Abstract Purpose Ovarian clear cell carcinoma (OCCC) is strongly associated with endometriosis and shows geographic variation in incidence. We investigated whether OCCC and adjacent endometriosis exhibit distinct transcriptional states and whether these patterns differ between United Kingdom (UK) and Japanese cohorts. Experimental Design We performed whole-transcriptome spatial profiling on specimens from 16 OCCC cases (8 UK, 8 Japan) in which tumor and endometriosis were both present. Gene expression was analyzed in tumor, endometriosis and stroma. ARID1A status was assessed by immunohistochemistry. Results Median age was 59 years (range 26–82). 13/16 cases (81.3%) had early-stage disease. Tissue compartment rather than cohort of origin was the dominant source of variation across endometriosis and tumor regions. Endometriosis was enriched for inflammatory and immune-related pathways compared to tumor, whilst there was greater representation of chromatin and protein–DNA complex assembly pathways in tumor regions. These patterns were conserved across both cohorts and after stratification by ARID1A status. Mesenchymal-associated gene expression scores also significantly differed across stroma, endometriosis and tumor with clear compartmental separation. Cell type deconvolution analyses showed clear compositional differences between stromal and epithelial disease compartments. Conclusions OCCC and coexisting endometriosis are transcriptionally distinct, with the dominant contrast being compartmental rather than geographic. ARID1A alone is unlikely to account for the principal spatial transcriptional states identified here. Further analyses will be required to ascertain whether these differences reflect genuine biological differences between OCCC and coexisting endometriosis or represent different stages of endometriosis-associated tumorigenesis. Translational Relevance Ovarian clear cell carcinoma often arises in association with endometriosis, yet the biological transition between these lesions remains poorly understood. Using spatial transcriptomics in matched tumor and adjacent endometriosis from Japanese and UK cohorts, we showed that endometriosis is characterized by inflammatory and antigen-presentation features, whereas tumor regions showed chromatin-organization and oncogenic transcriptional states. These patterns were largely maintained irrespective of ARID1A status and geographic background. In addition, spatial deconvolution suggested differences in local immune composition, with tumor regions showing relatively greater neutrophil- and T cell-associated signals. Together, our data suggest that OCCC and coexisting endometriosis share a spatially linked tissue context, but that tumor regions have distinct transcriptional profile and microenvironment that may be involved in the malignant transformation and inform interpretation of molecular classification in endometriosis-associated OCCC.

OBJECTIVE:This study aimed to investigate the impact of ileostomy on both short- and long-term renal function in patients with advanced ovarian cancer. METHODS:This retrospective, multi-institutional study included patients diagnosed with stage II-IV ovarian cancer who underwent primary or interval debulking surgery with rectal resection at five institutions in Japan between April 2013 and March 2022. We assessed renal function during and up to 12 months following postoperative adjuvant chemotherapy (AC), using estimated glomerular filtration rate (eGFR) values and the incidence of chronic kidney disease (CKD) in patients with or without ileostomy. RESULTS:A total of 215 patients were included in the study, of whom 87 patients (40.5 %) underwent ileostomy. When comparing patients with and without ileostomy, those with ileostomy had a lower eGFR from the first cycle of chemotherapy up to 12 months after AC (p < 0.0001). Additionally, patients who underwent ileostomy were more likely to develop CKD 12 months after AC (p < 0.0001). Logistic regression analysis identified age (p = 0.039), baseline renal dysfunction (p = 0.013), and ileostomy (p < 0.001) as independent risk factors for CKD at 12 months after AC. Furthermore, stoma closure did not result in an improvement in eGFR. In patients who underwent ileostomy, high stoma output (>1500 mL/day) was independently associated with CKD development at 12 months after AC. CONCLUSIONS:In patients with ovarian cancer, ileostomy can impair renal function following AC, and this effect persists even after stoma closure.

Over half of ovarian clear cell carcinoma (OCCC) cases exhibit deficiencies in the ARID1A gene, a chromatin remodeling complex component. OCCC is resistant to chemotherapy and challenging to treat, necessitating new drug treatment strategies. This study used a publicly available dependency factor database to identify synthetic lethal targets for ARID1A-deficient cancer. The DepMap portal was used to identify genes on which ARID1A-deficient cancer cell lines are highly dependent. Our analysis limited to ovarian cancer cell lines only identified the deubiquitinating enzyme USP8 as a synthetic lethal target in ARID1A-deficient OCCC cancer cell lines and mouse xenograft models. In addition, USP8 inhibitors were more selective for ARID1A-deficient cells than existing candidate drugs used in promising clinical trials for ARID1A-deficient cancers. Suppression of USP8 in ARID1A-deficient cells led to degradation of FGFR2 via the proteasome. Deficiency of ARID1A causes abnormalities in the STAT3 pathway, which is one of the downstream pathways of FGFR2, but suppression of USP8 attenuates phosphorylation of STAT3 pT705 and induces apoptosis. Taken together, our data suggest that USP8 is a novel therapeutic target for ARID1A-deficient OCCC and that USP8 inhibitors suppress FGFR2-STAT3 signaling.

PARP inhibitors have changed the management of advanced high-grade epithelial ovarian cancer (EOC), especially homologous recombinant (HR)-deficient advanced high-grade EOC. However, the effect of PARP inhibitors on HR-proficient (HRP) EOC is limited. Thus, new therapeutic strategy for HRP EOC is desired. In recent clinical study, the combination of PARP inhibitors with anti-angiogenic agents improved therapeutic efficacy, even in HRP cases. These data suggested that anti-angiogenic agents might potentiate the response to PARP inhibitors in EOC cells. Here, we demonstrated that anti-angiogenic agents, bevacizumab and cediranib, increased the sensitivity of olaparib in HRP EOC cells by suppressing HR activity. Most of the γ-H2AX foci were co-localized with RAD51 foci in control cells. However, most of the RAD51 were decreased in the bevacizumab-treated cells. RNA sequencing showed that bevacizumab decreased the expression of CRY1 under DNA damage stress. CRY1 is one of the transcriptional coregulators associated with circadian rhythm and has recently been reported to regulate the expression of genes required for HR in cancer cells. We found that the anti-angiogenic agents suppressed the increase of CRY1 expression by inhibiting VEGF/VEGFR/PI3K pathway. The suppression of CRY1 expression resulted in decrease of HR activity. In addition, CRY1 inhibition also sensitized EOC cells to olaparib. These data suggested that anti-angiogenic agents and CRY1 inhibitors will be the promising candidate in the combination therapy with PARP inhibitors in HR-proficient EOC.

Logistic regression classifiers' normalized coefficient and confidence interval

OBJECTIVE Most ovarian clear cell carcinomas are resistant to platinum-based chemotherapy, while a small subset shows a positive response. The aim of this study was to clarify the clinical, pathological and genetic characteristics of platinum-sensitive ovarian clear cell carcinomas. METHODS The study included 53 patients with stage III-IV ovarian clear cell carcinoma who had residual tumours after primary surgery and received platinum-based therapy between 2009 and 2018. A retrospective examination of platinum sensitivity was performed using the criterion of ≥6 months from the last day of first-line platinum therapy until recurrence/progression. Cases determined to be platinum-sensitive were subjected to immunohistochemical staining, genomic analyses using target sequencing (i.e. NCC Oncopanel) and homologous recombination deficiency (myChoice® HRD Plus) assays. RESULTS Of the 53 stage III-IV ovarian clear cell carcinoma cases, 11 (21%) were platinum-sensitive. These cases showed better progression-free and overall survival than platinum-resistant cases (hazard ratio = 0.16, P < 0.001). Among the seven sensitive cases whose tumour tissues were available for molecular profiling, five were pure ovarian clear cell carcinoma based on pathological and genetic features, whereas the remaining two cases were re-diagnosed as high-grade serous ovarian carcinoma. The pure ovarian clear cell carcinomas lacked BRCA1 and BRCA2 mutations, consistent with the absence of the homologous recombination deficiency phenotype, whereas two cases (40%) had ATM mutations. By contrast, the two high-grade serous ovarian carcinoma cases had BRCA1 or BRCA2 mutations associated with the homologous recombination deficiency phenotype. CONCLUSION The subset of platinum-sensitive ovarian clear cell carcinomas includes a majority with pure ovarian clear cell carcinoma features that lack the homologous recombination deficiency phenotype.

Diagnostic accuracy of clinicopathological factors using Machine Learning Algorithms

Pretreatment peripheral blood tests of 334 patients with epithelial ovarian cancer and 101 patients with benign ovarian tumor

Explanation and evaluation of the random forest (RF) classifier. (A) Schematic illustration of the classification of samples by the RF. (B, C) Representative classification trees from the discrimination between malignant and benign tumors. These trees are only representations out of 4,000 trees constructed in the RF classifier. The final class is determined as a result of voting by all 4,000 trees. (D, E) The highest accuracy of prediction (D) and the AUC (E) using different numbers of samples in RF classification between malignant and benign tumors. The mean accuracy and AUC with these 95% confidence intervals were presented for 10 independent sets of randomly selected data of 20%, 40%, 60%, and 80% of patients from the training and test cohorts.

Aim The purpose of this study was to investigate whether the Ki67 values were associated with survival for predicting prognosis in patients with advanced ovarian cancer receiving neoadjuvant chemotherapy (NACT). Methods Among 17 patients treated with NACT, 13 patients were available for tissue samples from matched pre- and post-therapy tissues. Ki67 scores were transformed to a logarithmic scale for the statistical analyses. The optimal cutoff values of the log-phase Ki67 were assessed by receiver operating characteristic (ROC) analysis. Kaplan-Meier analysis, the log-rank test, and Cox regression analysis were carried out to analyze survival. Results The Ki67-decrease and post-NACT Ki67 were the independent factors associated with relapse-free survival (RFS) (p < 0.001 and p = 0.003). No association was observed on overall survival. The optimal cutoff values for the Ki67-decrease and the post-NACT Ki67 were 6.67% and 5.46 based on ROC where the area under ROC curves (AUC) were 1.00 (p < 0.001) with the 100% sensitivity and specificity. The median RFS was 537 days in patients showing Ki67-decrease >6.66% or post-NACT Ki67 level <5.46, while it was 224 days in those with Ki67 decrease <= 6.66% or post-NACT Ki67 level >= 5.46 (p = 0.001). Conclusions The Ki67-decrease and the lower post-NACT Ki67 are independent factors associated with favorable RFS, indicating that they could be precise biomarker candidates for prognosis in NACT-administered patients with advanced ovarian cancer.

Aim This study aimed to identify the postoperative histological features affecting the prognosis of patients with early-stage cervical cancer who underwent open radical hysterectomy. Methods This retrospective study enrolled 374 patients with pT1a, 1b1 and 2a1 early-stage cervical cancer who underwent open radical hysterectomy between 2001 and 2018. Survival outcomes were analyzed by Kaplan-Meier method and compared with log-rank test. Using the Cox proportional hazards regression test, we conducted a multivariate analysis for disease-free survival and overall survival. Results Others histology, including other epithelial tumors and neuroendocrine tumors, had a significantly worse prognosis in both disease-free survival and overall survival than those of squamous cell carcinoma and adenocarcinoma (hazard ratio, 4.37 and 11.76;P= 0.006 andP= 0.002, respectively), along with lymph node metastasis (hazard ratio, 2.99 and 7.03;P= 0.009 andP= 0.001, respectively). Conclusion Others histology including adenosquamous carcinoma had a poor prognosis in early-stage cervical cancer as with high-risk factors.

Objective Venous thromboembolism (VTE) is increasingly being treated with oral direct Xa inhibitors, including edoxaban. However, direct evidence supporting the use of edoxaban for thrombosis associated with gynecological cancer is limited. Thus, we compared edoxaban to warfarin with regard to their efficacy, safety and convenience in gynecological cancer patients with VTE. Method We reviewed the medical records of 317 gynecological cancer patients who received edoxaban or warfarin treatment for VTE between January 2011 and December 2018. Result The median follow-up period was 712 days (16–2868). Of the 317 patients, 180 and 137 were treated with edoxaban or warfarin, respectively. Details of cancer types were as follows: ovarian cancer 110 (62%), endometrial cancer 40 (22%), cervical cancer 22 (12%) and others 8 (4%) in edoxaban group and 81 (59%), 37 (27%), 16 (12%), 3 (2%) in warfarin group. There was no significant difference between two treatments groups in terms of BMI, VTE site, cancer type, histological subtype and stage. Recurrence of VTE occurred in 16 patients (8.9%) in edoxaban group and 18 (13.1%) in warfarin group (p=0.31). Adverse events that required discontinuation of anticoagulation occurred in 1 patient (0.6%) with edoxaban and 6 patients (4.4%) with warfarin (p=0.06), and no fatal events in either group. Initial heparin bridge was employed in 63 patients (37.7%) and 115 patients (92.0%) of edoxaban and warfarin group, respectively (p<0.01). Conclusion Edoxaban is effective, safe and convenient for VTE patients with gynecological cancers.

Introduction:The traditional studies documented that peritoneal washing cytology in ovarian tumour could detect a subclinical intraperitoneal extension effectively though, they didn't mention the detailed methodological technique for it. In conventional Cytological Smears (CS), identification of malignant cells has occasionally posed a diagnostic problem, whereas there are some studies corroborating that undetermined malignancies on CS showed conclusive diagnosis with the aid of Cellblock (CB) preparation. Aim: To assess and compare the accuracy of CB method in the cytological diagnosis of ascites in ovarian cancer with CS. Materials and Methods: All ovarian cancer specimens for cytopathology consisting of both CS and CB over a 4-year period were reviewed and analysed. The available specimens from 64 cases were compared on sensitivity and yield for malignancy by histologic type. Results: The overall sensitivity of CS (91%) was almost the same as CB (95%). However, the yield for malignancy could be improved by 6.3% (4/64) when CB were utilised together. The same trend is noted on high grade serous (100% vs 100%; N=27) and clear cell carcinoma (100% vs 92%; N=17) though no improvement on definitive cytologic conclusion for malignancy was observed. Whereas, in endometrioid carcinoma (N=11), the sensitivity of CS (20%) was remarkably inferior to CB (80%) and the yield for malignancy on CS alone (8.2%; 1/11) was significantly improved to 45.5% (5/11) (p=0.048) when CB was combined with CS. More importantly, all four cases exhibiting negative CS with positive CB showed endometrioid carcinoma with endometriosis comorbidity. Conclusion: These findings strongly suggest that, compared to CS alone, CB technique along with CS provided significant improvement on the yield for malignancy specifically in endometrioid carcinoma.

AbstractPurpose: We aimed to develop an ovarian cancer–specific predictive framework for clinical stage, histotype, residual tumor burden, and prognosis using machine learning methods based on multiple biomarkers. Experimental Design: Overall, 334 patients with epithelial ovarian cancer (EOC) and 101 patients with benign ovarian tumors were randomly assigned to “training” and “test” cohorts. Seven supervised machine learning classifiers, including Gradient Boosting Machine (GBM), Support Vector Machine, Random Forest (RF), Conditional RF (CRF), Naïve Bayes, Neural Network, and Elastic Net, were used to derive diagnostic and prognostic information from 32 parameters commonly available from pretreatment peripheral blood tests and age. Results: Machine learning techniques were superior to conventional regression-based analyses in predicting multiple clinical parameters pertaining to EOC. Ensemble methods combining weak decision trees, such as GBM, RF, and CRF, showed the best performance in EOC prediction. The values for the highest accuracy and area under the ROC curve (AUC) for segregating EOC from benign ovarian tumors with RF were 92.4% and 0.968, respectively. The highest accuracy and AUC for predicting clinical stages with RF were 69.0% and 0.760, respectively. High-grade serous and mucinous histotypes of EOC could be preoperatively predicted with RF. An ordinal RF classifier could distinguish complete resection from others. Unsupervised clustering analysis identified subgroups among early-stage EOC patients with significantly worse survival. Conclusions: Machine learning systems can provide critical diagnostic and prognostic prediction for patients with EOC before initial intervention, and the use of predictive algorithms may facilitate personalized treatment options through pretreatment stratification of patients.

Introduction: Heterotopic pregnancies are rare, with an incidence of approximately 0.003% in a natural ovulation cycle. We report a case of combined ovarian and intrauterine pregnancies, in which laparoscopic surgery confirmed the diagnosis and enabled successful pregnancy.

Objective: Intestinal obstruction and infertility are significant adverse effects related to the formation of postoperative adhesions after gynecological surgery. INTERCEED (Ethicon) and Seprafilm (Kaken Pharmaceutical Co., Ltd.) are widely used adsorbable-type adhesion barriers suited for open surgery. However, in December 2016, AdSpray (Terumo), a spray-type adhesion barrier that allows the insertion of a long nozzle through a trocar, became available for use in Japan. We studied the utility of AdSpray during laparoscopic surgeries. Methods: We studied 37 patients who underwent a total laparoscopic hysterectomy at our hospital between April 2016 and August 2017. Patients were categorized into 2 groups to receive either AdSpray or INTERCEED. A retrospective intergroup comparison was performed based on the distribution/adhesion time, white blood cell count, and the C-reactive protein levels on day 1 postoperatively, and the number of days hospitalized after surgery. Results: The AdSpray group showed a shorter distribution/adhesion time than the INTERCEED group (118 ± 25 s vs. 170 ± 61 s, respectively, p = 0.013). No significant differences were observed in terms of any other outcomes. Neither group showed perioperative complications. Conclusion: The tip of the nozzle of AdSpray can be bent freely to allow passage through the trocar for distribution over uneven surfaces. Thus, AdSpray is easier and safer to use during laparoscopic surgeries than adsorbable-type

We identified the stepwise increase of MIB-1 index in a long-surviving malignant peritoneal mesothelioma (MPM) patient with a history of frequent relapse. A 29-year-old Japanese woman showed upper abdominal induration with adnexal tumor. Imaging study with biochemical analyses strongly suggested peritoneal tumor. On primary surgery, all tumors were resected completely without any residual tumor. Histologically, the tumor was diagnosed as MPM, for which she received adjuvant chemotherapy containing platinum agent. Two years later, the tumor relapsed in her pelvic cavity, but was resected completely with hysterectomy and salpingo-oophorectomy. Histologically, the tumor was diagnosed as MPM relapse. She underwent intraperitoneal chemotherapy with cisplatin that achieved progression-free survival of 5 years. However, relapse was detected again in pelvic cavity without any dissemination in upper abdominal cavity. The tumors were completely removed and were revealed to be compatible with MPM. She received gemcitabine and carboplatin chemotherapy. However, 2 years later, the tumor relapsed again in left upper abdominal cavity, for which she wouldn’t receive 4th treatment. To investigate the longevity of this patient in association with the histologic findings, the MIB-1 index was examined in the primary and relapse tumors. The rate of MIB-1 index positive cells was calculated by counting 500 cells. MIB-1 indices were 4.2 ± 1.1 (mean ± SE), 11.8 ± 2.3, and 37.3 ± 2.5 in primary, 1st- and 2nd-relapsed tumor, respectively, demonstrating stepwise increase of MIB-1 expression over the surviving time of more than 9 years. Increase in MIB-1 index was not associated with mitotic index but may be indicating drug sensitivity, resulting in >2-year progression-free interval in each relapse.