Recurrent Granulosa Cell Tumor Research Articles

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.

Rapidly Growing Ovarian Granulosa Cell Tumor Following Complete Debulking for Suspected Ovarian Cancer with Histopathology Result of Benign Ovarian Cyst

Ovarian granulosa cell tumor (GCT) is a rare low-grade malignancy condition. One type of GCT is adult GCT (AGCT), which has the tendency for late recurrence. AGCT is clinically palpable and focally cystic and solid. In this case report, a condition of recurrent ovarian cancer after laparotomy debulking surgery was reported. A 57-year-old woman, who was diagnosed with AGCT, had a history of laparotomy debulking three months prior and complained of abdominal pain and enlargement, along with significant weight loss. Ultrasound examination revealed a solid cyst, raising suspicion of recurrent ovarian cancer. Laboratory results indicated elevated CA-125 levels. Histopathology results confirmed metastasis of AGCT, after the second laparotomy debulking was done. Recurrence of GCT is uncommon within three months of debulking. In this rare condition, we suggested a laparotomy debulking and adjuvant chemotherapy as a treatment. Effectiveness of treatment of recurrent disease is an independent risk factor to reduce the risk of another relapse and increase the survival rate.Keywords: granulosa cell tumor, ovarian cancer, debulking

Clinical outcomes with leuprolide acetate for the treatment of recurrent granulosa cell tumor (160)

Clinical outcomes with leuprolide acetate for the treatment of recurrent granulosa cell tumor (160)

Clinical outcomes of leuprolide acetate in the treatment of recurrent ovarian granulosa cell tumors

The optimal treatment of recurrent ovarian granulosa cell tumors is not known. Preclinical studies and small case series have suggested direct antitumor activity of gonadotropin-releasing hormone agonists in the treatment of this disease, but little is known about the efficacy and safety of this approach. This study aimed to describe patterns of use and clinical outcomes of leuprolide acetate in a cohort of patients with recurrent granulosa cell tumors. This was a retrospective cohort study of patients enrolled in the Rare Gynecologic Malignancy Registry at a large cancer referral center and affiliated county hospital. Patients meeting inclusion criteria had a diagnosis of recurrent granulosa cell tumor and received either leuprolide acetate or traditional chemotherapy as cancer treatment. Outcomes were separately examined for leuprolide acetate used as adjuvant treatment, maintenance therapy, and the treatment of gross disease. Demographic and clinical data were summarized using descriptive statistics. Progression-free survival was calculated from the initiation of treatment to the date of disease progression or death, and compared between groups with the log-rank test. The 6-month clinical benefit rate was defined as the percentage of patients without disease progression 6 months after starting therapy. Sixty-two patients received a total of 78 leuprolide acetate-containing therapy courses, owing to 16 instances of retreatment. Of these 78 courses, 57 (73%) were for treatment of gross disease, 10 (13%) were adjuvant to tumor reductive surgery, and 11 (14%) were for maintenance therapy. Patients had received a median of 2 (interquartile range, 1-3) systemic therapy regimens before their first leuprolide acetate treatment. Tumor reductive surgery (100% [62/62]) and platinum-based chemotherapy (81% [50/62]) were common before first leuprolide acetate exposure. The median duration of leuprolide acetate therapy was 9.6 months (interquartile range, 4.8-16.5). Nearly half of the therapy courses were single-agent leuprolide acetate (49% [38/78]). Combination regimens most often included an aromatase inhibitor (23% [18/78]). Disease progression was the most common cause of discontinuation (77% [60/78]); only 1 patient (1%) discontinued leuprolide acetate because of adverse events. In the treatment of gross disease, the 6-month clinical benefit rate for first use of leuprolide acetate was 66% (95% confidence interval, 54-82). Median progression-free survival was not statistically different compared with that which followed chemotherapy (10.3 months [95% confidence interval, 8.0-16.0] vs 8.0 months [95% confidence interval, 5.0-15.3]; P=.3). In a large cohort of patients with recurrent granulosa cell tumors, the 6-month clinical benefit rate of first-time leuprolide acetate treatment of gross disease was 66% and progression-free survival was comparable to patients treated with chemotherapy. Leuprolide acetate regimens were heterogeneous, but significant toxicity was rare. These results support leuprolide acetate as safe and effective for the treatment of relapsed adult granulosa cell tumors in the second line and beyond.

Prolonged Disease-Free Survival in a Relapsed Adult Granulosa Cell Tumor of the Ovary Treated by Combined Leuprolide and Letrozole: Case Report

Relapsing ovarian granulosa-cell tumor (GCT) is a challenge for physicians due to the lack of effective therapy. Current strategies did not improve the 80% death rate of recurrent disease. GCTs synthesize estrogens and express follicle-stimulating hormone, gonadotropin-releasing hormone, and estrogen and progesterone receptors. The FOXL2-C134W mutation is shared in all GCTs, and its downregulation of hormone-related apoptosis appears causal in induction of tumor phenotype. On these assumptions, hormone anti-estrogenic therapies have been proposed for recurrent GCTs. A 32-year-old woman suffering from GCT was first treated by surgery in 2004 and staged as IA disease. Two subsequent pelvic relapses were diagnosed in 2006 and 2007, and the patient underwent surgery and chemotherapy to treat both recurrences. Overall, she underwent five subsequent surgical interventions and two chemotherapy instances. A third single pelvic relapse above the vaginal cuff was diagnosed in 2013. Based on the patient’s refusal to undergo further surgery we proposed an anti-estrogen therapy consisting of combined GnRH analogue leuprolide and the aromatase inhibitor letrozole. Complete remission was obtained after 3 months from the start of therapy. Subsequently, we found that disease-free survival was maintained over 9 years of treatment. Although recent reports indicate poor effectiveness of hormone therapy to treat recurrent GCTs, the success of this case indicates that a subset of patients with recurrent GCT maintain a tumor phenotype highly responsive to anti-estrogen drugs.

Pathogenic and therapeutic particularities in recurrent ovarian granulosa cell tumors

Ovarian granulosa cell tumors represent a rare histopathological subtype of ovarian malignancies which are usually diagnosed in early stages of the disease and have a favorable prognosis. However, in certain cases recurrence might occur even if long disease free survival periods are encountered. The aim of the current paper is to discuss the patterns of spread in this histopathological subtype as well as the most important therapeutic strategies in cases diagnosed with ovarian granulosa cell tumors recurrence.

Estradiol promotes cell survival and induces Greb1 expression in granulosa cell tumors of the ovary through an ERα-dependent mechanism.

Granulosa cell tumor (GCT) is a form of ovarian tumor characterized by its tendency to recur years after surgical ablation. Little is known about the mechanisms involved in GCT development and progression. GCTs can produce estradiol (E2), but whether this hormone could play a role in this cancer through its nuclear receptors, i.e. ERα and ERβ, remains unknown. Here, we addressed this issue by cell-based and molecular studies on human GCTs and GCT cell lines. Importantly, we observed that E2 significantly increased the growth of GCT cells by promoting cell survival. The use of selective agonists of each type of receptor, together with Esr1 (ERα) or Esr2 (ERβ)-deleted GCT cells, revealed that E2 mediated its effects through ERα-dependent genomic mechanisms and ERβ/ERα-dependent extra-nuclear mechanisms. Notably, the expression of Greb1, a prototypical ER target gene, was dose-dependently upregulated by E2 specifically through ERα in GCT cells. Accordingly, using GCTs from patients, we found that GREB1 mRNA abundance was positively correlated to intra-tumoral E2 concentrations. Tissue microarray analyses showed that there were various combinations of ER expression in primary and recurrent GCTs, and that ERα expression persisted only in combination with ERβ in ~40% of recurrent tumors. Altogether, this study demonstrates that E2 can promote the progression of GCTs, with a clear dependence on ERα. In addition to demonstrating that GCTs can be classified as a hormone-related cancer, our results also highlight that the nature of ER forms present in recurrent GCTs could underlie the variable efficiency of endocrine therapies. © 2021 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Treatment patterns and survival outcomes of recurrent adult-type granulosa cell tumors

Objectives: Granulosa cell tumors are characterized by indolent growth and late recurrence; treatment of recurrent disease is not standardized. We sought to evaluate the outcomes of patients who underwent secondary and tertiary cytoreductive surgery as part of treatment for recurrent granulosa cell tumor. Methods: A retrospective review was conducted of women diagnosed with primary or recurrent granulosa cell tumors at an urban university system between 2010 and 2019. Data collected included demographic, clinicopathologic, and treatment factors. Endpoints of treatment outcome was progression free survival. Statistical analyses were preformed using the Kaplan-Meier method, the log-rank test, and Fisher's exact test. Results: 75 patients diagnosed with primary or recurrent granulosa cell tumor were identified. After excluding cases with inadequate follow-up and juvenile granulosa cell tumor, 69 patients were analyzed. The average age at diagnosis was 48.3 years (21.2-86.0). 82.6% of patients had stage I disease; the remainder had stage II (8.7%) or stage III (8.7%) disease. 15 of 69 patients (21.7%) were treated for recurrent disease. The average time to recurrence was 6.27 years (range 1.05-20.71). There was a significant correlation between optimal resection or staging (including omentectomy and peritoneal biopsies) and recurrence (OR 0.171, 95% CI 0.0553-0.560, p=0.0076). Fertility preservation was not associated with recurrence (p=0.08). 71% of women with recurrent disease underwent secondary cytoreduction. Secondary CRS was associated with a significantly higher progression free survival compared to medical management alone at time of recurrence (median 2.3 vs 1.6 yrs, p=-0.01). 10 women were subsequently treated for a second recurrence; 50% were treated with cytoreductive surgery. No PFS benefit was seen with surgical management compared to medical management for the second recurrence (p=0.31). Seven women were then treated for a third recurrence or progression and six women for a fourth. PFS after treatment for second, third, or fourth recurrence or progression was longer among patients whose treatment included surgery compared to those who did not (median 1.708 vs 0.997 years), although this difference was not statistically significant. Conclusions: Complete staging for granulosa cell tumors was associated with decreased risk of recurrence. Secondary CRS at first recurrence is associated with a significantly higher progression free survival.

Procaspase-Activating Compound-1 Synergizes with TRAIL to Induce Apoptosis in Established Granulosa Cell Tumor Cell Line (KGN) and Explanted Patient Granulosa Cell Tumor Cells In Vitro.

Granulosa cell tumors (GCT) constitute only ~5% of ovarian neoplasms yet have significant consequences, as up to 80% of women with recurrent GCT will die of the disease. This study investigated the effectiveness of procaspase-activating compound 1 (PAC-1), an activator of procaspase-3, in treating adult GCT (AGCT) in combination with selected apoptosis-inducing agents. Sensitivity of the AGCT cell line KGN to these drugs, alone or in combination with PAC-1, was tested using a viability assay. Our results show a wide range in cytotoxic activity among the agents tested. Synergy with PAC-1 was most pronounced, both empirically and by mathematical modelling, when combined with tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). This combination showed rapid kinetics of apoptosis induction as determined by caspase-3 activity, and strongly synergistic killing of both KGN as well as patient samples of primary and recurrent AGCT. We have demonstrated that the novel combination of two pro-apoptotic agents, TRAIL and PAC-1, significantly amplified the induction of apoptosis in AGCT cells, warranting further investigation of this combination as a potential therapy for AGCT.

Role of inhibin B in detecting recurrence of granulosa cell tumors of the ovary in postmenopausal patients

IntroductionSeveral biomarkers have been proposed for the detection of recurrences in adult-type granulosa cell tumors of the ovary. Here we validate the value of inhibin B in detecting recurrences and...

Mixtures of persistent organic pollutants increase ovarian granulosa tumor cell line migration and spheroid invasion by upregulating MMP2 expression and activity via IGF1R

Granulosa cell tumors (GCT) of the ovary have a good prognosis. Recurrence tends to be late; however, > 66 % of patients with recurrent GCT die from the disease. Most recurrences are abdominopelvic, although distant metastases have been documented. Here, we tested the hypothesis that a mixture of persistent endocrine-disrupting chemicals (EDCs) stimulates the invasion of GCT cells. We selected perfluorooctanoate (PFOA, 2 ng/mL), perfluorooctanesulfonate (PFOS, 8 ng/mL), 2,2-dichlorodiphenyldichloroethylene (p,p’-DDE, 1 ng/mL), polychlorinated biphenyl 153 (PCB153, 100 pg/mL), and hexachlorobenzene (HCB, 50 pg/mL), which have the highest measured concentrations in follicular fluid of women undergoing treatment with assisted reproductive technology. The human GCT cell lines COV434 and KGN have been used as in vitro models of juvenile (JGCT) and adult (AGCT) GCT subtypes, respectively. Cells were treated with a mixture of the test compounds for 15 min prior to analysis of protein phosphorylation; for 4 h prior to analysis in a circular chemorepellent-induced defect assay; for 6 h prior to analysis of matrix metalloproteinase 2 (MMP2) activity; for 24 h prior to analysis of migration, invasion, and gene expression; and for 48 h prior to analysis of protein expression. First, we showed that KGN cells migrated and exhibited invasive behavior. By contrast, COV434 cells lacked migration and invasion potential. Moreover, expression of mesenchymal genes and the gene encoding MMP2 was higher in KGN cells, and that of epithelial genes lower, than that in COV434 cells. Treatment of KGN cells with the EDC mixture stimulated cell migration, invasion, and lymphatic dissemination. The results suggest that the role of the EDC mixture in AGCT invasion is not related to changes in expression of epithelial and mesenchymal genes; rather, it is related to increased expression and activity of MMP2. Additionally, silencing insulin-like growth factor 1 (IGF1R) in AGCT abolished the stimulatory effect of the EDC mixture on KGN spheroid invasion. These results demonstrate that the EDC mixture increased KGN spheroid invasion by stimulating expression and activity of MMP2 via IGF1R.

GnRHa as A Treatment for Letrozole-Resistent Recurrent Adult Granulosa Cell Tumors:A Case Report and Literature Review

GnRHa as A Treatment for Letrozole-Resistent Recurrent Adult Granulosa Cell Tumors:A Case Report and Literature Review

Management of recurrent granulosa cell tumor of the ovary: Contemporary literature review and a proposal of hyperthermic intraperitoneal chemotherapy as novel therapeutic option.

Granulosa cell tumors of the ovary (GCT) are the most common type of sex cord stromal tumors. Although most of patients are diagnosed at early stage and has favorable 5-year overall survival rate, 16-23% of GCT ultimately develop recurrent disease. Recurrences are characterized by disseminated peritoneal metastasis. The treatment options include systemic chemotherapy, secondary CRS or palliative localized radiation therapy have not yet standardized due to the rarity of disease. Aggressive CRS followed up by hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to provide benefit in other peritoneal disease but limited data available for recurrent GCT. We have a case of recurrent Adult-type GCT (AGCT) who was treated with CRS followed by HIPEC with mitomycin C and doxorubicin. The patient has no evidence of recurrence for approximately 11 years. An electronic search of the PubMed database with the following search terms: GCT, HIPEC showed that there were total 21 patients with recurrent GCT treated in seven different studies and 13 of 21 (61.9%) patients had no evidence of disease during follow-up ranging from 6 to 100 months. Three patients (14.2%) died of the disease. Six studies used cisplatin for HIPEC. At least 76.2% (16 of 21, data not available for five patients) had complete cytoreduction with total 16 cases of perioperative complications but no perioperative mortality was observed. Although further investigation is needed, we propose that CRS and HIPEC can be an effective therapeutic option for recurrent GCT at experienced institutions.

S2447 Acute Abdominal Pain; The Answer Lies in the Remote History

INTRODUCTION: Granulosa cell tumors (GCT) encompass 2-3% of ovarian tumors characterized by low malignancy potential and late relapse, which rarely metastasize to the liver. We describe a patient with a recurrent ovarian GCT with liver and diaphragm metastasis 12 years after her initial diagnosis. CASE DESCRIPTION/METHODS: 51-year-old diabetic female with a history of cholecystectomy, and stage IA granulosa cell tumor status post total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-SBO) with post-procedure chemotherapy with carboplatin-taxol in 2008, currently in remission; presented with intermittent and sharp right upper quadrant abdominal pain for a week. Her liver chemistry showed ALT: 379; AST: 254; ALP: 171 U/l. Her viral markers were negative. Abdominal imaging showed a new subcapsular liver lesion involving the right hepatic lobe concerning for hematoma versus metastases. MRI showed a persistent hepatic subcapsular process of unclear etiology. Diagnostic laparotomy was performed which showed multiple implants of soft, removable tissue throughout the dome of the liver, and the diaphragm. Pathology revealed granulosa cells consistent with the recurrence of granulosa cells as liver metastasis. The patient was later discharged with multidisciplinary outpatient follow up. DISCUSSION: Granulosa cell tumors (GCT) are the most common type of sex cord-stromal tumors which represent 2–3 % of total ovarian tumors. GCT tends to bleed, often presenting with intrapelvic bleeding and lower abdominal pain. They are associated with a favorable prognosis, especially when they are detected in the early stages. Reported 5-year survival rates range from 55% to 97%. Several series have shown the recurrence rates range between 9 and 35%. GCTs are associated with a low incidence of hepatic metastasis (<5–6%). Call-Exner bodies are pathognomonic for its diagnosis with immunohistochemistry analysis positive for CD56, CD99, inhibin-alfa, and S-100. Long-term free disease periods can prolong in some cases to more than 20 years. Surgical resection of the liver lesion remains to be the most successful approach to provide a better percentage of remission, quality of life, and disease-free intervals despite its possible complications. It is usually followed by systemic chemotherapy to obtain better tumor control and an improved long-term survival rate.Figure 1.: Subcapsular process along the right lobe of the liver.Figure 2.: Lower and high magnification tumor cells consistent with granulosa cell tumor.Figure 3.: Call-exner body.

Basket study of the oral progesterone antagonist onapristone ER in women with progesterone receptor positive (PR+) recurrent granulosa cell tumor (GCT), low-grade serous ovarian cancer (LGSOC), or endometrioid endometrial cancer (EEC).

TPS6098 Background: Onapristone extended release (ER) is a type I full progesterone antagonist that inhibits progesterone mediated PR activation and stabilizes PR association with corepressors. Onapristone has shown activity across multiple preclinical models of hormonally driven cancer. A phase I dose escalation study of onapristone ER in PR+ breast, endometrial and ovarian cancer patients found all doses tested to be well tolerated, with 50mg PO BID determined to be the recommended phase 2 dose (RP2D). GCT (98% of cases PR+), LGSOC (58% of cases PR+) and EEC (67% of cases PR+) are hormonally driven cancers which generally have poor responses to chemotherapy and limited treatment options in the recurrent setting. Methods: This is an open-label, investigator-initiated basket study of onapristone ER in patients with PR+ recurrent GCT, LGSOC, or EEC currently enrolling patients at Memorial Sloan Kettering Cancer Center in NY, USA (NCT03909152). The primary objective is to evaluate the efficacy, in terms of response rate by RECIST 1.1 criteria, within 36 weeks of treatment. Eligible patients must have received at least 1 prior line of chemotherapy, have measurable disease by RECIST 1.1 criteria, and have tumor tissue collected within 3 years prior to enrollment with PR expression ≥ 1% by IHC. Patients are allowed to have unlimited additional prior lines of chemotherapy, biologic therapy, immunotherapy or hormonal therapy. Enrolled patients are treated with onapristone ER 50mg PO BID until time of progression or intolerable toxicity. The 3 disease cohorts are currently enrolling to Stage I in parallel with expansion from stage I to stage II planned when the prespecified response criteria are met for each cohort as described in the table below. Clinical trial information: NCT03909152. [Table: see text]

Abstract LB-C18: An integrated multiplexing approach for the immunoprofiling of the tumor microenvironment of ovarian granulosa cell tumors

Abstract Background: Granulosa cell tumors (GCTs) are rare tumor in ovaries accounting for 2-5% of all ovarian cancers. The main current treatment for GCT is surgery, however a subset require chemotherapy for residual and recurrent disease. GCT malignancies are often low-grade with a five-year survival rate up to 90%, however a clinical characteristic of these tumors is a tendency for late recurrence and a high recurrent rate is the most critical factor for GCT death. As the onset of recurrence is unpredictable, future research should focus on identifying both biomarkers for prognosis prediction, as well as targets that could help guide clinical trials in the development of targeted therapies for this rare indication. As GCTs are rare tumors and tissue availability is very limited, we used a dual multiplexing approach in order to maximize the data output from a total of 14 FFPE tumor samples (6 primary tumors, and 8 recurrent tumors). With this approach we used a single 4 μm section to detect 15 markers in an IF multiplexing assay, and an adjacent 10 μm section to analyze expression of 770 immuno-related cancer genes with the aim to spatially profile T cell subsets, tumor-associated macrophages (TAMs), B cells, tumor proliferation, angiogenic vessels, as well as markers differentially expressed between primary and recurrent tumors. Methods: For protein multiplexing we have used MultiOmyx™, an immunofluorescence (IF) multiplexing assay utilizing a pair of directly conjugated Cyanine dye-labeled (Cy3, Cy5) antibodies per round of staining. Each round of staining is imaged and followed by dye inactivation, and deep learning based cell classification algorithms identify positive cells for each biomarker to identify a 15-marker panel consisting of CD3, CD4, CD8, FoxP3, CD68, CD163, HLA-DR, CD34, CTLA-4, PD-1, PD-L1, Ki67, vimentin, S100, and Pan Cytokeratin. Gene expression analysis was done using the Nanostring nCounter assay, specifically the 770 gene PanCancer Immune Panel. RNA was extracted from the adjacent 10μm section and then proceeded with hybridization, purification and immobilization and count based on manufacturer’s protocol. Results: On protein level we confirmed previous findings that ovarian GCTs are so-called “cold” tumors, with a very low density of T cell infiltration. Likewise, levels of both CTLA-4, PD-1, and PD-L1 were very low in all GCTs. We are currently analyzing gene expression signatures for tumor antigens, defects in antigen presentation, and absence of T cell activation in order to detect some of the mechanisms behind the low T cell infiltration in this tumor type. When we analyzed the presence of TAMs in the tumor microenvironment (TME) however, we found a 113% increase in TAM density in recurrent tumors compared to primary tumors, and when doing a nearest neighbor analysis of the proximity between M2-type TAMs and angiogenic vessels in the TME, we found M2 TAMS to be much closer associated with the vessels. Interestingly, on gene level we found SPP1 (the gene coding for osteopontin) to have a 9-fold higher expression in recurrent versus primary GCT tumors, while VEGFA was found to have a 3-fold higher expression. As a pro-inflammatory cytokine osteopontin is thought to both facilitate the recruitment of TAMs and to stimulate angiogenesis by inducing VEGF expression in endothelial cells, suggesting that osteopontin could be a therapeutic target in patients with recurrent GCT. Citation Format: Anna Juncker-Jensen, Tyvette S Hilliard, Nicholas Stavrou, Mate Nagy, Erinn Parnell, Judy Kuo, Eric Leones, Sharon Stack. An integrated multiplexing approach for the immunoprofiling of the tumor microenvironment of ovarian granulosa cell tumors [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr LB-C18. doi:10.1158/1535-7163.TARG-19-LB-C18

Abstract NT-089: TRAIL-EXPRESSING ONCOLYTIC VACCINIA VIRUS COMBINED WITH SMALL-MOLECULE DRUG PAC1 IS A POTENTIALLY EFFECTIVE TREATMENT ALTERNATIVE FOR OVARIAN CANCERS

Abstract INTRODUCTION: Procaspase activating compound-1 (PAC1) is a small-molecule drug shown in vitro to sequester inhibitory zinc ions from caspase-3. TNF-related apoptosis-inducing ligand (TRAIL) is a pro-apoptotic ligand that binds membrane-bound death receptors, triggering the extrinsic apoptotic pathway. Both agents display low toxicity in humans. Vaccinia virus (VACV) is a double-stranded DNA virus that has shown therapeutic efficacy in clinical trials and has an established safety profile in humans due to its use as the smallpox vaccine. First-line standard of care for ovarian cancer is combination taxane and carboplatin, which has significant potential toxicity and 70% of women who receive it suffer relapse. Clinical trials involving TRAIL, both alone and combined with other drugs, have shown that while it is well-tolerated it is ineffective partly due to insufficient dosing at the tumour site. In an effort to uncover a safer, more effective therapeutic for ovarian cancer we report here on the successful construction of a recombinant oncolytic vaccinia virus expressing TRAIL (VACVTRAIL). Secretion of TRAIL by VACV-infected cancer cells will result in localized administration of TRAIL at higher dosages and minimize potential side-effects. We posit that treatment with PAC1 and VACVTRAIL represents a potentially safe, effective treatment for ovarian cancers. RESULTS: Testing in cell line models of granulosa cell tumour (GCT) have shown that recombinant human (rh)TRAIL is effective in combination with PAC1. Dose-response assays established that combination of PAC1 (20 μM) with rhTRAIL (10 ng/mL) dramatically reduced viability of cancer cells while being substantially less toxic to normal cells. Replication of those assays on patient-derived primary and recurrent GCT cells confirmed PAC1 combined with rhTRAIL was dramatically more cytotoxic than treatment with rhTRAIL or PAC1 alone. To optimize delivery of TRAIL to tumour cells, we constructed a recombinant VACVTRAIL virus that secretes TRAIL in the range of 70–80 ng/mL. Dose-response curves showed VACVTRAIL to be strongly cytotoxic with an ED50 of 0.1 plaque forming unit (PFU) per cell. Comparing toxicity of VACVTRAIL to a non-TRAIL-expressing VACV established that secretion of TRAIL is the basis for VACVTRAIL superiority in killing GCT cells, and supernatant collected from infected cells is more effective at reducing cell viability when combined with PAC1 than is rhTRAIL combined with PAC1. CONCLUSION: We have successfully constructed a TRAIL-expressing oncolytic VACV which produces effective levels of active TRAIL from infected cells. Results in vitro suggest combining PAC1 with oncolytic VACVTRAIL will allow localized delivery of TRAIL resulting in a safe, synergistic, self-amplifying therapy. Citation Format: Powel Crosley, Kate Agopsowicz, Kyle Potts, Ryan Noyce, Marjut Pihlajoki, Markku Heikinheimo, Anniina Färkkilä, David Evans, Mary Hitt. TRAIL-EXPRESSING ONCOLYTIC VACCINIA VIRUS COMBINED WITH SMALL-MOLECULE DRUG PAC1 IS A POTENTIALLY EFFECTIVE TREATMENT ALTERNATIVE FOR OVARIAN CANCERS [abstract]. In: Proceedings of the 12th Biennial Ovarian Cancer Research Symposium; Sep 13-15, 2018; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2019;25(22 Suppl):Abstract nr NT-089.

Clinical Determinants Affecting Indications for Surgery and Chemotherapy in Recurrent Ovarian Granulosa Cell Tumor.

Background: Because reports on the management of recurrent granulosa cell tumor have been sparse, a consensus as to which patients should undergo surgical resection and which patients should be considered for chemotherapy has not been established. Methods: A total of 21 tumor recurrences in eight patients with granulosa cell tumor were reviewed. Results: Surgery was performed as the main treatment for 13 recurrences, while chemotherapy was chosen as the main treatment for eight recurrences. Complete tumor resection could be accomplished in 13 of 16 surgeries (81.3%), which include all the ten recurrences without involvement of liver or diaphragm and without ascites. The number of recurrent masses was significantly higher in the early recurrence group (progression free survival < 2 years) than in the late recurrence (progression free survival > 2 years). All cases with a solitary recurrent tumor at an extra-peritoneal site presented a significantly longer progression free survival. Conclusions: For patients with recurrent granulosa cell tumor, surgery may provide the best disease control. In cases with complete resection, the number of recurrent masses was the predictive factor for the next recurrence, and adjuvant chemotherapy might be considered in such cases.

Molecular pathway activation-based analysis for personalized prescription of tyrosine kinase inhibitors for advanced solid tumor patients.

e15636 Background: Tyrosine-kinases (TKs) play key roles in cancer by acting as major components of various signaling pathways. Tyrosine kinase inhibitors (TKIs) act by inhibiting TKs, thereby modulating downstream signaling. Here we report a molecular pathway analysis-based approach to personalize prescription of TKIs for advanced and recurrent solid tumors, exemplified by successful cases of off-label prescriptions of TKIs to unresectable metastatic cholangiocarcinoma (MCC) and to recurrent ovarian granulosa cell tumor (GCT) patients. Methods: To isolate RNA, we used patient’s tumor histologically verified formalin fixed, paraffin embedded (FFPE) tissue blocks containing &gt; 75% tumor cells. Gene expression levels were established using CustomArray platform. Tumor expression was compared with the corresponding normal tissues and a second-opinion platform Oncobox (Omicsway, USA) was applied for finding abnormally activated molecular pathways and for the corresponding ranking of target drugs. Results: For a 26-year-old woman with progressive ovarian GCT despite multiple previous lines of therapy who underwent salvage therapy selection, the following target drugs could be potentially most effective for treatment according to the Oncobox test: Regorafenib, Sorafenib, Sunitinib, Pazopanib, Axitinib, Imatinib. In Oct 2015, patient was administered Sorafenib, but it was not well tolerated, and this therapy was terminated after 2 months. However, ultrasound examination indicated an associated decrease in the size of neoplasms. Therapy regimen was switched to Imatinib, which was well tolerated and resulted in a disease stabilization. As for Feb 2019, Imatinib administration is continued and patient is physically active with Karnofsky scale index 90%. Another patient with MCC was prescribed with subsequent TKI monotherapies for Sorafenib and Pazopanib that occupied, respectively, 2nd and 4th positions of the Oncobox drug rating. It resulted in a two-year stabilization. Conclusions: Our results evidence that sequential personalized prescription of different TKIs based of gene expression tests may be a perspective avenue of further clinical investigations.

Recurrent Granulosa Cell Tumors of the Ovary Successfully Treated with Laparoscopic Surgery

Objective: To report the case of recurrent granulosa cell tumors of an ovary that were successfully treated with laparoscopic surgery.