Adult-type Granulosa Cell Tumors Research Articles

Abstract 942: Response to systemic therapies in patient-derived cell lines from primary and recurrent adult granulosa cell tumors

Abstract Introduction: In patients with adult-type granulosa cell tumor (aGCT), a rare subtype of ovarian cancer, surgery is the preferred treatment for both primary and recurrent disease. However, the probability of complete resection decreases after multiple recurrences, in which case systemic treatment is an alternative option. Response rates of systemic therapy are variable, resistance is a problem and it is difficult to predict which therapy will work in which patient. Drug screen testing on patient-derived aGCT cell lines may offer a solution. Methods: In a national prospective study on aGCT, fresh tissue was collected immediately after surgery. Tumor tissue was cultured and developed into 2D cell lines. Both clinically applicable and experimental drugs were tested on the patient-derived cell lines and two control cell lines. Dose-response curves and synergy were calculated using GraphPad Prism and Compusyn software. Results: We cultured 34 patient-derived cell lines from tissue of seven patients with primary aGCT and from 13 patients with recurrence. In eight patients multiple sites were cultured. A total of 27 drugs were tested, including 10 monotherapies and 17 combinations. Carboplatin/gemcitabine showed efficacy and synergy 33 of 34 patient-derived cell lines (97%), in contrast to the regular carboplatin/paclitaxel and carboplatin/etoposide combinations (50% and 74%, respectively). The experimental combinations alpelisib/fulvestrant and alpelisib/gemcitabine showed efficacy of more than 75%. Testing of anti-hormonal therapy was not sufficiently reliable with this technique. Conclusion: Drug screening on patient-derived tumor cell lines adequately reflects the reality of the variable response to systemic therapy in aGCT. In future research, this technique could be used to personalize the systemic treatment of aGCT patients. The response to carboplatin/gemcitabine in our patient-derived cell lines is striking. Citation Format: Geertruid Brink, Nizar Hami, Sander Mertens, Ward Hofhuis, Jurgen Piek, Cor de Kroon, Christianne Lok, Eva Maria Roes, Luc van Lonkhuijzen, Hans Nijman, Hugo Snippert, Jolijn Groeneweg, Petronella Witteveen, Ronald Zweemer. Response to systemic therapies in patient-derived cell lines from primary and recurrent adult granulosa cell tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 942.

A phase II, multicenter, open-label study of abemaciclib and letrozole in patients with estrogen receptor-positive rare ovarian cancer: ALEPRO trial

BackgroundLow-grade serous and endometrioid ovarian cancers and adult-type granulosa cell tumors are rare ovarian malignancies that show high estrogen receptor positivity. Recurrences of these subtypes of ovarian cancer are often...

Abstract B057: Oncogenic Foxl2 directs enhancer reprogramming and changes in 3D genome structure in ovarian granulosa cell tumors

Abstract Background: Adult-type granulosa cell tumors (aGCTs) are a rare monogenic disease. Nearly all aGCTs carry a missense point mutation in the Forkhead domain containing FOXL2 (Foxl2 p.C134W) transcription factor, but the oncogenic mechanism of this mutation is unknown. Other Forkhead family transcription factors have well-described “pioneer” activity, binding to compacted, nucleosome-bound DNA and increasing accessibility for other regulatory proteins. Objectives: To investigate if oncogenic Foxl2-C134W has pioneering activity and if mutant Foxl2 operates its oncogenic activity through enhancer reprogramming. Methods: CRISPR/Cas9 editing was used to generate isogenic granulosa cell tumor cells lacking either the FOXL2 wild-type allele (single knock-out; SKO) or both the mutant and wild-type FOXL2 alleles (double knock-out; DKO). ATAC-Seq and endogenous Foxl2 ChIP-Seq were performed on these isogenic lines to determine the differential chromatin accessibility at Foxl2-bound regulatory regions across genotypes. Promoter capture HiC was performed using a bespoke genome-wide hybrid capture probe set, CHiCAGO was used to identify significant HiC interactions, and an activity-by-contact model was constructed to identify enhancer elements bound by endogenous Foxl2-C134W and determine their target promoter contact frequency (promoter capture HiC) and enhancer activity (geometric mean of H3K27ac and ATACseq signal. Results: Endogenous ChIP-seq of Foxl2-C134W from the SKO cell line identified 1147 high-confidence peaks. De novo motif discovery identified the canonical Foxl2 binding motif (TGTTTACATT, P = 1.4 × 10−7) in 44.9% of peaks, as well as a novel variant motif (TGTTTTGTCT, P = 6.7 × 10−15) in 68.5% of peaks. Median chromatin accessibility at Foxl2-C134W peak regions, as measured by ATAC-seq, was significantly decreased in the DKO cells compared to either SKO or parental cell lines (P < 2 × 10-16 for both comparisons). Decreased chromatin accessibility at Foxl2-C134W ChIP-seq peaks in the DKO cells was driven by peaks containing the novel variant Foxl2 binding motif. Promoter capture HiC through activity-by-contact model identified promoter-enhancer interactions lost in the DKO cell line involving several genes, including ADAMTS5, FOXF2, and PRICKLE1 (adjusted P < 0.05). Conclusion: Foxl2-C134W exhibits “pioneering” activity, increasing chromatin accessibility at key gene regulatory elements with associated re-programming of promoter-enhancer interactions. The oncogenic mechanism of Foxl2-C134W in granulosa cell tumors may involve changes in DNA binding specificity, re-directing this pioneering function to sites containing a novel variant Foxl2 binding motif. Citation Format: Veena K. Vuttaradhi, Eleonora Khlebus, Thomas Welte, Barrett Lawson, Robert Tyler Hillman. Oncogenic Foxl2 directs enhancer reprogramming and changes in 3D genome structure in ovarian granulosa cell tumors [abstract]. In: Proceedings of the AACR Special Conference on Ovarian Cancer; 2023 Oct 5-7; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(5 Suppl_2):Abstract nr B057.

Abstract A023: Pre-clinical evaluation of the gamma-secretase inhibitor nirogacestat in an adult-type ovarian granulosa cell tumor model

Abstract Introduction: Adult type ovarian granulosa cell tumors (GCTs) represent 5-7% of ovarian cancers and are the most common subtype of ovarian sex cord stromal tumors. Primarily driven by a C134W mutation in FOXL2 (present in ~97% of tumors), GCTs have a tendency for late recurrence without effective treatment options. Expression of mutant FOXL2 results in modified binding to transcription factors, including members of the SMAD family, and changes in apoptotic pathway signaling. Notch is an essential pathway for development of the ovary and plays important roles in the post-natal ovary including regulation of folliculogenesis, meiosis, vasculogenesis, and steroid hormone production. Notch signaling has been shown to promote FOXL2 expression, and cleavage of the Notch intracellular domain (NICD) by the enzyme gamma secretase (GS) can enhance SMAD signaling and promote interactions of SMADs with binding partners, including NICD. Emerging evidence suggests that Notch signaling, which is activated by GS-mediated cleavage, can promote tumor growth. Nirogacestat is an investigational, oral, small-molecule, selective gamma-secretase inhibitor (GSI) which, in a phase 3 study in patients with progressing desmoid tumors, significantly improved progression-free survival compared with placebo. Previous studies showed that inhibition of Notch signaling in a granulosa tumor cell line by the GSI “DAPT” could increase apoptosis and inhibit proliferation. Therefore, this study sought to evaluate effects of nirogacestat in FOXL2 C134W mutant granulosa cells. Methods: The effects of nirogacestat were evaluated in vitro using the “KGN” GCT cell line, which harbors a FOXL2 C134W mutation. Cell proliferation of KGN cells was analyzed by MTT assay, and clonogenic survival was analyzed using crystal violet staining in a dose-response assay. Furthermore, gene expression analysis of markers of cell cycle (TOP2A, CCNE2), epithelial to mesenchymal transition (SNAI2, MMP2), and apoptosis (CASP6) was performed by qPCR. Results: Nirogacestat significantly inhibited the proliferation of KGN cells in a dose-dependent manner. Similarly, clonogenic survival was significantly reduced after 10 days of treatment and correlated with administered concentration of nirogacestat treatment in vitro. We also observed a significant reduction in the expression of cell cycle markers TOP2A and CCNE2 by qPCR after 1 week of treatment with nirogacestat. Additionally, we found a significant induction of the apoptotic marker CASP6 and reductions of the EMT markers SNAI2 and MMP2 after high-dose treatment with nirogacestat. Conclusion: Treatment of the KGN GCT cell line with nirogacestat in vitro inhibited cell proliferation and growth in a concentration-dependent manner. Furthermore, nirogacestat markedly inhibited the expression of cell cycle markers, suggesting a cytostatic effect in granulosa cells which aligns with results from studies in desmoid tumor models. Collectively, these data suggest that nirogacestat represents a potential novel therapeutic agent for treatment of adult type GCTs. Citation Format: Maeva Y. Chauvin, David Pépin. Pre-clinical evaluation of the gamma-secretase inhibitor nirogacestat in an adult-type ovarian granulosa cell tumor model [abstract]. In: Proceedings of the AACR Special Conference on Ovarian Cancer; 2023 Oct 5-7; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(5 Suppl_2):Abstract nr A023.

A cellular model provides insights into the pathogenicity of the oncogenic FOXL2 somatic variant p.Cys134Trp.

FOXL2 is a transcription factor expressed in ovarian granulosa cells. A somatic variant of FOXL2 (c.402 C > G, p.Cys134Trp) is the hallmark of adult-type granulosa cell tumours. We generated KGN cell clones either heterozygous for this variant (MUT) or homozygous for the wild-type (WT) allele by CRISPR/Cas9 editing. They underwent RNA-Seq and bioinformatics analyses to uncover pathways impacted by deregulated genes. Cell morphology and migration were studied. The differentially expressed genes (DEGs) between WT/MUT and WT/WT KGN cells (DEGs-WT/MUT), pointed to several dysregulated pathways, like TGF-beta pathway, cell adhesion and migration. Consistently, WT/MUT cells were rounder than WT/WT cells and displayed a different distribution of stress fibres and paxillin staining. A comparison of the DEGs-WT/MUT with those found when FOXL2 was knocked down (KD) in WT/WT KGN cells showed that most DEGs-WT/MUT cells were not so in the KD experiment, supporting a gain-of-function (GOF) scenario. MUT-FOXL2 also displayed a stronger interaction with SMAD3. Our work, aiming at better understanding the GOF scenario, shows that the dysregulated genes and pathways are consistent with this idea. Besides, we propose that GOF might result from an enhanced interaction with SMAD3 that could underlie an ectopic capacity of mutated FOXL2 to bind SMAD4.

Adult-type granulosa cell tumor associated with elevated luteinizing hormone: Two rare case reports.

Adult-type granulosa cell tumors (AGCTs), which account for 2% to 5% of all malignant ovarian tumors, are rare sex cord-stromal tumors that usually secrete excess estrogens, but they can also secrete androgens. We report 2 patients of childbearing age with AGCT who presented with the complaint of abnormal menstruation and elevated luteinizing hormone (LH), and mildly elevated testosterone. The ovarian tumors had hormonal activity. The 2 patients underwent laparoscopic left adnexectomy. The second patient underwent 4 cycles of chemotherapy with paclitaxel and carboplatin as adjuvant treatments. Their postoperative pathology confirmed AGCTs. Also, their menstrual cycle returned to normal, with normal serum LH and testosterone levels. There was no sign of recurrence. The cases suggest that elevated serum LH levels may be a sign of unknown tumors in cases of oligomenorrhea or secondary amenorrhea. It is useful to evaluate the serum levels of inhibin B and anti-Müllerian hormone to improve the early recognition of ovarian granulosa cell tumors.

Effectiveness of adjuvant systemic therapy following complete cytoreductive surgery in patients with recurrent granulosa cell tumours of the ovary

Aim of the present analysis is to compare the impact of antihormonal therapy versus cytotoxic chemotherapy versus a watch a wait approach on disease-free survival (DFS) in the adjuvant setting of patients who underwent complete cytoreductive surgery(CRS) for recurrent adult type granulosa cell tumours of the ovary (GCT). Moreover, we wished to identify prognostic risk factors for recurrence. We included recurrent GCT-patients who underwent CRS resulting in total macroscopic tumour clearance, treated in two gynaecological cancer centres over a 20-year period (2000–2020). CRS was performed for 51 recurrences in 26 GCT-patients. Adjuvant systemic treatments were as follows: chemotherapy in 21 cases, hormonotherapy in 10 cases, no systemic treatment in 20 cases. There were no statistically significant differences in DFS between chemotherapy, hormonotherapy and no systemic treatment: median DFS was 57, 36 and 57 months, respectively (p = 0.616). Extra-pelvic and/or multifocal tumour dissemination were found to be independent predictive factors for subsequent recurrences. In the cases with both lower and upper abdominal involvement (n = 18), patients who received chemotherapy (n = 9) had longer DFS than those who had hormonotherapy (n = 2) or no adjuvant therapy (n = 7) at all: median DFS was 36, 13 and 15 months, respectively (p = 0.9). Our findings do not encourage the administration of adjuvant therapy following complete CRS for GCT-relapse. Selected high-risk patients with disseminated disease may derive clinical benefit from additional chemotherapy, larger-scale multicentre studies are warranted to define treatment algorithms for this rare disease.

Serial cytoreductive surgery and survival outcomes in recurrent adult-type ovarian granulosa cell tumors

BackgroundFew studies have evaluated the role of cytoreductive surgery in patients with recurrent adult granulosa cell tumors of the ovary. Despite a multitude of treatment modalities in the recurrent setting, the optimal management strategy is not known. Cytoreductive surgery offers an attractive option for disease confined to the abdomen/pelvis. However, few studies have evaluated the role of surgery compared to systemic therapy alone following the first recurrence and subsequent disease progressions. ObjectiveTo determine the impact of secondary, tertiary, and quaternary cytoreductive surgery on survival outcomes in recurrent adult granulosa cell tumors of the ovary. Study DesignThis is a multicenter, retrospective cohort study evaluating patients with recurrent adult granulosa cell tumor of the ovary enrolled in the MD Anderson Rare Gynecologic Malignancy Registry from 1970 to 2022. Study inclusion criteria consisted of histology-proven recurrent disease, at least one documented recurrence, and treatment/treatment planning at MD Anderson Cancer Center or Lyndon B. Johnson General Hospital. The primary exposure was cytoreductive surgery and the outcomes of interest were progression-free survival and overall survival. Survival analyses were restricted to eligible patients with resectable disease without medical barriers to surgery at each progression episode. Demographic and Clinicopathologic characteristics were summarized using descriptive statistics. Progression-free survival (after first, second, and third progression) and overall survival were estimated with methods of Kaplan and Meier and were modeled via cox proportional hazards regression. Multivariable analyses were performed for progression-free survival after first progression and overall survival. ResultsAmong the 369 patients with adult granulosa cell tumors of the ovary in the registry, there were 149 patients who met the study inclusion criteria. Secondary cytoreductive surgery was associated with a significant improvement in progression-free survival on univariable (HR 0.37, 95% CI 0.17 – 0.81, p = 0.01) and multivariable analyses (HR 0.42, 95% CI 0.19 – 0.92, p = 0.03). Those who underwent secondary cytoreductive surgery had a significantly improved median overall survival compared to those who did not undergo cytoreductive surgery (181.92 months vs 61.56 months, respectively; p = 0.002). Overall survival benefit remained statistically significant on multivariable analysis (HR 0.28, 95% CI 0.11 – 0.67, p = 0.004). Tertiary cytoreductive surgery was similarly associated with a significant improvement in progression-free survival (HR 0.43, 95% CI 0.26 – 0.70, p = 0.001). Despite a similar trend, quaternary cytoreductive surgery was not associated with a significant improvement in progression-free survival (HR 0.74, 95% CI 0.42 – 1.26, p = 0.27). ConclusionsAmong those with resectable disease and no medical contraindications to surgery, cytoreductive surgery may offer a beneficial impact on progression-free survival and overall survival in patients with recurrent adult granulosa cell tumor of the ovary.

Is there a role of cytoreductive surgery with HIPEC in recurrent ovarian granulosa cell tumors? An Indian cancer center experience with review of literature

Abstract Background: Granulosa cell tumors of the ovary represent the most common sex-cord stromal tumors. Though characterized by an indolent course and a good five-year survival rate, they tend to have late recurrences and subsequent poorer survival. The role of hyperthermic intraperitoneal chemotherapy (HIPEC) in women with recurrent granulosa cell tumors with peritoneal dissemination has not been well defined. Methods: All patients with adult or juvenile type granulosa cell tumors who underwent cytoreductive surgery with HIPEC with 70 mg/m2 of cisplatin for 60 minutes over a period of four years were retrospectively evaluated. We also performed a review of the literature on similar cases reported. Results: We identified eight patients with recurrent adult granulosa cell tumors (AGCT) who fulfilled our inclusion criteria. The mean operative duration was 340 minutes, inclusive of the duration of HIPEC. Fifty percent of patients suffered from postoperative morbidity. Grade 4 morbidity was observed in one patient. At a median follow-up of 35 months, four patients experienced disease recurrence. The median disease-free survival was 10 months (range: 6–31 months) and the median overall survival was 11.5 months (range: 7–40 months). Conclusion: Cytoreductive surgery (CRS) and HIPEC provides a unique opportunity for treating peritoneal dissemination in patients with recurrent ovarian AGCTs. This procedure is well tolerated with acceptable morbidity. Prospective studies are warranted to further elucidate the efficacy of this novel therapeutic approach in recurrent ovarian granulosa cell tumors.

Rare malignant tumors of the ovary during pregnancy: a clinical case report

This article describes a clinical case of a malignant ovarian neoplasm, which was first detected during an urgent visit of a pregnant woman with signs of fetal distress in the third trimester of pregnancy. The relevance of this problem lies in the possibility of early diagnosis of adnexal tumors during routine ultrasound screenings, the lack of definitive recommendations for the management of such patients and the limited range of treatment methods during pregnancy. The aim of the study is to demonstrate a clinical case of pregnancy with late-detected ovarian malignancy. A 39-year-old pregnant woman at 35 weeks and 4 days' gestation consulted the antenatal clinic of a city maternity hospital with complaints of a decrease in the number and change in the nature of fetal movements over the past 24 hours. After assessment of the fetal condition (cardiotocography, ultrasound), the woman was hospitalized with a diagnosis: Pregnancy III, 35 weeks and 4 days. Fetal distress in the antenatal period. Fetal growth restriction, stage I. Gestational hypertension without significant proteinuria. Multicompartmental cyst of the right ovary. An urgent cesarean section was performed. Clinical diagnosis: рremature delivery by cesarean section. Medical care for the mother with fetal growth restriction of the first degree, fetal distress in the antenatal period. Cyst of the right ovary. Right-sided adnexectomy. Omental resection. Gestational hypertension. On the 5th day, the patient was discharged in a satisfactory condition with a recommendation for further examination in an oncology hospital. Pathological examination of the right ovary: morphological picture, taking into account the results of immunohistochemical examination, in favor of undifferentiated carcinoma; on repeated viewing - granular cell tumor of the ovary of adult type. The patient was routinely hospitalized at the city oncology center for surgical treatment and further examination. Clinical diagnosis: Bl ovarii gr I, adult-type granulosa cell tumor, T1Nx Mx. Condition after surgical treatment: lower midline laparotomy. Pangisterectomy, omentectomy. Sampling of the retroperitoneal lymph nodes on the right. Sanitation and drainage of the abdominal cavity. Clinical group II. The results of this article are of great practical importance for obstetricians-gynecologists, general surgeons and ultrasound diagnosticians in the differential diagnosis of indirect signs of malignant tumors during pregnancy, in the need to examine all pelvic organs during routine ultrasound screening of pregnant women and in establishing cause and effect relationships in the diagnosis of obstetric complications.

Impact of cytoreductive surgery on survival outcomes for recurrent adult-type granulosa cell tumors of the ovary.

5573 Background: Adult-type granulosa cell tumor of the ovary (aGCT) is a rare tumor that often relapses and the optimal management strategy is not known. Cytoreductive surgery (CRS) offers an attractive option for disease confined to the abdomen/pelvis. However, few studies have evaluated the role of CRS compared to systemic therapy alone. Thus, the study objective was to determine the impact of secondary, tertiary, and quaternary CRS on survival outcomes for patients with relapsed aGCT. Methods: This was an IRB-approved retrospective cohort study that evaluated all patients with relapsed aGCT who were enrolled in the Rare Gynecologic Malignancy Registry at MD Anderson. Study inclusion criteria were patients who had histology-proven aGCT, were above 18 years of age, had at least one documented relapse, and had received treatment or treatment planning at MD Anderson. Progression-free survival (PFS) endpoints were the outcomes of interest and were defined as follows: PFS2 was defined from first recurrence to subsequent progression or death (PFS2), PFS3 was defined as second relapse/progression to third relapse/progression or death, and PFS4 was similarly defined. PFS2, PFS3, and PFS4 were estimated with methods of Kaplan and Meier and were modeled via cox proportional hazards regression. Analyses were performed among those with resectable disease at time of disease progression. Results: Among the 369 aGCT patients identified from January 1970 to October 2022, 162 met the study inclusion criteria for analysis. The mean age of diagnosis was 44.4 years old and the majority were initially diagnosed with stage 1 disease (72.8%). The median follow-up time for all patients was 5.86 years (range 0.09 – 34.27). At the first relapse, there were 151 patients who had resectable disease with 128 who underwent secondary CRS. PFS2 was significantly improved among those who underwent CRS compared to those who did not (HR 0.50, 95% CI 0.30 – 0.81; p = 0.005) with the median PFS2 difference being 18.24 months (p = 0.006). At the second relapse/progression, there were 120 patients with resectable disease with 52 who underwent tertiary CRS. PFS3 was significantly improved among those who underwent CRS compared to those who did not (HR 0.57, 95% CI 0.39 – 0.84; p = 0.004) with the median PFS3 difference being 6 months (p = 0.01). At the third relapse/progression, there were 96 patients with resectable disease with 46 who underwent quaternary CRS. There was a trend towards improved PFS3 among those who underwent CRS compared to those who did not (HR 0.69, 95% CI 0.45 – 1.06; p = 0.09). The use of systemic or hormonal therapy did not confer additional PFS benefit among those who underwent CRS. Conclusions: For relapsed, resectable aGCT, CRS may offer a beneficial impact on PFS. Future studies should evaluate the role of CRS on survival outcomes.

Abstract 1462: Oncogenic Foxl2 is a chromatin-remodeling pioneer transcription factor in adult-type ovarian granulosa cell tumors

Abstract Background: A missense mutation in the Forkhead domain-containing FOXL2 (Foxl2 p.C134W) transcription factor is found in nearly all adult-type granulosa cell tumors, but the oncogenic mechanism of this mutation is not known. Other Forkhead family transcription factors have well-described “pioneer” activity, binding to compacted, nucleosome-bound DNA and increasing accessibility for other regulatory proteins. Objectives: To develop novel cell culture model systems and determine whether oncogenic Foxl2-C134W has pioneering activity. Methods: CRISPR/Cas9 editing was used to generate isogenic granulosa cell tumor cells lacking either the FOXL2 wild-type allele (single knock-out; SKO) or both the mutant and wild-type FOXL2 alleles (double knock-out; DKO). ATAC-Seq and endogenous Foxl2 ChIP-Seq were performed on these isogenic lines to determine the differential chromatin accessibility at Foxl2-bound regulatory regions across genotypes. ENCODE pipelines and data standards were used for analysis, and the irreproducible discovery rate was used to identify high-reliability ATAC-seq and ChIP-seq peaks. De novo motifs were identified with STREME. Promoter capture HiC was performed using a bespoke genome-wide hybrid capture probe set, and CHiCAGO was used to identify significant HiC interactions. Results: Endogenous ChIP-seq of Foxl2-C134W from the SKO cell line identified 1147 high-confidence peaks. De novo motif discovery identified the canonical Foxl2 binding motif (TGTTTACATT, P = 1.4 x 10-7) in 44.9% of peaks, as well as a novel variant motif (TGTTTTGTCT, P = 6.7 x 10-15) in 68.5% of peaks. Median chromatin accessibility at Foxl2-C134W peak regions, as measured by ATAC-seq, was significantly decreased in the DKO cells compared to either SKO or parental cell lines (P < 2 x 10-16 for both comparisons). No difference was observed between SKO and parental cell lines (P = 0.19). Decreased chromatin accessibility at Foxl2-C134W ChIP-seq peaks in the DKO cells was driven by peaks containing the novel variant Foxl2 binding motif. Promoter capture HiC identified promoter-enhancer interactions lost in the DKO cell line involving several genes, including HUNK, NOVA1, andSFRP2 (adjusted P < 0.05). Conclusion: Foxl2-C134W exhibits “pioneering” activity, increasing chromatin accessibility at key gene regulatory elements with associated re-programming of promoter-enhancer interactions. The oncogenic mechanism of Foxl2-C134W in granulosa cell tumors may involve changes in DNA binding specificity, re-directing this pioneering function to sites containing a novel variant Foxl2 binding motif. Citation Format: Veena Vuttaradhi, Eleonora Khlebus, Thomas Welte, Namrata Khurana, Barrett Lawson, Robert Tyler Hillman. Oncogenic Foxl2 is a chromatin-remodeling pioneer transcription factor in adult-type ovarian granulosa cell tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1462.

Abstract 453: Targeting FOXL2C402Gvulnerabilities in adult type ovarian granulosa cell tumors

Abstract Background: Nearly all adult-type granulosa cell tumors of the ovary (aGCTs) carry the same oncogenic mutation affecting the second winged helix domain of the Forkhead family transcription factor FOXL2 (c.C402G; p.C134W). There are no currently available therapies that exploit the high prevalence of FOXL2 mutations in this disease. Objectives: Exploit FOXL2-C402G oncogenic addiction in order to identify FDA-approved compounds with differential potency in KGN-FOXL2WT/C402G cells and isogenic KGN-FOXL2—/— cells. Methods: CRISPR/Cas9 was used to generate isogenic derivatives of KGN, a cell line derived from a recurrent aGCT. Parental cells (KGN-FOXL2WT/C402G) or isogenic cells lacking both FOXL2 alleles (KGN-FOXL2—/—) were functionally characterized and loss of Foxl2 protein was confirmed by immunoblot. Two drug libraries comprising a total of 2,416 compounds (majority FDA approved) were screened for effectiveness in KGN-FOXL2WT/C402G cells and KGN-FOXL2—/— cells. Our assay included staining with DAPI, followed by automated image analysis of each well to enumerate nuclei/cell numbers. Based on Fraction Affected (FA) statistics, compounds were ranked according to effectiveness in KGN-FOXL2WT/C402G cells. FA-area under the curve (FA-AUC) cutoff >0.1 yielded 152 drug candidates, categorized into 13 drug classes. 40 drug candidates, including the top 1-4 hits in each drug class were chosen for further validation. Validation rate in the confirmatory screen was at 95%. A novel primary tumor organoid culture system for aGCT was developed and validated using whole exome sequencing and immunophenotype. Selected candidate compounds were further investigated in aGCT organoid cultures from two relapsed tumors. Results: We identified classes of drugs such as the inhibitors of Bromodomain family proteins and Hydroxy-Camptothecin analogs, with enhanced activity in KGN-FOXL2WT/C402G cells relative to KGN-FOXL2—/— cells. Unexpectedly glucocorticoids as a class were found to stimulate proliferation of KGN-FOXL2WT/C402G cells whereas they lacked this activity in KGN-FOXL2—/— cells. For 36 glucocorticoids present in the screen, FA-AUC ranged from -0.3191 to -0.1342 (highest proliferation index among all test compounds) in KGN-FOXL2WT/C402G cells compared to -0.0353 to +0.1667 in KGN-FOXL2—/— cells. In recurrent aGCT organoids, the high-potency glucocorticoid dexamethasone induced cell proliferation and co-treatment with glucocorticoids increased the IC50 of paclitaxel in KGN-FOXL2WT/C402G cells from 1.43 nM to 4.04 nM. Conclusion: Mutant FOXL2 mediates a proliferative response to glucocorticoids in cultured cells and primary aGCT organoids. Paclitaxel is a standard of care chemotherapy in the treatment of aGCTs and is often administered with glucocorticoid pre-medication. The adverse effect of glucocorticoids on paclitaxel efficiency shown here should thus be taken into consideration in the clinic. Citation Format: Thomas Welte, Veena Vuttaradhi, Eleonora Khlebus, Barrett Lawson, Robert T. Hillman, Nghi Nguyen, Mary Sobieski, Reid T. Powell, Clifford Stephan. Targeting FOXL2C402Gvulnerabilities in adult type ovarian granulosa cell tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 453.

AN OVARIAN GRANULOSA CELL TUMOR IN A PATIENT WITH POLYCYSTIC OVARIAN SYNDROME: A CASE REPORT

Granulosa cell tumors (GCTs) are the second most common ovarian sex cord stromal tumors after fibroma/thecomas, accounting for less than 2% of all ovarian malignancies. GCTs are most common in postmenopausal women between the ages of 50 and 55, are usually diagnosed early, and have a good prognosis. GCTs are typically characterized by hyperestrogenism and have an average size of 10 to 15 cm. A 39-year-old nulligravida with polycystic ovarian syndrome (PCOS) discovered a 50-mm mass in her right ovary on ultrasonography. Pathological examination revealed an adult-type granulosa cell tumor with necrosis and hemorrhage. The tissue was positive for inhibin-, Wilms tumor-1, and CD56 but negative for cytokeratin 7. Finally, we performed a right salpingo-oophorectomy, an endometrial biopsy, a peritoneal biopsy, and a partial omentectomy. Pathology revealed an adult-type granulosa cell tumor. IA stood for International Federation of Gynecology and Obstetrics staging. The patient did not require any additional care. Surprisingly, her normal menstruation returned two weeks later, and she had a normal pregnancy and parturition. Following the surgery, There have been no complications and the patient is disease-free.

The Oncogenic FOXL2 C134W Mutation Is a Key Driver of Granulosa Cell Tumors.

A newly generated mouse model carrying a FOXL2 mutation characteristic of adult-type granulosa cell tumors shows that FOXL2 C134W shifts the transcriptome towards a signature of granulosa cell cancer and drives tumorigenesis.

Adult-Type Ovarian Granulosa Cell Tumour: Treatment Outcomes From a Single-Institution Experience.

Ovarian granulosa cell tumour is rare. This study aims to report the clinical characteristics and long-term outcomes of adult-type ovarian granulosa cell tumour (AOGCT) at King Faisal Specialist Hospital and Research Centre (KFSH&RC) and to determine the prognostic factors affecting relapse and survival. We retrospectively reviewed patients with AOGCT, from 1988 to 2014, who were treated at our institution. Baseline characteristics, pathological findings, and outcomes were analysed and reported. Sixty-one patients with AOGCT were identified with a median age of 49 years. Median follow-up was 5.0 years (range 2.1-8.2 years). 74% of patients were FIGO (InternationalFederationofGynecologyandObstetrics) stage I, whereas 7% were stage II, 5% were stage III, and unknown in 14% of the cases.The most common presenting symptoms included abdominal pain (43%) and vaginal bleeding (43%). The majority of patients (38 patients, 62%) were treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy.Five (8%) patients received adjuvant chemotherapy. Sixteen patients (26%) relapsed with a median time to relapse of 5.5 years (0.7-8.1 years). Half of the recurrences (eight patients, 50%) occurred after five years of diagnosis. Five-year overall survival and disease-free survival (DFS) were 93% and 84%, respectively. Factors associated with a high risk of recurrence were the presence of ascites (p=0.000) and elevated preoperative CA 125 level (p=0.048). The overall survival was significantly influenced by the menopausal status (premenopausal 100% vs. postmenopausal 84%; p=0.02), preoperative CA 125 (normal 100% vs. elevated 64%; p=0.005), ascites (present 33% vs. absent 100%; p=0.000), and age (<55 years 100% vs. ≥ 55 years 77%; p= 0.002). This study confirms a good outcome for patients with AOGCT.They require long-term follow-up as late recurrences can occur many years post definitive therapy.The presence of ascites and elevated preoperative CA 125 levels were associated with a higher risk of recurrence and poor prognosis. Outcomes appear unaffected by fertility-sparing surgery or adjuvant chemotherapy.

Adult-Type Granulosa Cell Tumor, an Unusual Site of Recurrent Tumor at The Sigmoid Colon: A Case Report and Literature Review

Granulosa cell tumor constitutes approximately 1% of all ovarian tumors. Extraovarian spread can occur as a late recurrence. The authors reported a case of 41-year-old woman with adult-type granulosa cell tumor at sigmoid colon. The patient visited the outpatient department for a yearly medical check-up with no specific complaints. She had a history of ovarian cystectomy 12 years prior. A mass in left pelvic cavity was revealed upon transvaginal ultrasonography and computer tomography (CT). At the time of laparoscopy, a well-defined subserosa mass was detected at the antimesenteric side of the sigmoid colon. The right and left ovaries appeared grossly normal. The tumor was successfully removed with laparoscopic sigmoidectomy. The pathologic findings were that of adult-type granulosa cell tumor, which was corresponding to the previous diagnosis made in the ovarian cystectomy specimen 12 years ago. The authors presented this case as an example of late recurrence of ovarian granulosa cell tumor in sigmoid colon, which could potentially be mistaken as other usual colonic tumors in the absence of previous history of ovarian tumor. Keywords: Colonic granulosa cell tumor; Extraovarian granulosa cell tumor; Sex cord-stromal tumor

A Descriptive Analysis of Patients Undergoing Cytoreductive Surgery for the First Peritoneal Recurrence from Adult Granulosa Cell Tumours: Focus on Disease Distribution, Morphology of Peritoneal Disease and the Role of HIPEC - a Retrospective Study by INDEPSO.

The aim of the present study was to report the clinical outcome and factors affecting survival in patients with first recurrence of AGC treated with cytoreductive surgery with or without HIPEC. The second aim was to study the disease distribution in the peritoneal cavity according to the peritoneal carcinomatosis index (PCI) and the morphology of peritoneal deposits. In this retrospective multicentric study, all patients of adult granulosa cell tumor with peritoneal recurrence were treated with CRS with or without HIPEC. Relevant clinical and demographic data were captured. Multivariable logistic regression was performed to evaluate the factors affecting recurrence after CRS ± HIPEC. Factors affecting survival and second recurrences were evaluated in addition to studying the disease distribution at first recurrence. In the period from January 2013 to December 2021, 30 consecutive patients of recurrent adult type granulosa cell tumor of the ovary undergoing CRS ± HIPEC were included in this study. The median follow-up duration was 55months [12-96months]. The median rPFS and rOS were both not reached. HIPEC (p = 0.015) was the only factor independently associated with a longer rPFS. CRS with or without HIPEC can be performed with an acceptable morbidity in patients with the first recurrence from adult granulosa cell tumours. The role of HIPEC, patterns of peritoneal spread and impact of other prognostic factors on the treatment outcome all need further evaluation in larger series of patients.

Tumor reductive surgery and survival outcomes in recurrent adult type granulosa cell tumors of the ovary (152)

Tumor reductive surgery and survival outcomes in recurrent adult type granulosa cell tumors of the ovary (152)

Anatomic patterns of recurrence in adult type granulosa cell tumors of the ovary (161)

<b>Objectives:</b> The objective of this study was to describe the anatomic patterns of recurrence, through multiple relapses, of adult-type granulosa cell tumors of the ovary (aGCTs). <b>Methods:</b> This was a retrospective cohort study that included women over the age of 18 with a histologic diagnosis of aGCT who were seen at one of two academic centers for the treatment of recurrent disease. Following IRB approval, demographic and clinical data were obtained from the medical records. Descriptive statistics were used to compare variables by treatment modality; p<0.05 was considered significant. <b>Results:</b> A total of 81 women met our study criteria and was included in the final cohort. The median age at initial diagnosis was 45 years (interquartile range [IQR]: 36-53 years). The median age at first recurrence was 53 years (IQR: 40-60 years). A total of 73 (90%) women had documented disease sites at first recurrence, which included the pelvis and pelvic lymph nodes (PLN) (37/73, 51%), paraaortic lymph nodes (PALN) (4/73, 6%), extra-pelvic abdomen or bowel (35/73, 48%) liver parenchyma (8/73, 11%), and lung (3/73, 4%). Of these patients, 58 (80%) received secondary tumor reductive surgery (TRS), while 45 (62%) received cytotoxic chemotherapy. A total of 48 (91%) women with a second recurrence had documented disease sites, of whom 30 (62%) received TRS and 21 (44%) received chemotherapy. Sites of disease in the second recurrence included pelvis/PLN (27/48, 56%), extra-pelvic abdomen or bowel (24/48, 50%), liver parenchyma (5/48, 10%), and/or lung (1/48, 2%). A total of 42 (79%) women with a third recurrence had documented sites of disease, of whom 21 (50%) received TRS and 14 (33%) received chemotherapy. Sites of disease include pelvis/PLN (21/42, 50%), extra-pelvic abdomen or bowel (17/42, 40%), liver parenchyma (4/42, 10%), and/or lung (2/42, 5%). A total of 31 (82%) women with a fourth recurrence had documented disease sites, with involvement of the pelvic cavity pelvis/PLN (14/31, 45%), extra-pelvic abdomen or bowel (14/31, 45%), liver parenchyma (5/31, 16%), and/or lung (1/31, 3%). Only nine women (29%) received TRS, and seven (23%) received chemotherapy for a fourth recurrence. Rates of TRS significantly decreased with each relapse (p<0.001). Rates of cytotoxic chemotherapy also decreased significantly (p<0.001). There were also no significant differences in the rate of locoregional disease (p=0.8) or distant metastases (p=0.9) between recurrences (Figure 1). No women in this cohort had documented central nervous system metastases.Fig. 1 <b>Conclusions:</b> Distant metastases of aGCT are rare, even after multiple lines of relapse, with the most recurrent disease confined to the abdomen and pelvis. Despite this, the frequency of TRS decreased through subsequent lines of treatment, suggesting that additional patient-related factors, such as performance status, may impact the decision to perform surgery for recurrent disease.