<b>Objectives:</b> Research on ovarian cancer (OC) initiation has primarily focused on the transformation from normal epithelium to invasive serous carcinoma; however, the role of the stromal microenvironment in cancer initiation is largely unexplored. We previously demonstrated that mesenchymal stem cells (MSCs), stromal progenitor cells in the OC microenvironment, are reprogrammed by tumor cells into cancer-associated MSCs (CA-MSCs). These reprogrammed CA-MSCs promote cancer growth, chemoresistance, and metastases. We sought to determine if changes in the stromal microenvironment occur prior to OC initiation. We identified a subset of MSCs in the fallopian tubes of women with germline <i>BRCA</i> mutations without cancer that have acquired a CA-MSC phenotype, which we term high-risk MSCs (HR-MSCs). We hypothesized that HR-MSCs acquire a tumor supportive phenotype prior to OC initiation that enhances the transformation of the normal epithelium into carcinoma. <b>Methods:</b> MSCs and fallopian tube epithelial cells (FTE) were isolated from fallopian tubes of women with germline <i>BRCA</i> mutations undergoing risk-reducing salpingo-oophorectomies without findings of cancer or pre-cancerous lesions upon standard pathologic examination. MSCs were characterized as low-risk (LR-MSCs) or high-risk (HR-MSCs) using a previously described MSC classifier score. Co-cultures were performed using normal FTE, <i>BRCA</i>-mutated (<i>BRCA</i>mut) FTE, and <i>BRCA</i>/p53-mutated FTE with LR-MSCs or HR-MSCs. FTE and MSC growth and proliferation were assessed using <i>in vitro</i> assays. We investigated the impact of HR-MSCs on FTE DNA damage after co-culture using FTE alone as control with yH2AX foci quantification. Long-term organoid co-cultures of MSCs and FTE were implanted into NSG mice to assess tumor initiation capacity. <b>Results:</b> HR-MSCs significantly enhance <i>BRCA</i>mut FTE growth compared to LR-MSCs. HR-MSCs also induced DNA damage in FTE. Strikingly, DNA damage induced by HR-MSCs was similar to that seen with hydrogen peroxide (H2O2) treatment of FTE. HR-MSCs also increased the survival of <i>BRCA</i>mut FTE after the induction of DNA damage by H2O2 treatment, indicating that HR-MSCs induce FTE DNA damage and promote survival of DNA-damaged FTE. HR-MSCs were also able to induce full malignant transformation as injecting HR-MSCs + <i>BRCA</i>mut FTE organoids-initiated tumors in one of three mice, and HR-MSCs + <i>BRCA</i>/p53-mut FTE organoids-initiated tumors in two of three mice (one of which developed metastasis). No mice injected with LR-MSCs or FTE alone developed tumors. <b>Conclusions:</b> A subset of women with <i>BRCA</i> mutations at high risk for OC contains fallopian tube-derived MSCs, which functionally support ovarian cancer initiation. These HR-MSCs increase FTE proliferation, induce FTE DNA damage, enhance survival of DNA-damaged FTE, and ultimately have the capacity to induce full malignant transformation with tumor initiation and metastasis <i>in vivo</i>. This highlights a critical role for the stromal microenvironment in OC initiation.Fig. 1
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