Olaparib plus bevacizumab first-line maintenance in ovarian cancer: final overall survival results from the PAOLA-1/ENGOT-ov25 trial

Controversies and clinical unknowns in the use of PARP inhibitors in ovarian cancer

Poly (adenosine diphosphate-ribose) polymerase inhibitors (PARPi) have significantly improved the treatment of advanced ovarian cancer, however, there are still many aspects of their use that require further understanding. The optimal duration, timing and dosage of these agents and how to manage (oligo) progression occurring both during and following PARPi therapy are discussed. The evidence supporting their rechallenge, and how to overcome resistance are addressed. The long-term impacts of PARPi and monitoring patients during therapy are all important research themes to expand on.

Signalomics for molecular tumor boards and precision oncology of breast and gynecological cancers

Precision oncology led to the establishment and widespread application of molecular tumor boards (MTBs)-multidisciplinary units combining molecular and clinical assessment of individual cancer cases for swift selection of personalized treatments. Whole-exome or gene panel sequencing, combined with transcriptomic, immunohistochemical, and other molecular analyses, often permits dissection of molecular drivers of a tumor and identification of its potential targetable vulnerabilities, instructing clinical oncologists on sometimes unconventional treatment options. However, cancer drivers are often unleashed mutation-independently, especially in breast and gynecological cancers, and deleterious mutations are not always pathogenic. To complement the MTB arsenal, we chart here the molecular toolset we call Signalomics that permits fast and robust assessment of a panel of oncogenic signaling pathways in fresh tumor samples. Using transcriptional reporters introduced in primary tumor cells, this approach identifies the pathways overactivated in a given tumor and validates their sensitivity to targeted therapies, providing actionable insights for personalized treatment strategies. Integration of Signalomics into MTB workflows bridges the gap between molecular profiling and functional pathway analysis, refining clinical treatment decisions and advancing precision oncology.

Efficacy of Maintenance Therapy With Adjuvant Chemotherapy of Three Steps in Patients Newly Diagnosed With Advanced Ovarian Cancer: A Phase II Randomised Clinical Trial

OBJECTIVE

To evaluate the efficacy and safety of adjuvant chemotherapy of three steps (ACTS) in patients newly diagnosed with advanced ovarian cancer.

DESIGN

Randomised clinical trial.

SETTING

The study was conducted at a single centre.

POPULATION

Newly diagnosed patients with advanced ovarian cancer who showed a complete response to standard chemotherapy (paclitaxel plus carboplatin) were included in this study.

METHODS

In this open-label phase II trial, patients were randomised 1:1 to receive either ACTS therapy or no maintenance treatment. The ACTS group received step-2 chemotherapy with cyclophosphamide and etoposide (six cycles) and step-3 chemotherapy with cyclophosphamide and carboplatin (six cycles). Key endpoints were overall survival (OS), progression-free survival (PFS) and adverse events.

MAIN OUTCOME MEASURES

The main outcome measures were OS, PFS and adverse events.

RESULTS

Of the 130 enrolled patients, 65 were assigned to the ACTS group and 65 to the control group. The median OS in the ACTS group was 61.2 months, and patients in the ACTS group had a significantly longer PFS than those in the control group (22.2 vs. 9.73 months). The most common grade ≥ 3 adverse events were thrombocytopenia and neutropenia. No treatment-related deaths occurred during the study period.

CONCLUSIONS

The Maintenance ACTS Regimen Improved PFS but Not OS and Showed a Tolerable Safety Profile in Patients Newly Diagnosed With Advanced Ovarian cancer.

TRIAL REGISTRATION

ClinicalTrials.org NCT02562365.

Clinical Practice of Poly (ADP-Ribose) Polymerase Inhibitors for Maintenance Treatment of Platinum-Sensitive Recurrent Ovarian Cancer in China

Clinical trials of three poly (ADP-ribose) polymerase (PARP) inhibitors, olaparib, niraparib and fuzuloparib, in platinum-sensitive recurrent ovarian cancer (PSR OC) in China showed that PARP inhibitors improved progression-free survival and achieved an all-comer indication in this population. We reviewed the efficacy and safety of these PARP inhibitors in patient populations studied in clinical trials and highlighted the positive role of PARP inhibitors in improving patient outcomes using clinical trials and real-world studies conducted in China. This article also discusses the issues encountered in clinical practice and how to evaluate the different indications for PSR OC in China and abroad.

Optimal bevacizumab treatment strategy in advanced ovarian cancer: A review

Bevacizumab was the first targeted therapy developed for newly diagnosed and recurrent advanced ovarian cancer (AOC). Although bevacizumab has been approved for the treatment of AOC for several years, identifying patients who may benefit most from this treatment is still debated. Bevacizumab has been associated with improved progression-free survival (PFS) regardless of clinical risk, but in some countries the use of bevacizumab in the treatment of newly diagnosed AOC has been restricted to higher-risk patients (stage III inoperable or suboptimally debulked disease, or stage IV disease); this is primarily due to the findings of exploratory subgroup analyses from phase III trials that suggest only higher-risk patients derive an overall survival (OS) advantage with bevacizumab. Recently reported post hoc analyses from the PAOLA-1 trial of maintenance olaparib plus bevacizumab versus bevacizumab alone for patients with newly diagnosed AOC and homologous recombination deficiency-positive tumors suggested PFS and OS benefit was achieved in both lower-risk (with stage III disease who had undergone upfront surgery and had complete resection) and higher-risk (with stage III disease who had undergone upfront surgery and had residual disease or who had received neoadjuvant chemotherapy, or with stage IV disease) patients, prompting reassessment of the role of bevacizumab in lower-risk patients. This review examines the role of bevacizumab in the AOC treatment pathway by discussing its efficacy and safety in the first-line, maintenance and recurrent settings, and evaluates the clinical implications of bevacizumab use across risk groups and lines of therapy.

Robust Assessment of Homologous Recombination Deficiency Genomic Instability by OncoScan Microarrays

Genomic instability scars are markers for detecting homologous recombination deficiency (HRD) status in patients with ovarian cancer and predicting the response to poly (ADP-ribose) polymerase inhibitor treatment. Currently, only a few reliable and validated assays are available, with the Myriad myChoice CDx being the most commonly used commercial assay for genomic instability scar score determination. Given the need for a more straightforward, accessible, and reliable method for detecting genomic instability scars methods, in this work, we describe the feasibility of using the microarray OncoScan copy number variant assay and open-source software packages to quantify genomic instability scores, and the development of an open-access online platform for genomic instability score calculation. The laboratory-developed test accurately classified homologous recombination-proficient and recombination-deficient samples based on genomic instability scores derived from the OncoScan copy number variant assay. Internally evaluated genomic instability scores demonstrated a 92% overall agreement and a higher sample success rate compared with externally analyzed genomic instability scar scores. The availability of HRD determination has doubled the number of patients eligible for poly (ADP-ribose) polymerase therapy. The assay can be conveniently performed on individual samples, and the open-access online platform facilitates HRD determination without the need for specialized bioinformatics support.

The Forefront of Maintenance Therapy for Newly Diagnosed Advanced Ovarian Cancer in China: A Review of Updated Evidence With PARP Inhibitors

BACKGROUND

In the first-line (1L) maintenance treatment of newly diagnosed advanced ovarian cancer (OC), poly (ADP-ribose) polymerase inhibitors (PARPi) have demonstrated significant benefits in progression-free survival (PFS) and an encouraging trend in overall survival (OS).

OBJECTIVES

To provide a summary of advances and evidence regarding the use of PARPi in the maintenance treatment of newly diagnosed advanced OC in the Chinese population.

SEARCH STRATEGY

Systematic search of PubMed from January 2016 to June 2024.

SELECTION CRITERIA

Phase III randomized trials and real-world studies conducted in China were included.

MAIN RESULTS

PARPi 1L maintenance studies conducted in China have shown that PARPi can prolong PFS in OC patients with manageable safety. Chinese patients differ from foreign patients in baseline characteristics and safety data. Given the current situation of 1L maintenance therapy in China, recommendations are made for maintenance strategies based on different biomarker status.

CONCLUSIONS

PARPi 1L maintenance therapy offers survival benefit to Chinese patients with newly diagnosed advanced OC. OC has become a chronic disease that requires the selection of appropriate maintenance regimens based on multiple factors.

State of the Art: Therapies Now and Around the Corner for Gynecologic Cancers

Therapeutic advances across the gynecologic cancer continuum have resulted in improvements in patient care and outcomes over the past decade, yet challenges remain. In ovarian cancer, the evolution of poly (ADP-ribose) polymerase (PARP) inhibitor therapy has resulted in marked benefit for patients with BRCA-mutated cancers but has also unmasked the need for new therapies in patients whose cancers are proficient in homologous recombination and lack vulnerability to PARP inhibitors, as well as for those patients whose cancers progress on PARP inhibitors. In endometrial cancer, immune checkpoint inhibitors (ICIs) have improved outcomes for patients receiving first-line therapy for advanced or recurrent disease when combined with standard-of-care chemotherapy. However, there remains uncertainty around which patients are most likely to benefit from the addition of immunotherapy, and treatment beyond first-line therapy remains an area of high unmet need. Similarly, ICIs added to chemotherapy for recurrent or metastatic cervical cancer or to chemoradiation for high-risk locally advanced cervical cancers has resulted in improved outcomes, but treatment options beyond this remain limited. Across gynecologic cancers, antibody-drug conjugates (ADCs) hold the promise for further improvement in patient outcomes. A prime example is the demonstrated benefit of mirvetuximab soravtansine over other standard chemotherapy options in folate receptor alpha-high platinum-resistant ovarian cancer. Maximizing such potential will require developing a deeper understanding of relationships between ADC target expression and activity, mechanisms of resistance, and potential approaches to sequencing. Beyond ADCs, additional therapies, including those targeting DNA damage response, remain in development.

Proton beam therapy achieves excellent local control for recurrent epithelial ovarian cancer: a single-center retrospective study

BACKGROUND

Previous studies have demonstrated the benefit of radiation therapy for patients with recurrent epithelial ovarian cancer; however, the effects of proton beam therapy in these patients remain unelucidated. This study aimed to evaluate the use of proton beam therapy in recurrent epithelial ovarian cancer and to identify factors predictive of local control.

RESULTS

This retrospective study included 13 patients with a total of 30 lesions who underwent proton beam therapy for recurrent epithelial ovarian cancer at our institution between October 2008 and March 2021. The median age of the patients at the initial proton beam therapy was 62 (range, 42-82) years. Eight patients had stage III or IV disease, and seven had serous carcinoma; ten patients exhibited platinum resistance. The irradiated sites included 16 lymph nodes and 9 pelvic or abdominal masses. The median tumor size and maximum standardized uptake value (SUVmax) of fluorine-18-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) were 25 (range, 9-83) mm and 12.6 (range, 3.9-25.1), respectively. The median total dose was 65 (range, 45-72) Gy (relative biological effectiveness). The 1- and 2-year local control were 91.5% and 71.3%, respectively. The SUVmax of 18F-FDG-PET/CT was a significant predictor of local control (cutoff value, 17.7). The median progressing-free and overall survival after proton beam therapy initiation were 9.6 and 21.5 months, respectively. No grade 3 or higher proton beam therapy-induced adverse events were observed.

CONCLUSION

Proton beam therapy demonstrated excellent local control of recurrent epithelial ovarian cancer, with tolerable toxicity, suggesting that this modality may represent a promising treatment option. The SUVmax of 18F-FDG-PET/CT performed prior to proton beam therapy may serve as a predictor of local control.

CLINICAL TRIAL NUMBER

Not applicable.

Unraveling Homologous Recombination Deficiency in Ovarian Cancer: A Review of Currently Available Testing Platforms

Homologous recombination deficiency (HRD) is a key biomarker associated with increased sensitivity to PARP inhibitors (PARPi) in advanced epithelial ovarian cancer. Accurate identification of HRD status is essential for selecting patients most likely to benefit from these therapies. Current diagnostic approaches combine sequencing to detect mutations in homologous recombination repair genes-particularly BRCA1 and BRCA2-with genome-wide analysis of structural genomic alterations indicative of HRD. This review briefly outlines the biological basis of HRD and its clinical significance and then focuses on currently available assays for HRD assessment. We compare their molecular strategies, including the use of targeted gene panels and genomic instability metrics such as loss of heterozygosity, telomeric allelic imbalance, and large-scale state transitions. The review also highlights the strengths and limitations of each platform and discusses their role in guiding clinical decision-making. Challenges related to dynamic tumor evolution and the interpretation of HRD status in recurrent disease settings are also addressed.

Interleukin-6 Is a Crucial Factor in Shaping the Inflammatory Tumor Microenvironment in Ovarian Cancer and Determining Its Hot or Cold Nature with Diagnostic and Prognostic Utilities

Ovarian cancer (OC) remains the leading cause of cancer-related deaths among women, often diagnosed at advanced stages due to the lack of effective early diagnostic procedures. To reduce the high mortality rates in OC, reliable biomarkers are urgently needed, especially to detect OC at its earliest stage, predict specific drug responses, and monitor patients. The cytokine interleukin-6 (IL6) is associated with low survival rates, treatment resistance, and recurrence. In this review, we summarize the role of IL6 in inflammation and how IL6 contributes to ovarian tumorigenesis within the tumor microenvironment, influencing whether the tumor is subsequently classified as "hot" or "cold". We further dissect the molecular and cellular mechanisms through which IL6 production and downstream signaling are regulated, to enhance our understanding of its involvement in OC development, as well as OC resistance to treatment. We highlight the potential of IL6 to be used as a reliable diagnostic biomarker to help detect OC at its earliest stage, and as a part of predictive and prognostic signatures to improve OC management. We further discuss ways to leverage artificial intelligence and machine learning to integrate IL6 into diverse biomarker-based strategies.

Homologous recombination deficiency and immunotherapy response in microsatellite-stable colorectal cancer: Evidence from a cohort study in China

BACKGROUND

Patients with colorectal cancer (CRC) exhibiting microsatellite instability (MSI)-high generally demonstrate a favorable response to immunotherapy. In contrast, the efficacy of immunotherapy in microsatellite-stable (MSS) CRC patients is considerably restricted. This study sought to evaluate the effectiveness of immunotherapy in MSS patients characterized by homologous recombination deficiency (HRD) as opposed to those with homologous recombination proficiency (HRP).

AIM

To investigate and compare the clinicopathological characteristics, treatment modalities, and outcomes between the HRD and HRP groups in CRC.

METHODS

Next-generation sequencing was performed on 268 CRC patients to identify tumor-associated genetic alterations and assess their HRD scores and MSI status. Patients with HRD-related gene alterations or an HRD score ≥ 30 were classified into the HRD group, while the remaining patients were assigned to the HRP group. Clinical data, including staging and treatment regimens, were collected for analysis. Cox regression and Kaplan-Meier survival curves were employed to evaluate whether the HRD group demonstrated improved survival outcomes following immunotherapy treatment.

RESULTS

Among the 268 patients, 64 were classified into the HRD group, which had a higher proportion of early-stage CRC diagnoses compared to the HRP group. Kaplan-Meier survival curves indicated significantly better survival rates in the HRD group compared to the HRP group across all cohorts, as well as among MSS patients treated with immunotherapy (P < 0.05).

CONCLUSION

This study demonstrates that CRC patients with HRD have a more favorable prognosis and suggests that HRD status could serve as a predictive marker for immunotherapy response in MSS patients.

Whole-exome sequencing provides assessment of homologous recombination deficiency for identification of PARPi-responsive ovarian tumors

BACKGROUND/OBJECTIVES

Homologous recombination repair deficiency (HRD) is frequently detected in gynecological cancers and is associated with sensitivity to poly-ADP ribose polymerase inhibition (PARPi). BRCA1/2 mutations have been approved as biomarkers for PARPi therapy, along with genomic patterns such as genomic loss of heterozygosity (gLOH) and large-scale transitions (LSTs). Clinical applications of various HRD assays are still under investigation. Here we validate the performance of a novel HRD assay based on whole-exome sequencing (WES).

METHODS

WES was used to evaluate gLOH, LST, and BRCA mutations and this data was compared to standard assays. An optimized genomic scar score (GSS) was based on combined gLOH and LST. A comprehensive HRD score was then developed, combining GSS and BRCA status. Survival data from 1661 PARPi-treated ovarian cancer patients was queried to optimize GSS and HRD scores associated with PARPi response.

RESULTS

A comparison of WES results to the OncoScan CNV assay and Myriad MyChoice assay showed high concordance for LOH values and GSS values, respectively. Median overall survival in PARPi-treated patients was 50.8 months for GSS-high, BRCA1/2-mut, 42.7 months for GSS-high, BRCA1/2-WT, and 36.6 months for GSS-low, BRCA1/2-WT patients with significant differences between each group. Combining the BRCA1/2-mut and WT GSS-high groups resulted in a median OS value of 47.8 months, significantly higher than the GSS-low BRCA1/2-WT group.

CONCLUSIONS

The use of a WES assay to assess BRCA results, along with a GSS method incorporating gLOH and LST, produced a HRD test that is predictive for PARPi therapy.

PARP Inhibitors in Ovarian Cancer: Resistance Mechanisms, Clinical Evidence, and Evolving Strategies

The introduction of poly (ADP-ribose) polymerase inhibitors (PARPi) into the management of ovarian cancer has transformed the treatment landscape for patients affected by this malignancy. However, as the use of PARPi expands into both frontline maintenance and recurrence settings, the emergence of drug resistance has become a significant clinical challenge in the treatment of these patients. Although platinum-based chemotherapy (PBC) and PARPi act through different mechanisms-PBC causes DNA damage while PARPi blocks its repair-both depend on the integrity of DNA damage repair (DDR) pathways, leading to overlapping mechanisms of resistance. Here, we review the key resistance mechanisms shared by PARPi and PBC, and then we discuss their clinical implications in the management of patients with ovarian cancer. We also examine clinical rationale supporting the hypothesis that prior PARPi exposure may reduce the efficacy of subsequent PBC in patients experiencing a disease recurrence. Furthermore, we review preliminary clinical data assessing the potential role of PARPi retreatment in patients who have previously progressed on PARPis.

Oncologist perceptions of "cure" and long-term management in advanced ovarian cancer in the United States: results from a cross-sectional survey

OBJECTIVES

Treatment advancements have improved survival outcomes for patients with advanced ovarian cancer. In advanced ovarian cancer, some physicians believe discussing "cure" as a potential treatment goal may be premature. In contrast, others note that the durable responses observed among some patients may suggest that long-term remission or "cure" are legitimate outcomes to strive for. Despite this, the term 'cure' has no accepted definition in this setting, and whether physicians are willing to use this language is unknown.

METHODS

A cross-sectional, internet-based survey was conducted to evaluate United States oncologists' attitudes and beliefs related to "cure" in the context of treating patients with newly diagnosed advanced ovarian cancer. The survey included questions on attitudes and beliefs toward patient prognosis with newly diagnosed advanced ovarian cancer, oncologists' perceptions of clinical outcomes, oncologist characteristics, and clinical practice details.

RESULTS

Among 150 oncologists, when addressing the topic of disease prognosis or treatment goals in patients newly diagnosed with stage III-IV ovarian cancer, the terms endorsed by more than half of oncologists were "achieve long-term remission" and "achieve long-term response." Terms including "cure" or "curable" were endorsed by less than 35% of oncologists. Among several patient characteristics evaluated, no evidence of disease for 5 to 10 years was most indicative of cure. In the context of primary disease, the proportion of oncologists who would tell a patient with advanced ovarian cancer they were cured, even if they believe it to be true, decreased with the stage (II = 73.8%; III = 60.8%; IV = 50.5%).

CONCLUSIONS

The current study found that while oncologists may believe a cure is possible across early stages of ovarian cancer, many remain hesitant to discuss the potential of "cure" with patients, particularly those with stage IV disease.

Comparative efficacy and safety of low-dose versus high-dose bevacizumab in ovarian cancer: An indirect treatment comparison

OBJECTIVE

First-line therapy for ovarian cancer involves cytoreductive surgery and platinum-based chemotherapy, with or without bevacizumab. Bevacizumab can be administered at low (7.5 mg/kg every three weeks [Q3W]) or high dose (15 mg/kg Q3W). This study compared the efficacy and safety of these dosing strategies.

METHODS

Systematic literature review of Embase, MEDLINE®, and CENTRAL (18/09/2023) identified randomized controlled trials (RCTs) evaluating bevacizumab versus any therapy or control in ovarian, fallopian tube, or primary peritoneal cancer. Indirect treatment comparisons (ITC) of response, survival, and safety outcomes were performed, including sensitivity/subgroup analyses adjusting for heterogeneity.

RESULTS

Six RCTs (sample size: 24-1528 patients) were included for ITC. Five evaluated high-dose bevacizumab with chemotherapy. The common comparator was carboplatin + paclitaxel. Trials mainly included stage III (n = 4) or stage II-III (n = 1) ovarian cancer patients; one did not report cancer stage. Primary analyses showed no significant differences between low- versus high-dose bevacizumab for partial response (risk ratio [95 % confidence interval]: 0.66 [0.42, 1.02]), complete response (1.76 [0.76, 4.11]), objective response rate (1.01 [0.63, 1.61]), progressive disease (1.08 [0.38, 3.10]), clinical benefit (0.89 [0.76, 1.03]), any grade ≥ 3 adverse event (1.53 [0.96, 2.44]), specific grade ≥ 3 adverse events, overall survival (hazard ratio: 0.93 [0.77, 1.13]), or progression-free survival (1.02 [0.86, 1.22]). Sensitivity and subgroup analyses confirmed findings.

CONCLUSIONS

This ITC found no significant difference in clinical outcomes between low- and high-dose bevacizumab combination therapy. Despite limitations of small sample size and heterogeneities, findings suggest that bevacizumab dose may not significantly impact ovarian cancer outcomes.

Overall survival with maintenance olaparib in platinum-sensitive relapsed ovarian cancer by somatic or germline BRCA and homologous recombination repair mutation status

BACKGROUND

The open-label, single-arm, multicentre ORZORA trial (NCT02476968) evaluated maintenance olaparib in patients with platinum-sensitive relapsed ovarian cancer (PSR OC) with a germline (g) or somatic (s) BRCA1 and/or BRCA2 mutation (BRCAm) or a non-BRCA homologous recombination repair mutation (non-BRCA HRRm).

METHODS

Patients were in response to platinum-based chemotherapy after ≥2 prior lines of treatment and underwent prospective central screening for tumour BRCA status, then central gBRCAm testing to determine sBRCAm or gBRCAm status. An exploratory cohort evaluated non-BRCA HRRm in 13 predefined genes. Patients received olaparib 400 mg (capsules) twice daily until investigator-assessed disease progression. Secondary endpoints included overall survival (OS) and safety.

RESULTS

177 patients received olaparib. At the final data cutoff (25 June 2021), median OS from study enrolment was 46.8 (95% confidence interval [CI] 37.9-54.4), 43.2 (31.7-NC [not calculated]), 47.4 (37.9-NC) and 44.9 (28.9-NC) months in the BRCAm, sBRCAm, gBRCAm and non-BRCA HRRm cohorts, respectively. No new safety signals were identified.

CONCLUSION

Maintenance olaparib showed consistent clinical activity in the BRCAm and sBRCAm cohorts; exploratory analysis suggested similar activity in the non-BRCA HRRm cohort. These findings highlight that patients with PSR OC, beyond those with gBRCAm, may benefit from maintenance olaparib.

External validation of prediction models for early relapse in advanced epithelial ovarian cancer using Australian and Dutch population-based data

OBJECTIVE

To externally validate the published postoperative and BRCA models predictive of early relapse in patients with advanced-stage epithelial ovarian cancer (EOC) using independent Australian and Dutch cohorts.

METHODS

Advanced-stage EOC patients diagnosed between January 1, 2002, and June 1, 2006, in Australia, and between January 1, 2016, and December 31, 2017, in the Netherlands were included. Data from patients who underwent cytoreductive surgery and platinum-based chemotherapy were used to validate both models. Missing data were addressed through multiple imputation. Model updates included recalibration-in-the-large, recalibration, and model revision, with a closed testing procedure to identify the most suitable approach. Model performance was assessed for calibration, discrimination, and the Brier score.

RESULTS

The Australian cohort (N = 1334) included 457 early relapsers and 859 late or non-relapsers, showing baseline differences compared to the development cohort. Discrimination was adequate for both the postoperative and BRCA models (c-statistics: 0.69 and 0.70, respectively). The postoperative model required full revision, while recalibration-in-the-large was sufficient for the BRCA model in the Australian cohort. The Dutch cohort (N = 1212) included 283 early relapsers and 929 late or non-relapsers, with baseline characteristics similar to those of the development cohort. Both models demonstrated adequate discrimination (c-statistics: 0.71 and 0.70, respectively). Recalibration-in-the-large corrected miscalibration in the Dutch cohort.

CONCLUSION

The postoperative and BRCA model were successfully validated for predicting early relapse in advanced-stage EOC patients, confirming their robustness. However, local data updates are advised to enhance accuracy across clinical settings. Online calculators were built for clinical use (Link 1; Link 2).

PARP Inhibitors in the Neoadjuvant Setting; A Comprehensive Overview of the Rationale for their Use, Past and Ongoing Clinical Trials

PURPOSEOF REVIEW

Poly (ADP-ribose) polymerases (PARPs) are enzymes essential for detecting and repairing DNA damage through poly-ADP-ribosylation. In cancer, cells with deficiencies in homologous recombination repair mechanisms often become more dependent on PARP-mediated repair mechanisms to effectively repair dsDNA breaks. As such, PARP inhibitors (PARPis) were introduced into clinical practice, serving as a key targeted therapy option through synthetic lethality in the treatment of cancers with homologous recombination repair deficiency (HRD). Though PARPis are currently approved in the adjuvant setting for several cancer types such as ovarian, breast, prostate and pancreatic cancer, their potential role in the neoadjuvant setting remains under investigation. This review outlines the rationale for using PARPi in the neoadjuvant setting and evaluates findings from early and ongoing clinical trials.

RECENT FINDINGS

Our analysis indicates that numerous studies have explored PARPi as a neoadjuvant treatment for HRD-related cancers. The majority of neoadjuvant PARPi trials have been performed in breast and ovarian cancer, while phase II/III evidence supporting efficacy in prostate and pancreatic cancers remains limited. Studies are investigating PARPi in the neoadjuvant setting of HRD-related cancers. Future research should prioritize combination strategies with immune checkpoint inhibitors and expand outcome measures to include patient satisfaction and quality-of-life metrics.

PARP inhibitors in ovarian cancer: Mechanisms of resistance and implications to therapy

Advanced epithelial ovarian cancer of the high-grade serous subtype (HGSOC) remains a significant clinical challenge due to the development of resistance to current platinum-based chemotherapies. PARP1/2 inhibitors (PARPi) exploit the well-characterised homologous recombination repair deficiency (HRD) in HGSOC and offer an effective targeted approach to treatment. Several clinical trials demonstrated that PARPi (olaparib, rucaparib, niraparib) significantly improved progression-free survival (PFS) in HGSOC in the recurrent maintenance setting. However, 40-70 % of patients develop Resistance to PARPi presenting an ongoing challenge in the clinic. Therefore, there is an unmet need for novel targeted therapies and biomarkers to identify intrinsic or acquired resistance to PARPi in ovarian cancer. Understanding the mechanisms of resistance to PARPi is crucial for identifying molecular vulnerabilities, developing effective biomarkers for patient stratification and guiding treatment decisions. Here, we summarise the current landscape of mechanisms associated with PARPi resistance such as restored homologous recombination repair functionality, replication fork stability and alterations to PARP1 and PARP2 and the DNA damage response. We highlight the role of circulating tumour DNA (ctDNA) in identifying acquired resistance biomarkers and its potential in guiding 'real-time' treatment decisions. Moreover, we explore other innovative treatment strategies aimed at overcoming specific resistance mechanisms, including the inhibition of ATR, WEE1 and POLQ. We also examine the role of PARPi rechallenge in patients with acquired resistance.

Intergroup-statement: statement of the german ovarian cancer commission, the North-Eastern German Society of gynecological Oncology (NOGGO), AGO Austria and AGO Swiss regarding the use of homologous repair deficiency (HRD) assays in advanced ovarian cancer

INTRODUCTION

Homologous recombination deficiency (HRD) is a key biomarker in the management of high-grade serous ovarian cancer (HGSOC), guiding treatment decisions, particularly regarding the use of poly(ADP-ribose) polymerase inhibitors (PARPi). As multiple HRD assays are available, each with distinct methodologies and cutoff values, the interpretation and clinical application of HRD testing remain complex. This intergroup statement, endorsed by the German Ovarian Cancer Commission, NOGGO, AGO Austria, and AGO Swiss, aims to provide guidance on the indications, appropriate use, and limitations of HRD testing in ovarian cancer.

MATERIALS AND METHODS

The statement is based on an interdisciplinary review of available literature, clinical trial data, and expert consensus. The recommendations focus on the current landscape of HRD assays, their clinical applicability, and practical considerations regarding the optimal timing and indications for testing.

RESULTS AND DISCUSSION

Various HRD assays, including established commercial tests and emerging academic-clinical approaches, are reviewed in this statement. The document outlines key eligibility criteria for HRD testing in ovarian cancer, emphasizing its relevance in specific histological subtypes and clinical scenarios. Additionally, exclusion criteria are defined, highlighting cases where HRD testing may not be appropriate due to insufficient clinical validation or lack of therapeutic implications. Finally, the statement discusses the pathological minimum requirements for tissue samples used in HRD testing, ensuring adequate sample quality and tumor content for reliable results.

CONCLUSION

HRD testing is a valuable tool for personalizing ovarian cancer treatment, particularly in identifying patients who may benefit from PARPi therapy. However, assay selection, timing, and result interpretation require careful consideration. This statement provides a structured approach to optimize HRD testing, aiming to improve clinical decision-making and patient outcomes.

Role of KLF5 in enhancing ovarian cancer stemness and PARPi resistance: mechanisms and therapeutic targeting

BACKGROUND

Ovarian cancer (OC) often presents at advanced stages with poor prognosis. Although poly(ADP-ribose) polymerase inhibitors (PARPi) offer clinical benefits, resistance remains a major challenge. This study investigates the role of KLF5 in regulating OC cell stemness and contributing to PARPi resistance.

METHODS

Gene expression analysis was conducted on OC cell lines and their PARPi-resistant counterparts. qRT-PCR and Western blotting assessed the expression levels of stemness markers and KLF5. IHC evaluated KLF5 expression in ovarian cancer tissue samples. Sphere formation and ALDH activity assays were used to evaluate stemness. Chromatin immunoprecipitation (ChIP) investigated KLF5's binding to the Vimentin promoter. The effects of the KLF5 inhibitor ML264 were tested in vitro using cell viability and apoptosis assays, and in vivo using a xenograft mouse model to evaluate tumor growth and response to PARPi treatment.

RESULTS

PARPi-resistant OC cells showed elevated stemness, indicated by increased SOX2, KLF4, Nanog, and OCT4 expression. KLF5 was significantly upregulated in these cells and linked to poor clinical outcomes. PARPi-resistant cells formed larger and more numerous spheres and had higher ALDH activity. KLF5 bound to the Vimentin promoter, upregulating its expression. Inhibition of KLF5 with ML264 reduced stemness features, decreased Vimentin expression, and resensitized resistant cells to PARPi. In vivo, ML264-treated mice with PARPi-resistant tumors exhibited reduced tumor growth and increased sensitivity to PARPi.

CONCLUSION

KLF5 enhances stemness and contributes to PARPi resistance in ovarian cancer through Vimentin regulation. Targeting KLF5 offers a promising therapeutic strategy to overcome resistance and improve patient outcomes.

Clinical differences among the PARP inhibitors in the first-line treatment of advanced-stage ovarian carcinoma

INTRODUCTION

Despite favorable patient response rates to first-line chemotherapy, 5-year overall survival rates in ovarian cancer are dismal. Fortunately, the inclusion of PARP inhibitors (e.g. olaparib, niraparib, and rucaparib) following the completion of primary induction chemotherapy, has conferred improved progression-free survival rates.

AREAS COVERED

There are treatment outcome differences among the various PARP inhibitors that coincide with a patient's specific homologous recombination deficit (HRD) status; moreover, only single-agent olaparib and olaparib with bevacizumab have conferred a 5-year overall survival benefit. In the current review, we recount the clinical differences associated with the available PARP inhibitors in the management of advanced-stage ovarian carcinoma.

EXPERT OPINION

The inclusion of PARP inhibitors has significantly improved survival benefits in advanced-stage ovarian cancer, especially among patients with an identifiable HRD. While there are tolerability differences inherent to the specific PARP inhibitors, not to mention approval distinctions, olaparib is the only PARP inhibitor that has demonstrated consistent overall survival benefits.

Transforming treatment paradigms: Focus on personalized medicine for high-grade serous ovarian cancer

High-grade serous ovarian cancer (HGSOC) is the most common and aggressive subtype of ovarian cancer, accounting for approximately 70% of all ovarian cancer cases and contributing significantly to the high mortality rates associated with this disease. Because of the asymptomatic nature of early stage disease, most patients are diagnosed at advanced stages when the cancer has already spread into the abdominal cavity, requiring complex and intensive surgical and chemotherapeutic interventions followed by maintenance therapies. Although a minority of cases are associated with well defined genetic syndromes, specific risk factors and a clear etiology in many cases remain elusive. HGSOC tumors are characterized by a high frequency of somatic gene copy number alterations, often associated with defects in homologous recombination repair of DNA. All attempts to introduce an effective screening for HGSOC to date have been unsuccessful. This review elucidates the complexities surrounding HGSOC and encompasses its etiology, epidemiology, classification, pathogenesis, and the current array of treatment strategies. Understanding molecular underpinnings is crucial for the development of targeted therapies and personalized multimodal treatment approaches in centralized therapeutic structures. This review also examines the importance of the tumor microenvironment. In addition, the authors' objective is to underscore the critical importance of placing the patient's perspective and diversity at the forefront of therapeutic strategies, thereby fostering a genuinely participatory decision-making process and ultimately improving patient quality of life.

Endocrine Maintenance Therapy in High-Grade Serous Ovarian Cancer: A Retrospective Off-Label Real-World Cohort Study

BACKGROUND

Endocrine therapy is the standard-of-care maintenance treatment for estrogen receptor (ER)-positive breast cancers and is increasingly used in low-grade serous ovarian cancer. However, its therapeutic role in the early maintenance setting for ER-positive high-grade serous ovarian cancer (HGSC) remains undefined.

METHODS

A retrospective analysis was conducted on clinicopathological data from patients with newly diagnosed ER-positive HGSC following completion of adjuvant chemotherapy. Patients received maintenance therapy either with or without the aromatase inhibitor letrozole, in addition to standard maintenance care. ER expression levels and the administration of letrozole were analyzed, along with outcome measures for the entire cohort, with stratification based on residual disease status.

RESULTS

A total of 102 patients with newly diagnosed HGSC were included in the analysis, with 64 (62.7%) receiving letrozole and 38 (37.3%) not receiving letrozole. The median ER expression was 70%, with higher expression observed in the letrozole group compared to the no letrozole group (77.5% vs. 60%). No significant correlation was found between ER expression status and therapy response (p = 0.295 and p = 0.176, respectively). Letrozole therapy was well tolerated with no major adverse effects reported. In the overall cohort, maintenance letrozole therapy did not confer a significant improvement in progression-free survival (median 20.56 months vs. 29.34 months, p = 0.53) or overall survival (OS) (median 79.48 months vs. 46.85 months, p = 0.71) over a median follow-up duration of 23.5 months. However, among patients with no residual disease, maintenance letrozole therapy was associated with a statistically significant improvement in OS compared to those not receiving letrozole (median 114 months vs. 46.9 months, p = 0.006).

CONCLUSIONS

Maintenance letrozole therapy appears to be a well-tolerated and potentially beneficial intervention in a subset of patients with ER-positive HGSC with no residual disease post-treatment. These findings highlight the need for further validation through prospective randomized trials to comprehensively assess the efficacy of endocrine therapy in this setting and its implications for patient quality of life.

Failure of early interval debulking surgery after standard neoadjuvant chemotherapy: May bevacizumab add something? A large retrospective study

INTRODUCTION

Data are limited on the use of bevacizumab in neoadjuvant setting for High-Grade Serous ovarian Cancer (HGSC) patients. This study explores the effect of adding bevacizumab to standard neoadjuvant chemotherapy (NACT) following the failure of early Interval Debulking Surgery (eIDS).

MATERIALS AND METHODS

This monocentric study retrospectively enrolled FIGO stage IIIC-IV HGSC patients (2017-2021), persisting unresectable after three NACT cycles. Eligible patients had an ECOG performance status ≤2, were aged 40-75 years, and had no contraindications to bevacizumab administration. Patients were stratified whether they added bevacizumab from cycles 4 to 6 (CPB group) or not (CP group). The primary endpoint was the cytoreduction rate after six cycles (delayed IDS, dIDS).

RESULTS

Overall, 58(23 %) patients received neoadjuvant bevacizumab(CPB), and 190 (77 %) did not (CP). Delayed IDS was performed in 117(47.6 %) patients (CPB:31-53.4 %; CP:86-45.8 %; p = 0.38), with complete gross resection rates of 83.9 % and 88.5 %, respectively (p = 0.72). Severe postoperative complications were comparable (CP: 8 %, CPB: 9.7 %, p = 0.069). Median overall survival (OS) for dIDS patients showed no significant difference (CPB: not reached, CP:38 months, p = 0.55), nor did progression-free survival (PFS; CPB:14 months, CP:12 months, p = 0.830). Conversely, among 130(52 %) patients persisting unresectable, bevacizumab significantly improved OS in the CPB group (not reached vs.18 months, p = 0.015), although PFS remained similar (CPB: 6 months, CP: 7 months, p = 0.741).

CONCLUSION

While adding bevacizumab to NACT does not seem to increase the dIDS rate, it significantly extends OS in unresectable patients. Its use may be a valuable option in selected cases after eIDS' failure.

Targeting CCNE1 amplified ovarian and endometrial cancers by combined inhibition of PKMYT1 and ATR

Ovarian cancers (OVCAs) and endometrial cancers (EMCAs) with CCNE1-amplification are often resistant to standard treatment and represent an unmet clinical need. Synthetic-lethal screening identified loss of the CDK1 regulator, PKMYT1, as synthetically lethal with CCNE1-amplification. We hypothesize that CCNE1-amplification associated replication stress will be more effectively targeted by combining PKMYT1 inhibitor lunresertib (RP-6306), with ATR inhibitor camonsertib (RP-3500/RG6526). Low dose combination RP-6306 with RP-3500 synergistically increases cytotoxicity more so in CCNE1-amplified compared to non-amplified cells. Combination treatment produces durable antitumor activity, reduces metastasis and increases survival in CCNE1-amplified patient-derived OVCA and EMCA xenografts. Mechanistically, low doses of RP-6306 with RP-3500 increase CDK1 activation more so than monotherapy, triggering rapid and robust induction of premature mitosis, DNA damage, and apoptosis in a CCNE1-dependent manner. These findings suggest that targeting CDK1 activity by combining RP-6306 with RP-3500 is an effective therapeutic approach to treat CCNE1-amplifed OVCAs and EMCAs.

Predictors of olaparib discontinuation owing to adverse drug events in patients with ovarian, peritoneal, or fallopian tube cancer: a retrospective observational study

We investigated predictors of olaparib discontinuation owing to adverse effects. Patients with ovarian, peritoneal, or fallopian tube cancers treated with olaparib at Osaka Medical and Pharmaceutical University Hospital between April 2018 and September 2022 were included in this study. The exclusion criteria were as follows: discontinuation of treatment due to disease progression, use of anaemia medications, and use of cytochrome P450 (CYP3A4) inhibitors. The follow-up period was 90 d. Of the 46 eligible patients, 21 patients discontinued olaparib, including 15 patients with grade 3 or higher anaemia, eight patients with grade 3 or higher neutropenia, and four patients with non-haematological toxicity (including multiple onset). Multivariate logistic regression analysis showed that grade 4 neutropenia and anaemia progression to grades 2-3 due to chemotherapy administered before olaparib administration were predictors of olaparib discontinuation. The severity of neutropenia and anaemia due to chemotherapy before olaparib administration may be a potential marker for its discontinuation.

Olaparib-induced hyperglycemia in ovarian cancer patients - a case series analysis of a three-month therapy with a consideration of BMI

BACKGROUND

Olaparib is a relatively new poly(ADP-ribose) polymerase inhibitor (PARPi) administered to ovarian cancer (OC) patients with a complete or partial response to first-line chemotherapy. One of the metabolic side effects of olaparib is the disruption of glucose homeostasis, often resulting in hyperglycemia The study was a retrospective analysis of olaparib-induced hyperglycemia in OC patients with initial normoglycemia following the first, second, and third month of olaparib treatment METHODS: The study involved 32 OC patients, classified into three groups according to their Body Mass Index (BMI): normal BMI (BMI 18.5-24.9 kg/m2; n = 13), overweight (BMI 25-29.9 kg/m2; n = 13), and obese (BMI ≥ 30 kg/m2; n = 6). The fasting glucose (FG) concentration was evaluated after the first, second, and third cycle of olaparib treatment (a cycle is the equivalent of 28 days of treatment). The severity of the observed hyperglycemia was assessed using the Common Terminology Criteria for Adverse Events (CTCAE v5.0).

RESULTS

A significant increase in glycemia was observed after the first and second cycles of olaparib treatment in the group with normal BMI and after the third cycle in overweight and obese patients. There were no significant differences in glucose levels among the groups following the first, the second, and the third cycle. Grade 1 hyperglycemia with impaired fasting glucose levels (5.6-6.9 mmol/l) was found in 15 patients (normal BMI: n = 4, overweight: n = 9, and obesity: n = 2), while glycemia typical of diabetes (≥ 7.0 mmol/l) was observed in one obese patient.

CONCLUSIONS

Regardless of the weight of OC patients, it is essential to control glycemia during olaparib treatment.

Next-Generation Sequencing in Oncology-A Guiding Compass for Targeted Therapy and Emerging Applications

Multigene sequencing technologies provide a foundation for targeted therapy and precision oncology by identifying actionable alterations and enabling the development of treatments that substantially improve clinical outcomes. This review emphasizes the importance of having a molecular compass guiding treatment decision-making through the multitude of alterations and genetic mutations, showcasing why NGS plays a pivotal role in modern oncology.

Blocking Tumoral Angiogenesis VEGF/VEGFR Pathway: Bevacizumab-20 Years of Therapeutic Success and Controversy

The "angiogenesis switch"-defined as the active process by which solid tumors develop their own circulation-plays an important role in both tumoral growth and propagation. As the malignant tumor grows and reaches a critical size, the metabolic needs as a function of an ever-increasing distance to the nearest emergent blood vessel, can no longer be covered by the microenvironment of the peritumoral tissue. Although a relatively discrete process, the "angiogenic switch" acts as a limiting stage of tumoral development present from the avascular hyperplasia phase to the vascularized neoplastic phase, providing support for tumor expansion and metastasis. Over time, research has focused on blocking the angiogenetic pathways (such as VEGF/VEGFR signaling axis) leading to the development of targeted therapeutic agents such as Bevacizumab. Objectives: We conducted a review of the molecular principles of tumoral angiogenesis and we tried to follow the history of Bevacizumab from its first approval for human usage 20 years ago to current days, focusing on the impact this agent had in solid tumor therapy. A comprehensive review of clinical trials pertaining to Bevacizumab (from the era of the preclinic trials leading to approval for human usage, to the more recent randomized trial focusing on combination targeted therapy) further details the role of this drug. We aimed to establish if this ancient drug continues to have a place in modern oncology. Conclusions: Bevacizumab, one of the first drugs targeting tumoral microenvironment, remains one of the most important oncologic agents blocking the VEGF/VEGFR angiogenic pathway. otherwise, history of 20 years marked by numerous controversies (ranging from methodological errors of clinical trials to withdrawal of approval for human usage in breast cancer patients, from discussions about severe side effects to resistance to therapy and limited efficacity), Bevacizumab continues to provide an optimal therapeutic option for many solid tumors that previously had little to no means of treatment, improving otherwise bleak outcomes. Even in the era of personalized precision oncology, Bevacizumab continues to be a key element in many therapeutic regimens both as monotherapy and in combination with newer targeted agents.

Trabectedin Induces Synthetic Lethality via the p53-Dependent Apoptotic Pathway in Ovarian Cancer Cells Without BRCA Mutations When Used in Combination with Niraparib

This study investigated whether combining niraparib and trabectedin in BRCA-proficient epithelial ovarian cancer induces deficiencies in ssDNA break repair and dsDNA homologous recombination, leading to synthetic lethality. A2780 and SKOV3 ovarian cancer cell lines were treated with niraparib and trabectedin. Cell viability was assessed using CCK-8 assays, while RT-qPCR and Western blot analyzed the expression of DNA repair and apoptosis-related genes. Apoptosis was evaluated via Annexin V/PI assays. The combination therapy exhibited a synergistic effect on A2780 cells but not on SKOV3 cells. Treatment reduced BRCA1, BRCA2, RAD51, PARP1, and PARP2 expression, indicating impaired DNA repair. γ-H2AX levels increased, suggesting DNA damage. The therapy also upregulated p53, PUMA, NOXA, BAX, BAK, and p21, promoting p53-mediated apoptosis and cell cycle arrest. Apoptosis induction was confirmed via Annexin V/PI assays. Silencing p53 with siRNA abolished all synergistic effects in A2780 cells. Niraparib and trabectedin combination therapy impairs DNA repair in BRCA-proficient ovarian cancer, leading to synthetic lethality through p53-dependent apoptosis.

Mirvetuximab soravtansine: current and future applications

Ovarian epithelial cancer (OEC), particularly high-grade serous carcinoma (HGSC), remains a clinical challenge due to its late-stage diagnosis, high recurrence rates, and poor survival outcomes. Mirvetuximab soravtansine (MIRV), an antibody-drug conjugate targeting folate receptor alpha (FRα), has demonstrated promising efficacy in platinum-resistant OEC, particularly in high FRα-expressing populations, as evidenced by key clinical trials such as FORWARD I, FORWARD II, SORAYA, and MIRASOL. These trials highlight MIRV's ability to improve progression-free survival, response rates, and quality of life in advanced disease settings. Emerging data suggest that FRα is also highly expressed in serous tubal intraepithelial carcinoma (STIC), a non-invasive precursor lesion to HGSC. Although MIRV has not yet been studied for STIC management, we propose its potential application in this context to prevent progression to invasive carcinoma, particularly in high-risk populations undergoing risk-reducing bilateral salpingo-oophorectomy. This novel use could bridge the gap between prevention and treatment, offering a proactive strategy for hereditary cancer management. Furthermore, MIRV's therapeutic versatility extends to other FRα-positive tumors, such as endometrial and breast cancers, broadening its clinical relevance. Despite challenges such as accessibility and cost, MIRV represents a significant advancement in precision medicine, with potential to redefine prevention and treatment strategies for hereditary and sporadic cancers.

Predictive biomarkers for the efficacy of PARP inhibitors in ovarian cancer: an updated systematic review

BACKGROUND

PARP inhibitors are effective in treating ovarian cancer, especially for BRCA1/2 pathogenic variant carriers and those with HRD (homologous recombination deficiency). Concerns over toxicity and costs have led to the search for predictive biomarkers. We present an updated systematic review, expanding on a previous ESMO review on PARP inhibitor biomarkers.

METHODS

Following ESMO's 2020 review protocol, we extended our search to March 31, 2023, including PubMed and clinical trial data. We also reviewed the reference lists of review articles. We conducted a meta-analysis using a random-effects model to evaluate hazard ratios and assess the predictive potential of biomarkers and the effectiveness of PARP inhibitors in survival.

RESULTS

We found 375 articles, 103 of which were included after screening (62 primary research, 41 reviews). HRD remained the primary biomarker (95%), particularly BRCA1/2 variants (77%). In the non-HRD category, six articles (10%) introduced innovative biomarkers, including ADP-ribosylation, HOXA9 promoter methylation, patient-derived organoids, KELIM, and SLFN11.

DISCUSSION

Prospective assessment of real-time homologous recombination repair via nuclear RAD51 levels shows promise but needs validation. Emerging biomarkers like ADP-ribosylation, HOXA9 promoter methylation, patient-derived organoids, KELIM, and SLFN11 offer potential but require large-scale validation.

Development of model for identifying homologous recombination deficiency (HRD) status of ovarian cancer with deep learning on whole slide images

BACKGROUND

Homologous recombination deficiency (HRD) refers to the dysfunction of homologous recombination repair (HRR) at the cellular level. The assessment of HRD status has the important significance for the formulation of treatment plans, efficacy evaluation, and prognosis prediction of patients with ovarian cancer.

OBJECTIVES

This study aimed to construct a deep learning-based classifier for identifying tumor regions from whole slide images (WSIs) and stratify the HRD status of patients with ovarian cancer (OC).

METHODS

The deep learning models were trained on 205 H&E-stained sections which contained 205 ovarian cancer patients, 64 were found to have HRD status while 141 had homologous recombination proficiency (HRP) status from two institutions Memorial Sloan Kettering Cancer Center (MSKCC) and Zhongda Hospital, Southeast University. The framework includes tumor regions identification by UNet + + and subtypes of ovarian cancer classifier construction. Referring to the EasyEnsemble, we classified the HRP patients into three distributed subsets. These three subsets of HRP patients were combined with the HRD patients to establish three new training groups for subsequent model construction. The three models were integrated into a single model named Ensemble Model.

RESULTS

The UNet + + algorithm segmented tumor regions with 81.8% accuracy, 85.9% recall, 83.8% dice score and 68.3% IoU. The AUC of the Ensemble Model was 0.769 (Precision = 0.800, Recall = 0.727, F1-score = 0.762) in the study. The most discriminative features between HRD and HRP comprised S_mean_dln_obtuse_ratio, S_mean_dln_acute_ratio and mean_Graph_T-S_Betweenness_normed.

CONCLUSIONS

The models we constructed enables accurate discrimination between tumor and non-tumor tissues in ovarian cancer as well as the prediction of HRD status for patients with ovarian cancer.

Thirty Years of BRCA1: Mechanistic Insights and Their Impact on Mutation Carriers

SIGNIFICANCE

Here, we explore the impact of three decades of BRCA1 research on the lives of mutation carriers and propose strategies to improve the prevention and treatment of BRCA1-associated cancer.

The Landscape of PARP Inhibitors in Solid Cancers

PARP inhibitors are a class of agents that have shown significant preclinical activity in models defective in homologous recombination (HR). The identification of synthetic lethality between HR defects and PARP inhibition led to several clinical trials in tumors with known HR defects (initially mutations in BRCA1/2 genes and subsequently in other genes involved in HR). These studies demonstrated significant responses in breast and ovarian cancers, which are known to have a significant proportion of patients with HR defects. Since the approval of the first PARP inhibitor (PARPi), olaparib, several other inhibitors have been developed, expanding the armamentarium available to clinicians in this setting. The positive results obtained in breast and ovarian cancer have expanded the use of PARPi in other solid tumors with HR defects, including prostate and pancreatic cancer in which these defects have been identified. The clinical trials have demonstrated responses to PARPi which are now also available for the subset of patients with prostate and pancreatic cancer with HR defects. This review summarizes the results obtained in solid tumors with PARPi and their potential use when combined with other agents, including immune checkpoint inhibitors that are likely to further increase the survival of these patients which still needs a dramatic improvement.

Secondary cytoreductive surgery for ovarian cancer recurrence and first-line maintenance therapy: A multicenter retrospective study

PURPOSE

To investigate surgical and oncologic outcomes of secondary cytoreductive surgery for ovarian cancer recurrence, considering the exposure to previous first-line maintenance therapy.

METHODS

We retrospectively identified all women who underwent secondary cytoreductive surgery for ovarian cancer recurrence with cytoreductive intent at three Italian Gynecologic Oncology centers (1997-2022). Data on clinical, surgical, and pathological characteristics, neoadjuvant, adjuvant, and maintenance therapy, as well as follow-up information, were retrieved from prospectively collected databases and medical records.

RESULTS

We identified 189 patients. Maintenance therapy in the first-line setting was implemented in 108/189 (57 %) cases: bevacizumab in 77.7 % (84/108), PARP inhibitors (Olaparib, Niraparib, or Rucaparib) in 15.7 % (17/108), and bevacizumab + PARP-inhibitors in 4.6 % (5/108). Complete cytoreduction rate and perioperative complications in secondary surgery were not associated with previous maintenance therapy. Complete cytoreduction was achieved in 75 % (140/189) of patients, and any residual tumor was the strongest predictor of poor progression-free (Hazard ratio [HR] 3.91, 95 %CI 2.48-6.16) and cause-specific survival (HR 4.27, 95 %CI 2.36-7.70). First-line bevacizumab was independently associated with worse progression-free survival among patients with any residual tumor at secondary surgery. First-line PARP inhibitors were independently associated with worse progression-free and cause-specific survival regardless of complete cytoreduction. Second-line maintenance therapies were independently associated with better survival regardless of residual tumor after secondary surgery.

CONCLUSION

Complete cytoreduction during secondary surgery for ovarian cancer recurrence is the strongest predictor of prognosis. First-line maintenance therapies do not appear to affect the safety and feasibility of secondary cytoreduction, although they may influence prognosis after secondary surgery.

Bevacizumab beyond progression: Impact of subsequent bevacizumab re-treatment in patients with ovarian, fallopian tube, and peritoneal cancer after progression

BACKGROUND

This study evaluated whether patients with epithelial ovarian, fallopian tube, and primary peritoneal carcinoma (OC) who are immediately re-treated with bevacizumab derive benefit after disease progression on a bevacizumab-containing regimen.

METHODS

This multi-institutional, retrospective study compared patients with high grade non-mucinous epithelial OC who received bevacizumab followed directly by another bevacizumab-containing treatment regimen to patients who received bevacizumab followed by a regimen that did not contain bevacizumab (or received no further treatment). Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan Meier product-limit estimator and modeled via Cox proportional hazards regression.

RESULTS

Among 226 patients with OC who received bevacizumab as part of a treatment regimen,103 received sequential treatment with bevacizumab and 123 received a bevacizumab-containing regimen followed by a non-bevacizumab-containing regimen at the time of progression. Median follow-up for all subjects was 17.3 months (range, 1.2-138.2 months). Median PFS was 17.2 months (95 % CI, 14.3-21.2) for patients who received sequential bevacizumab re-treatment and 5.1 months (95 % CI, 4.3-6.3) for patients who received bevacizumab without bevacizumab-containing re-treatment (p < 0.001). Median OS was 29.9 months (95 % CI, 26.1-35.4) for patients who received sequential bevacizumab re-treatment (p < 0.001) and 12.4 months (95 % CI, 9.2-16.7) for patients who did not receive bevacizumab-containing re-treatment.

CONCLUSION

Patients with OC treated with bevacizumab-containing regimens sequentially at the time of progression have prolonged survival compared to patients who received no re-treatment with bevacizumab.

Trends in FDA approvals of gynecologic oncology therapeutics from 2019 to 2024

OBJECTIVE

To quantify the impact of Food and Drug Administration (FDA) therapeutic approvals in gynecologic oncology from 2019 to 2024 and compare these approvals to other solid tumor disease sites.

METHODS

The FDA Approval Notifications was evaluated to assess drug approvals for solid tumors between August 15, 2019 and August 15, 2024. Drug approvals were evaluated to determine if they replaced the current standard of care (SOC), were used in combination with currently approved drugs, were used for adjuvant or maintenance therapy, or were approved for recurrence. Average therapeutic approval growth for each solid tumor category was calculated using the slope (b) from a simple linear regression model. Statistics were performed via Prism v10.1.1.

RESULTS

There were 150 drug approvals for solid tumors with gynecologic cancers representing 9.3 %. Gynecologic oncology had the second highest number of drug approvals compared to all other solid tumor disease sites. Of these, 8 were add on therapies (57.1 %) and 6 were later line therapies (42.9 %). Most disease sites (61.0 %) experienced an average decrease in FDA drug approvals during the study period. However, gynecologic oncology had the third largest approval growth (b = 0.17) compared to all other solid tumors.

CONCLUSION

While only representing 5 % of the oncology field, gynecologic oncology held the second highest number of FDA approvals by disease site in solid tumors (Ackroyd et al., 2021 [1]). The add on therapies provide a significant benefit in progression free and overall survival in the frontline setting and the later line therapies offer promising response rates in a heavily pre-treated population. This study highlights the promising future of gynecologic oncology therapeutics given the third largest relative growth in drug approvals compared to all other solid tumors.

Niraparib as maintenance therapy in Japan: a retrospective observational study using a Japanese claims database

OBJECTIVE

Epithelial ovarian cancer (EOC) is the leading cause of female mortality in gynecologic malignancies, with a rising incidence in Japan. This study aimed to validate the treatment patterns and safety of niraparib as maintenance therapy for EOC following initial chemotherapy in clinical practice in Japan.

METHODS

Leveraging claims data between April 2008 and December 2022, this descriptive study comprised EOC-diagnosed patients receiving initial platinum-based chemotherapy, debulking surgery, and niraparib as maintenance therapy. Patient characteristics, prescription status, transfusion details, and laboratory data were assessed and reported as summary statistics and frequencies.

RESULTS

Among 291 patients, the median age was 64.0 years and 94.5% received a 200-mg daily dose of niraparib. At week 12, 78.7% (229/291) continued niraparib treatment, 21.3% (62/291) discontinued, and 52.2% (152/291) required treatment interruptions. Of the 62 patients who discontinued treatment, 27 patients initiated subsequent EOC treatment within 12 weeks following niraparib discontinuation. Blood transfusions were needed in 10.3% (30/291), and of 55 patients with available laboratory data, 61.8% (34/55) had decreased platelet count <100,000/µL, 25.5% (14/55) had decreased hemoglobin level <8 g/dL, and 22.7% (5/22) had decreased neutrophil count <1,000/µL, meeting the criteria for treatment interruption. Among those with thrombocytopenia, 88.2% (30/34) were able to either resume or continue treatment.

CONCLUSION

Niraparib demonstrated favorable tolerability in Japanese patients with advanced EOC, with effective management of thrombocytopenia through dose adjustments and supportive care, supporting its viability as post-chemotherapy maintenance therapy.

Carbon Nanotubes in the Diagnosis and Treatment of Ovarian Cancer

One of the most serious gynecological diseases in the world is ovarian cancer (OC). These days, the majority of patients are identified at an advanced stage (III or IV), with subpar diagnosis resulting in a return of the illness. Conventional medicines fail as a result of issues with early illness identification and treatment processing, including issues with dosage delivery, side effects, and treatment resistance. The carbon nanotube (CNT)-based drug delivery systems for specific OC therapy are highlighted in this review. These systems have several advantages against free drugs, including nontoxicity, biological compatibility, high biodegradability, increased therapeutic impact, and non-inflammatory effects. Crucially, functionalized CNTs with particular ligands like cancer antigen (CA125), Human epididymis protein 4 (HE4), Mucin 1, and folic acid (FA) allow for selective targeting of OC and ultimately increase therapeutic potential in comparison to their nonfunctionalized counterparts. This review focused on the potential applications of CNTs in the detection and treatment of OC, as well as their present status and future clinical developments.

Graphical Abstract

A pan-tumor review of the role of poly(adenosine diphosphate ribose) polymerase inhibitors

Poly(adenosine diphosphate ribose) polymerase (PARP) inhibitors, such as olaparib, talazoparib, rucaparib, and niraparib, comprise a therapeutic class that targets PARP proteins involved in DNA repair. Cancer cells with homologous recombination repair defects, particularly BRCA alterations, display enhanced sensitivity to these agents because of synthetic lethality induced by PARP inhibitors. These agents have significantly improved survival outcomes across various malignancies, initially gaining regulatory approval in ovarian cancer and subsequently in breast, pancreatic, and prostate cancers in different indications. This review offers a comprehensive clinical overview of PARP inhibitor approvals, emphasizing their efficacy across different cancers based on landmark phase 3 clinical trials.

Perspectives, Challenges, and Advances in Therapeutic Strategies for Gynecological Malignant Tumors

For years, treatment options for advanced gynecological malignancies have been limited, with the combination of carboplatin and paclitaxel being the preferred first-line therapeutic approach, regardless of disease type [...].

Predicting benefit from PARP inhibitors using deep learning on H&E-stained ovarian cancer slides

PURPOSE

Ovarian cancer patients with a Homologous Recombination Deficiency (HRD) often benefit from polyadenosine diphosphate-ribose polymerase (PARP) inhibitor maintenance therapy after response to platinum-based chemotherapy. HR status is currently analyzed via complex molecular tests. Predicting benefit from PARP inhibitors directly on histological whole slide images (WSIs) could be a fast and cheap alternative.

PATIENTS AND METHODS

We trained a Deep Learning (DL) model on H&E stained WSIs with "shrunken centroid" (SC) based HRD ground truth using the AGO-TR1 cohort (n = 208: 108 training, 100 test) and tested its ability to predict HRD as evaluated by the Myriad classifier and the benefit from olaparib in the PAOLA-1 cohort (n = 447) in a blinded manner.

RESULTS

In contrast to the HRD prediction AUROC of 72 % on hold-out, our model only yielded an AUROC of 57 % external. Kaplan-Meier analysis showed that progression free survival (PFS) in the PARP inhibitor treated PAOLA-1 patients was significantly improved in the HRD positive group as defined by our model, but not in the HRD negative group. PFS improvement in PARP inhibitor-treated patients was substantially longer in our HRD positive group, hinting at a biologically meaningful prediction of benefit from PARP inhibitors.

CONCLUSION

Together, our results indicate that it might be possible to generate a predictor of benefit from PARP inhibitors based on the DL-mediated analysis of WSIs. However, further studies with larger cohorts and further methodological improvements will be necessary to generate a predictor with clinically useful accuracy across independent patient cohorts.

Efficacy of subsequent therapies in patients with advanced ovarian cancer who relapse after first-line olaparib maintenance: results of the PAOLA-1/ENGOT-ov25 trial

BACKGROUND

The use of first-line poly(ADP-ribose) polymerase (PARP) inhibitor maintenance therapy is increasing in advanced ovarian cancer. Understanding the efficacy of first subsequent therapy (FST) in patients experiencing disease progression in the first-line setting is important to optimize postprogression treatments. We evaluated the efficacy of FST in patients from PAOLA-1/ENGOT-ov25 (NCT02477644) who received first-line olaparib maintenance.

PATIENTS AND METHODS

This post hoc analysis evaluated the efficacy of subsequent chemotherapy following disease progression by assessing time from FST to second subsequent therapy (SST) according to whether progression occurred during versus after first-line olaparib maintenance and FST type. A multivariate Cox model was used in the olaparib plus bevacizumab arm to identify prognostic factors influencing the efficacy of subsequent chemotherapy.

RESULTS

Of 806 randomized patients, 544 (67.5%) progressed and received subsequent chemotherapy. The median time from FST to SST was shorter in patients in the olaparib plus bevacizumab arm who progressed during first-line olaparib maintenance (6.1 months) than in those who progressed after first-line olaparib maintenance (11.4 months). Multivariate analysis indicated that progression after (versus during) first-line olaparib maintenance influenced time from FST to SST (hazard ratio 0.65, 95% confidence interval 0.50-0.84; P = 0.0011) independently of platinum-free interval or clinical risk. Among patients who progressed and received platinum-based chemotherapy with a PARP inhibitor as FST, the efficacy of subsequent therapies was also dependent on whether progression occurred during versus after first-line olaparib maintenance.

CONCLUSIONS

These results suggest that the timing of disease progression relative to first-line olaparib maintenance may impact the efficacy of subsequent platinum-based chemotherapy. Although results should be interpreted with caution, across all subgroups, including patients who received platinum-based chemotherapy with PARP inhibitor rechallenge as FST, the median time from FST to SST was longer if progression occurred after versus during first-line olaparib maintenance.

Homologous recombination deficiency testing in patients with high grade ovarian cancer: factors influencing test success

INTRODUCTION

Testing for tumor BRCA mutations and homologous recombination deficiency (HRD) is recommended for all patients with advanced high-grade epithelial ovarian cancer. Delays in the HRD testing process can significantly affect the treatment offered to patients.

METHODS

HRD testing pathways and sampling processes were analyzed for tests sent from a tertiary gynae-oncology referral center between December 2020 and January 2023.

RESULTS

A total of 148 hRD tests were performed in 125 patients. The overall success rate of HRD testing was 69.6%. The success rates of obtaining results were: from diagnostic image-guided biopsy 66.7% (n = 40/60), at primary surgery 91.5% (n = 42/47), and at interval debulking surgery 51.2% (n = 21/41). The use of a larger 16-gauge needle used at image-guided biopsy produced a 100% success rate. Of 148 tests carried out, the median time for result was 28 days (range 14-158 days), with only 27% returned results in 21 or fewer days. In successful tests, 44.7% were classified as HRD-positive. 97% of patients with HRD-positive tumors treated at the center received a PARP inhibitor as part of their first-line maintenance treatment.

CONCLUSIONS

By optimizing the factors affecting HRD test success, we can obtain faster results and offer patients appropriate treatment at earlier time points to improve patient outcomes.

Incorporating immune checkpoint inhibitors in epithelial ovarian cancer

OBJECTIVE

Therapeutic interventions for epithelial ovarian cancer (EOC) have increased greatly over the last decade but improvements outside of biomarker selected therapies have been limited. There remains a pressing need for more effective treatment options that can prolong survival and enhance the quality of life of patients with EOC. In contrast to the significant benefits of immunotherapy with immune checkpoint inhibitors (CPI) seen in many solid tumors, initial experience in EOC suggests limited efficacy of CPIs monotherapy.

METHODS

A systematic review of phase III studies testing the role of CPIs in ovarian cancer was performed.

RESULTS

Seven randomized trials testing CPIs in newly diagnosed (n = 3) and recurrent (n = 4) EOC are evaluated. Overall, those trials included data of 5671 patients. Single-agent PD-L1 inhibitor trials have not shown significant efficacy in newly diagnosed ovarian cancer. Triplet maintenance with bevacizumab plus olaparib and durvalumab is associated with longer progression-free survival than maintenance with bevacizumab alone in patients without tumor BRCA mutations. CPIs were not effective in platinum-sensitive (n = 1031) and platinum-resistant (n = 1420) EOC.

CONCLUSIONS

The value of adding CPI to standard treatment including poly (ADP-ribose) polymerase (PARP) inhibitors with or without bevacizumab remains unclear and is being addressed in ongoing clinical trials. The combination of cytotoxic T-lymphocyte associated protein 4 (CTLA-4) and programmed cell death protein 1 (PD-1) inhibitors may enhance the efficacy of immunotherapy in EOC and studies are underway to investigate the combination of CPI with other emerging treatment modalities. PROSPERO registration ID: CRD42024536017.

Disease-free survival of 15 years after primary surgery in a patient with advanced high-grade serous ovarian cancer: a case report and literature review

Background

Ovarian cancer, particularly high-grade serous ovarian cancer (HGSOC), is the most lethal gynecological tumor, with most patients experiencing recurrence within 5 years. Long-term survival in HGSOC patients with advanced stages is exceedingly rare.

Case summary

We report a case of advanced HGSOC with exceptional long-term recurrence-free survival following initial treatment. In June 2009, the patient underwent suboptimal cytoreductive surgery for stage IIIC ovarian cancer, including total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, appendectomy, and resection of mesenteric and peritoneal lesions. Postoperatively, residual lesions were observed in the mesenteries and para-aortic lymph nodes. Despite unfavorable prognostic factors (advanced stage, aggressive pathology, and incomplete resection), the patient showed remarkable chemosensitivity, remaining recurrence-free for 15 years.

Conclusion

The factors influencing long-term survival in HGSOC patients are not yet fully understood. We present this rare case to contribute data for further studies on long-term survival in advanced HGSOC.