inhibition of human ovarian cancer cell growth. KB9520-activated ERβ had an additive effect on growth inhibition in combination with cisplatin and paclitaxel, respectively. Loss of KDM6B expression had a negative effect on ERβ function as a ligand-dependent inhibitor of ovarian cancer cell growth. In contrast, loss or inhibition of SIRT1 deacetylase activity restored ligand-activated ERβ functionality. Presented data suggest that selective targeting of ERβ with an agonist potentiate chemotherapy efficacy for the treatment of ovarian cancer and that downregulation or inhibition of SIRT1 may further enhance its therapeutic effect.
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18
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Kulshrestha A, Katara GK, Ibrahim SA, Patil R, Patil SA, Beaman KD. Microtubule inhibitor, SP-6-27 inhibits angiogenesis and induces apoptosis in ovarian cancer cells. Oncotarget 2017; 8:67017-67028. [PMID: 28978013 PMCID: PMC5620153 DOI: 10.18632/oncotarget.17549] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 03/21/2017] [Indexed: 01/21/2023] Open
Abstract
In ovarian cancer (OVCA), treatment failure due to chemo-resistance is a serious challenge. It is therefore critical to identify new therapies that are effective against resistant tumors and have reduced side effects. We recently identified 4-H-chromenes as tubulin depolymerizing agents that bind to colchicine site of beta-tubulin. Here, we screened a chemical library of substituted 4-H-chromenes and identified SP-6-27 to exhibit most potent anti-proliferative activity towards a panel of human cisplatin sensitive and resistant OVCA cell lines with 50% inhibitory concentration (IC50; mean ± SD) ranging from 0.10 ± 0.01 to 0.84 ± 0.20 μM. SP-6-27 exhibited minimum cytotoxicity to normal ovarian epithelia. A pronounced decrease in microtubule density as well as G2/M cell cycle arrest was observed in SP-6-27 treated cisplatin sensitive/resistant OVCA cells. The molecular mechanism of SP-6-27 induced cell death revealed modulation in cell-cycle regulation by upregulation of growth arrest and DNA damage inducible alpha transcripts (GADD45). An enhanced intrinsic apoptosis was observed in OVCA cells through upregulation of Bax, Apaf-1, caspase-6, -9, and caspase-3. In vitro wound healing assay revealed reduced OVCA cell migration upon SP-6-27 treatment. Additionally, SP-6-27 and cisplatin combinatorial treatment showed enhanced cytotoxicity in chemo-sensitive/resistant OVCA cells. Besides effect on cancer cells, SP-6-27 further restrained angiogenesis by inhibiting capillary tube formation by human umbilical vein endothelial cells (HUVEC). Together, these findings show that the chromene analog SP-6-27 is a novel chemotherapeutic agent that offers important advantages for the treatment of ovarian cancer.
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Affiliation(s)
- Arpita Kulshrestha
- Department of Microbiology and Immunology, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | - Gajendra K Katara
- Department of Microbiology and Immunology, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | - Safaa A Ibrahim
- Department of Microbiology and Immunology, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, USA.,Department of Microbiology and Immunology, Faculty of Pharmacy, Cairo University, Giza, Egypt
| | - Renukadevi Patil
- Pharmaceutical Sciences Department, College of Pharmacy, Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | - Shivaputra A Patil
- Pharmaceutical Sciences Department, College of Pharmacy, Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | - Kenneth D Beaman
- Department of Microbiology and Immunology, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, USA
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19
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Choo M, Tan HL, Ding V, Castangia R, Belgacem O, Liau B, Hartley-Tassell L, Haslam SM, Dell A, Choo A. Characterization of H type 1 and type 1 N-acetyllactosamine glycan epitopes on ovarian cancer specifically recognized by the anti-glycan monoclonal antibody mAb-A4. J Biol Chem 2017; 292:6163-6176. [PMID: 28167527 PMCID: PMC5391748 DOI: 10.1074/jbc.m116.768887] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 02/02/2017] [Indexed: 01/23/2023] Open
Abstract
Cancer-specific glycans of ovarian cancer are promising epitopes for targeting with monoclonal antibodies (mAb). Despite their potential, structural characterization of these glycan epitopes remains a significant challenge in mAb preclinical development. Our group generated the monoclonal antibody mAb-A4 against human embryonic stem cells (hESC), which also bound specifically to N-glycans present on 11 of 19 ovarian cancer (OC) and 8 of 14 breast cancer cell lines tested. Normal cell lines and tissue were unstained by mAb-A4. To characterize the N-linked glycan epitopes on OC cell lines targeted by mAb-A4, we used glycosidases, glycan microarray, siRNA, and advanced high sensitivity matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS). The mAb-A4 epitopes were found to be Fucα1-2Galβ1-3GlcNAcβ (H type 1) and Galβ1-3GlcNAcβ (type 1 LacNAc). These structures were found to be present on multiple proteins from hESC and OC. Importantly, endo-β-galactosidase coupled with MALDI-MS allowed these two epitopes, for the first time, to be directly identified on the polylactosamines of N-glycans of SKOV3, IGROV1, OV90, and OVCA433. Furthermore, siRNA knockdown of B3GALT5 expression in SKOV3 demonstrated that mAb-A4 binding was dependent on B3GALT5, providing orthogonal evidence of the epitopes' structures. The recognition of oncofetal H type 1 and type 1 LacNAc on OC by mAb-A4 is a novel and promising way to target OC and supports the theory that cancer can acquire stem-like phenotypes. We propose that the orthogonal framework used in this work could be the basis for advancing anti-glycan mAb characterization.
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Affiliation(s)
- Matthew Choo
- From the Department of Life Sciences, Imperial College London, London SW7 2AZ, United Kingdom
- the Bioprocessing Technology Institute, Singapore 138668, Singapore
| | - Heng Liang Tan
- the Bioprocessing Technology Institute, Singapore 138668, Singapore
| | - Vanessa Ding
- the Bioprocessing Technology Institute, Singapore 138668, Singapore
| | | | | | - Brian Liau
- the Bioprocessing Technology Institute, Singapore 138668, Singapore
| | - Lauren Hartley-Tassell
- the Institute for Glycomics, Griffith University, Southport, Queensland 4215, Australia, and
| | - Stuart M Haslam
- From the Department of Life Sciences, Imperial College London, London SW7 2AZ, United Kingdom
| | - Anne Dell
- From the Department of Life Sciences, Imperial College London, London SW7 2AZ, United Kingdom,
| | - Andre Choo
- the Bioprocessing Technology Institute, Singapore 138668, Singapore,
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20
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Chu TQ, Li R, Shao MH, Ye JY, Han BH. RAD18 polymorphisms are associated with platinum-based chemotherapy toxicity in Chinese patients with non-small cell lung cancer. Acta Pharmacol Sin 2016; 37:1490-1498. [PMID: 27665847 DOI: 10.1038/aps.2016.100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 07/29/2016] [Indexed: 12/15/2022] Open
Abstract
AIM Although targeted therapy is very efficient for lung cancer, traditional platinum-based chemotherapies are still the principal strategy in the absence of positive biomarkers. The aim of the present study is to evaluate the contribution of RAD18 polymorphisms to platinum-chemotherapy response and its potential side effects in Chinese patients with non-small cell lung cancer (NSCLC). METHODS A total of 1021 Chinese patients with histological diagnosis of advanced NSCLC were enrolled. Treatment responses were classified into 4 categories (complete response, partial response, stable disease and progressive disease). Gastrointestinal and hematological toxicity incidences were assessed twice a week during the first-line treatment. Ten RAD18 SNPs were genotyped. A logistic regression model was utilized to analyze the associations between RAD18 SNPs and treatment response or toxicity. RESULTS Among the 10 SNPs tested, none was significantly correlated with the treatment response in a combined cohort. For gastrointestinal toxicity incidences, rs586014 was significantly associated with an increased risk of grade 3 or 4 gastrointestinal toxicity in non-smokers and in the combined cohort; rs654448 and rs618784 were significantly associated with gastrointestinal toxicity in non-smokers; rs6763823 was significantly associated with gastrointestinal toxicity in smokers. For hematological toxicity incidences, rs586014, rs654448 and rs618784 were significantly associated with hematologic toxicity in non-smokers; rs6763823 and rs9880051 were significantly associated with leukocytopenia in smokers. CONCLUSION RAD18 polymorphisms are correlated with the side effects of platinum-chemotherapy in Chinese patients with advanced NSCLC.
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Paclitaxel and Its Evolving Role in the Management of Ovarian Cancer. BIOMED RESEARCH INTERNATIONAL 2015. [PMID: 26137480 DOI: 10.1155/2015/413076] [] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Paclitaxel, a class of taxane with microtubule stabilising ability, has remained with platinum based therapy, the standard care for primary ovarian cancer management. A deeper understanding of the immunological basis and other potential mechanisms of action together with new dosing schedules and/or routes of administration may potentiate its clinical benefit. Newer forms of taxanes, with better safety profiles and higher intratumoural cytotoxicity, have yet to demonstrate clinical superiority over the parent compound.
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Paclitaxel and Its Evolving Role in the Management of Ovarian Cancer. BIOMED RESEARCH INTERNATIONAL 2015. [PMID: 26137480 DOI: 10.1155/2015/413076]+[] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Paclitaxel, a class of taxane with microtubule stabilising ability, has remained with platinum based therapy, the standard care for primary ovarian cancer management. A deeper understanding of the immunological basis and other potential mechanisms of action together with new dosing schedules and/or routes of administration may potentiate its clinical benefit. Newer forms of taxanes, with better safety profiles and higher intratumoural cytotoxicity, have yet to demonstrate clinical superiority over the parent compound.
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Kampan NC, Madondo MT, McNally OM, Quinn M, Plebanski M. Paclitaxel and Its Evolving Role in the Management of Ovarian Cancer. BIOMED RESEARCH INTERNATIONAL 2015; 2015:413076. [PMID: 26137480 PMCID: PMC4475536 DOI: 10.1155/2015/413076] [Citation(s) in RCA: 195] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 04/07/2015] [Indexed: 02/06/2023]
Abstract
Paclitaxel, a class of taxane with microtubule stabilising ability, has remained with platinum based therapy, the standard care for primary ovarian cancer management. A deeper understanding of the immunological basis and other potential mechanisms of action together with new dosing schedules and/or routes of administration may potentiate its clinical benefit. Newer forms of taxanes, with better safety profiles and higher intratumoural cytotoxicity, have yet to demonstrate clinical superiority over the parent compound.
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Affiliation(s)
- Nirmala Chandralega Kampan
- Department of Immunology, Monash University, Level 6, The Alfred, Commercial Road, Melbourne, VIC 3181, Australia
- Gynaeoncology Unit, Royal Women's Hospital, 20 Flemington Road, Parkville, Melbourne, VIC 3052, Australia
| | - Mutsa Tatenda Madondo
- Department of Immunology, Monash University, Level 6, The Alfred, Commercial Road, Melbourne, VIC 3181, Australia
| | - Orla M. McNally
- Gynaeoncology Unit, Royal Women's Hospital, 20 Flemington Road, Parkville, Melbourne, VIC 3052, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC 3052, Australia
| | - Michael Quinn
- Gynaeoncology Unit, Royal Women's Hospital, 20 Flemington Road, Parkville, Melbourne, VIC 3052, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC 3052, Australia
| | - Magdalena Plebanski
- Department of Immunology, Monash University, Level 6, The Alfred, Commercial Road, Melbourne, VIC 3181, Australia
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24
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Simulation of Chemoperfusion Treatment for Abdominal Carcinomatosis. Bull Exp Biol Med 2015; 159:81-4. [PMID: 26033596 DOI: 10.1007/s10517-015-2895-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Indexed: 10/23/2022]
Abstract
Experimental perfusion system and technology for normothermic and hyperthermic intraperitoneal chemoperfusion are developed for the treatment of abdominal carcinomatosis in rats with transplanted ovarian cancer. MTD of cisplatin in normothermic intraperitoneal chemoperfusion and hyperthermic perfusion are 40 and 20 mg/kg, i.e. by 10- and 5-fold higher than the dose of this cytostatic for routine intraperitoneal injection. Normothermic intraperitoneal chemoperfusion with cisplatin increases median survival time by 200% (p=0.039) in comparison with intraperitoneal injection.
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25
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He Y, Wu AC, Harrington BS, Davies CM, Wallace SJ, Adams MN, Palmer JS, Roche DK, Hollier BG, Westbrook TF, Hamidi H, Konecny GE, Winterhoff B, Chetty NP, Crandon AJ, Oliveira NB, Shannon CM, Tinker AV, Gilks CB, Coward JI, Lumley JW, Perrin LC, Armes JE, Hooper JD. Elevated CDCP1 predicts poor patient outcome and mediates ovarian clear cell carcinoma by promoting tumor spheroid formation, cell migration and chemoresistance. Oncogene 2015; 35:468-78. [PMID: 25893298 DOI: 10.1038/onc.2015.101] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 01/27/2015] [Accepted: 02/16/2015] [Indexed: 01/25/2023]
Abstract
Hematogenous metastases are rarely present at diagnosis of ovarian clear cell carcinoma (OCC). Instead dissemination of these tumors is characteristically via direct extension of the primary tumor into nearby organs and the spread of exfoliated tumor cells throughout the peritoneum, initially via the peritoneal fluid, and later via ascites that accumulates as a result of disruption of the lymphatic system. The molecular mechanisms orchestrating these processes are uncertain. In particular, the signaling pathways used by malignant cells to survive the stresses of anchorage-free growth in peritoneal fluid and ascites, and to colonize remote sites, are poorly defined. We demonstrate that the transmembrane glycoprotein CUB-domain-containing protein 1 (CDCP1) has important and inhibitable roles in these processes. In vitro assays indicate that CDCP1 mediates formation and survival of OCC spheroids, as well as cell migration and chemoresistance. Disruption of CDCP1 via silencing and antibody-mediated inhibition markedly reduce the ability of TOV21G OCC cells to form intraperitoneal tumors and induce accumulation of ascites in mice. Mechanistically our data suggest that CDCP1 effects are mediated via a novel mechanism of protein kinase B (Akt) activation. Immunohistochemical analysis also suggested that CDCP1 is functionally important in OCC, with its expression elevated in 90% of 198 OCC tumors and increased CDCP1 expression correlating with poor patient disease-free and overall survival. This analysis also showed that CDCP1 is largely restricted to the surface of malignant cells where it is accessible to therapeutic antibodies. Importantly, antibody-mediated blockade of CDCP1 in vivo significantly increased the anti-tumor efficacy of carboplatin, the chemotherapy most commonly used to treat OCC. In summary, our data indicate that CDCP1 is important in the progression of OCC and that targeting pathways mediated by this protein may be useful for the management of OCC, potentially in combination with chemotherapies and agents targeting the Akt pathway.
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Affiliation(s)
- Y He
- Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - A C Wu
- Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - B S Harrington
- Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - C M Davies
- Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia.,Mater Health Services, South Brisbane, Queensland, Australia
| | - S J Wallace
- Mater Health Services, South Brisbane, Queensland, Australia
| | - M N Adams
- Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - J S Palmer
- Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - D K Roche
- Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - B G Hollier
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Woolloongabba, Queensland, Australia
| | - T F Westbrook
- Verna and Marrs McLean Department of Biochemistry and Molecular Biology, Baylor College of Medicine, Houston, TX, USA
| | - H Hamidi
- University of California, Los Angeles, CA, USA
| | - G E Konecny
- University of California, Los Angeles, CA, USA
| | | | - N P Chetty
- Mater Health Services, South Brisbane, Queensland, Australia
| | - A J Crandon
- Mater Health Services, South Brisbane, Queensland, Australia
| | - N B Oliveira
- Mater Health Services, South Brisbane, Queensland, Australia
| | - C M Shannon
- Mater Health Services, South Brisbane, Queensland, Australia
| | - A V Tinker
- Division of Medical Oncology, Vancouver Centre, British Columbia Cancer Agency, Vancouver, British Columbia, Canada.,Cheryl Brown Ovarian Cancer Outcomes Unit, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - C B Gilks
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - J I Coward
- Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia.,Mater Health Services, South Brisbane, Queensland, Australia
| | - J W Lumley
- Wesley Hospital, Auchenflower, Queensland, Australia
| | - L C Perrin
- Mater Health Services, South Brisbane, Queensland, Australia
| | - J E Armes
- Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia.,Mater Health Services, South Brisbane, Queensland, Australia
| | - J D Hooper
- Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
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26
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Stefanou DT, Bamias A, Episkopou H, Kyrtopoulos SA, Likka M, Kalampokas T, Photiou S, Gavalas N, Sfikakis PP, Dimopoulos MA, Souliotis VL. Aberrant DNA damage response pathways may predict the outcome of platinum chemotherapy in ovarian cancer. PLoS One 2015; 10:e0117654. [PMID: 25659114 PMCID: PMC4320060 DOI: 10.1371/journal.pone.0117654] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 11/12/2014] [Indexed: 02/06/2023] Open
Abstract
Ovarian carcinoma (OC) is the most lethal gynecological malignancy. Despite the advances in the treatment of OC with combinatorial regimens, including surgery and platinum-based chemotherapy, patients generally exhibit poor prognosis due to high chemotherapy resistance. Herein, we tested the hypothesis that DNA damage response (DDR) pathways are involved in resistance of OC patients to platinum chemotherapy. Selected DDR signals were evaluated in two human ovarian carcinoma cell lines, one sensitive (A2780) and one resistant (A2780/C30) to platinum treatment as well as in peripheral blood mononuclear cells (PBMCs) from OC patients, sensitive (n = 7) or resistant (n = 4) to subsequent chemotherapy. PBMCs from healthy volunteers (n = 9) were studied in parallel. DNA damage was evaluated by immunofluorescence γH2AX staining and comet assay. Higher levels of intrinsic DNA damage were found in A2780 than in A2780/C30 cells. Moreover, the intrinsic DNA damage levels were significantly higher in OC patients relative to healthy volunteers, as well as in platinum-sensitive patients relative to platinum-resistant ones (all P<0.05). Following carboplatin treatment, A2780 cells showed lower DNA repair efficiency than A2780/C30 cells. Also, following carboplatin treatment of PBMCs ex vivo, the DNA repair efficiency was significantly higher in healthy volunteers than in platinum-resistant patients and lowest in platinum-sensitive ones (t1/2 for loss of γH2AX foci: 2.7±0.5h, 8.8±1.9h and 15.4±3.2h, respectively; using comet assay, t1/2 of platinum-induced damage repair: 4.8±1.4h, 12.9±1.9h and 21.4±2.6h, respectively; all P<0.03). Additionally, the carboplatin-induced apoptosis rate was higher in A2780 than in A2780/C30 cells. In PBMCs, apoptosis rates were inversely correlated with DNA repair efficiencies of these cells, being significantly higher in platinum-sensitive than in platinum-resistant patients and lowest in healthy volunteers (all P<0.05). We conclude that perturbations of DNA repair pathways as measured in PBMCs from OC patients correlate with the drug sensitivity of these cells and reflect the individualized response to platinum-based chemotherapy.
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Affiliation(s)
- Dimitra T. Stefanou
- Institute of Biology, Medicinal Chemistry and Biotechnology, National Hellenic Research Foundation, 11635 Athens, Greece
- Department of Clinical Therapeutics, Athens University Medical School, 11528 Athens, Greece
| | - Aristotelis Bamias
- Department of Clinical Therapeutics, Athens University Medical School, 11528 Athens, Greece
| | - Hara Episkopou
- Institute of Biology, Medicinal Chemistry and Biotechnology, National Hellenic Research Foundation, 11635 Athens, Greece
- Genetic and Epigenetic Alterations of Genomes, de Duve Institute, Catholic University of Louvain, Brussels, 1200, Belgium
| | - Soterios A. Kyrtopoulos
- Institute of Biology, Medicinal Chemistry and Biotechnology, National Hellenic Research Foundation, 11635 Athens, Greece
| | - Maria Likka
- Department of Clinical Therapeutics, Athens University Medical School, 11528 Athens, Greece
| | - Theodore Kalampokas
- Second Department of Obstetrics & Gynaecology, Athens University Medical School, 11528 Athens, Greece
| | - Stylianos Photiou
- Second Department of Obstetrics & Gynaecology, Athens University Medical School, 11528 Athens, Greece
| | - Nikos Gavalas
- Department of Clinical Therapeutics, Athens University Medical School, 11528 Athens, Greece
| | - Petros P. Sfikakis
- First Department of Propedeutic Medicine, Athens University Medical School, 11527 Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, Athens University Medical School, 11528 Athens, Greece
| | - Vassilis L. Souliotis
- Institute of Biology, Medicinal Chemistry and Biotechnology, National Hellenic Research Foundation, 11635 Athens, Greece
- * E-mail:
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