Mathematical modeling predicts pathways to successful implementation of combination TRAIL-producing oncolytic virus and PAC-1 to treat granulosa cell tumors of the ovary

The development of new cancer therapies requires multiple rounds of validation from in vitro and in vivo experiments before they can be considered for clinical trials. Mathematical models assist in this preclinical phase by combining experimental data with human parameters to provide guidance about potential therapeutic regimens to bring forward into trials. However, granulosa cell tumors of the ovary lack a relevant mouse model, complexifying preclinical drug development for this rare tumor. To bridge this gap, we established a mathematical model as a framework to explore the potential of using a tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)-producing oncolytic vaccinia virus in combination with the chemotherapeutic agent first procaspase activating compound (PAC-1). We have previously shown that TRAIL and PAC-1 act synergistically on granulosa tumor cells. In line with our previous results, our current model predicts that, although it is unable to stop the tumor from growing in its current form, combination oral PAC-1 with oncolytic virus (OV) provides the best result compared to monotherapies. Encouragingly, our results suggest that increases to the OV infection rate can lead to the success of this combination therapy within a year. The model developed here can continue to be improved as more data become available, allowing for regimen-tailoring via virtual clinical trials, ultimately shepherding effective regimens into trials.

Prevalence of predictive biomarkers in a large cohort of molecularly defined adult-type ovarian granulosa cell tumors

OBJECTIVE

The objective of this study was to determine the prevalence of predictive biomarkers associated with FDA-approved therapies in molecularly defined adult-type ovarian granulosa cell tumors (aGCTs).

METHODS

We performed a retrospective cross-sectional cohort study of tumor profiles using the inclusion criteria of molecularly defined (FOXL2 c.C402G positive) aGCTs previously sequenced at Foundation Medicine, Inc. The dataset included coding variants for up to 406 genes, microsatellite instability, tumor mutational burden, and genomic loss of heterozygosity (gLOH). PD-L1 expression was determined using the tumor proportion score, as measured using the DAKO 22C3 immunohistochemistry assay.

RESULTS

423 tumor profiles met inclusion criteria. The median age at the time of sample submission was 57 years (interquartile range 48-65). The mean tumor mutational burden was 1.8 mutations per megabase (range 0-8.8). No tumors exhibited microsatellite instability, and none were gLOH-High (≥16%). Sixty-seven tumors had PD-L1 expression measurement, and 94% were negative. Potentially actionable variants including MTAP deletion (12/173, 5.8%) and activating PIK3CA mutations (23/423, 5.4%) were identified. TP53-mutated aGCT had a higher tumor mutational burden (mean 2.4 mut/Mb, 95% CI 1.7-3.0 mut/Mb vs mean 1.7 mut/Mb, 95% CI 1.5-1.9 mut/Mb; P = .02) and higher gLOH score (mean 4.4%, 95% CI 2.7-6.1% vs mean 1.4%, 95% CI 1.2-1.6%; P = .002) than TP53 non-mutated tumors.

CONCLUSIONS

No women with molecularly defined aGCT in this large cohort would be eligible for FDA-approved pembrolizumab based on either microsatellite instability or high tumor mutational burden. TP53 mutation identified a subset of this tumor type with distinct molecular features. The development of precision treatment options remains a critical unmet need for this rare disease.

Laparoscopic surgery in the treatment of stage I adult granulosa cells tumors of the ovary: Results from the MITO-9 study

OBJECTIVE

Surgery represents the mainstay of treatment of stage I adult type granulosa cell tumors of the ovary (AGCTs). Because of the rarity and indolent course of the disease, no prospective trials are available. Open surgery has long been considered the traditional approach; oncological safety of laparoscopy is only supported by small series or case reports. The aim of this study was to compare the oncological outcomes between laparoscopic and open surgery in stage I AGCTs treated within the MITO (Multicenter Italian Trials in Ovarian cancer) Group.

METHODS

Data from patients with stage I AGCTs were retrospectively collected. Clinicopathological features were evaluated for association with relapse and death. Survival curves were calculated using the Kaplan-Meier method and compared with the log-rank test. The role of clinicopathological variables as prognostic factors for survival was evaluated using Cox's regression model.

RESULTS

223 patients were identified. Stage 1A, 1B and 1C were 61.5%, 1.3% and 29.6% respectively. 7.6% were apparently stage I. Surgical approach was laparoscopic for 93 patients (41.7%) and open for 130 (58.3%). 5-years DFS was 84% and 82%, 10-years DFS was 68% and 64% for the laparoscopic and open-group (p = 0.6).5-years OS was 100% and 99%, 10 years OS was 98% and 97% for the laparoscopic and open-surgery group (p = 0.8). At multivariate analyses stage IC, incomplete staging, site of primary surgery retained significant prognostic value.

CONCLUSION

The present study suggests that surgical route does not affect the oncological safety of patients with stage I AGCTs, with comparable outcomes between laparoscopic and open approach.

The Ovarian Cycle

The "ovarian cycle" is an exquisite and dynamic endocrine system that includes ovarian events, hypothalamic-pituitary interactions, uterine endometrial and myometrial changes during implantation and pregnancy, cervical alterations in structure, and breast development. The ovarian cycle and the steroid hormones produced by the ovary also impact epithelial cancer development in the ovary, uterus, cervix, and breast. This chapter provides a personal view of recent developments that occur in this complex endocrine environment.

The role of systemic chemotherapy in the management of granulosa cell tumors

OBJECTIVE

Granulosa cell tumors (GCTs) are rare, and the role of chemotherapy in their management is not clearly defined.

METHODS

We performed a retrospective cohort study of GCT patients diagnosed from January 1996 through June 2013 at the Memorial Sloan Kettering Cancer Center, comparing those who received adjuvant chemotherapy to those who did not. Differences between groups were assessed using the log-rank test. Statistical significance was set at p<0.05.

RESULTS

Of 118 patients, 10 (8%) received adjuvant chemotherapy (1 [1%] of 103 stage I and 9 [60%] of 15 stage II-IV patients). Thirty-two patients (27%) experienced disease recurrence. Four patients had residual disease after initial surgery, and all received adjuvant chemotherapy; each recurred within 24.3 months (median PFS, 8.2 months). The time to first recurrence was longer in patients who did not receive adjuvant chemotherapy. For patients with recurrent disease, receiving chemotherapy after surgery for first recurrence did not seem to improve time to second recurrence versus surgery alone (HR 0.98; p=0.965). Additionally, 12 patients (10%) had a previous diagnosis of breast cancer-an incidence rate 3.22 times higher than Surveillance, Epidemiology, and End Results (SEER) data predicts (p<0.001).

CONCLUSIONS

Although the numbers were small, in this analysis chemotherapy was not found to improve the recurrence-free interval of patients with GCTs, a finding that requires prospective validation. Residual disease after surgery was associated with poor prognosis. Finally, there was a significantly higher than expected incidence of antecedent breast cancer in this population, an association that deserves further exploration.

[Granulosa cell tumor of the ovary: retrospective study of 17 cases]

Granulosa cell tumors of the ovary are rare tumor of ovary, included in the sex cord-stromal tumor category, hormone secreting. Seventeen patients with adult-type granulosa cell tumor were identified between 1995 and 2012. All have received surgical treatment first at stage I. Thirty-three percent of the patients relapsed with peritoneal nodules in 68% of the cases, treated surgically and sometimes with complementary therapies, such as chemotherapy, radiotherapy, hormonal treatment. Overall survival and recurrence-free survival were 100% and 58.3%, respectively at 10 years with median time to recurrence of 6 years (4-27). These tumors have therefore a good prognosis and require long-time follow-up. Finally, the prognostic factors of recurrence identified in the literature are FIGO stage, the presence of residual tumor and tumor size.

Impact of a second opinion using expression and molecular analysis of FOXL2 for sex cord-stromal tumors. A study of the GINECO group & the TMRO network

OBJECTIVE

Ovarian sex cord-stromal tumors (SCSTs) are rare and their diagnosis is often difficult to establish. Recently, immunostaining and molecular analysis for Forkhead box L2 (FOXL2) have been developed in this pathology. This study aims to assess the benefit of an algorithm incorporating these new tools for a better diagnosis and classification of SCSTs

METHODS

Seventy-two tumors with a potential diagnosis of SCSTs were addressed by 37 different pathologists to one French rare ovarian tumor expert center, member of the Rare Malignant Ovarian Tumor network (TMRO). Then a "second opinion" (SO) through an algorithm incorporating immunostaining (IHC) and molecular analysis of FOXL2 was performed for all these cases. This algorithm was then validated by all pathologists of the TMRO network.

RESULTS

After a second opinion including molecular analysis and immunostaining for FOXL2 the initial diagnosis was changed in 15 of 72 samples (21%). FOXL2 mutation was present in 44 out of 47 adult granulosa cell tumors (94%), in 3 out of 8 Thecomas (37%), in 1 out of 10 Sertoli-Leydig cell tumors (SLSTs) (10%) and in 3 out of 5 undifferentiated-SCSTs (Und-SCSTs) (60%). Immunoexpression of FOXL2 was available in 45 cases of SCSTs: FOXL2 was expressed in 44 of them (98%).

CONCLUSIONS

A second opinion in an expert center for all cases of SCSTs is fundamental to get an optimal classification of these rare tumors. This second opinion could be performed with an algorithm which integrates FOXL2 mutation and expression status of FOXL2 in order to standardize the practice.