New tumor markers: CA125 and beyond

Electrochemical immunosensing of tumor markers

The rising incidence and mortality rates of cancer have led to a growing need for precise and prompt early diagnostic approaches to effectively combat this disease. However, traditional methods employed for detecting tumor cells, such as histopathological and immunological techniques, are often associated with complex procedures, high analytical expenses, elevated false positive rates, and a dependence on experienced personnel. Tracking tumor markers is recognized as one of the most effective approaches for early detection and prognosis of cancer. While onco-biomarkers can also be produced in normal circumstances, their concentration is significantly elevated when tumors are present. By monitoring the levels of these markers, healthcare professionals can obtain valuable insights into the presence, progression, and response to treatment of cancer, aiding in timely diagnosis and effective management. This review aims to provide researchers with a comprehensive overview of the recent advancements in tumor markers using electrochemical immunosensors. By highlighting the latest developments in this field, researchers can gain a general understanding of the progress made in the utilization of electrochemical immunosensors for detecting tumor markers. Furthermore, this review also discusses the current limitations associated with electrochemical immunosensors and offers insights into paving the way for further improvements and advancements in this area of research.

Efficient CAR T cell targeting of the CA125 extracellular repeat domain of MUC16

BACKGROUND

Ovarian cancer (OC) is the leading cause of death from gynecologic malignancies in the Western world. Contributing factors include a high frequency of late-stage diagnosis, the development of chemoresistance, and the evasion of host immune responses. Currently, debulking surgery and platinum-based chemotherapy are the treatment cornerstones, although recurrence is common. As the clinical efficacy of immune checkpoint blockade is low, new immunotherapeutic strategies are needed. Chimeric antigen receptor (CAR) T cell therapy empowers patients' own T cells to fight and eradicate cancer, and has been tested against various targets in OC. A promising candidate is the MUC16 ectodomain. This ectodomain remains on the cell surface after cleavage of cancer antigen 125 (CA125), the domain distal from the membrane, which is currently used as a serum biomarker for OC. CA125 itself has not been tested as a possible CAR target. In this study, we examined the suitability of the CA125 as a target for CAR T cell therapy.

METHODS

We tested a series of antibodies raised against the CA125 extracellular repeat domain of MUC16 and adapted them to the CAR format. Comparisons between these candidates, and against an existing CAR targeting the MUC16 ectodomain, identified K101 as having high potency and specificity. The K101CAR was subjected to further biochemical and functional tests, including examination of the effect of soluble CA125 on its activity. Finally, we used cell lines and advanced orthotopic patient-derived xenograft (PDX) models to validate, in vivo, the efficiency of our K101CAR construct.

RESULTS

We observed a high efficacy of K101CAR T cells against cell lines and patient-derived tumors, in vitro and in vivo. We also demonstrated that K101CAR functionality was not impaired by the soluble antigen. Finally, in direct comparisons, K101CAR, which targets the CA125 extracellular repeat domains, was shown to have similar efficacy to the previously validated 4H11CAR, which targets the MUC16 ectodomain.

CONCLUSIONS

Our in vitro and in vivo results, including PDX studies, demonstrate that the CA125 domain of MUC16 represents an excellent target for treating MUC16-positive malignancies.

Diagnostic biomarkers in ovarian cancer: advances beyond CA125 and HE4

Ovarian cancer (OC) is the most lethal gynaecologic malignancy, attributed to its insidious growth, non-specific symptoms and late presentation. Unfortunately, current screening modalities are inadequate at detecting OC and many lack the appropriate specificity and sensitivity that is desired from a screening test. Nearly 70% of cases are diagnosed at stage III or IV with poor 5-year overall survival. Therefore, the development of a sensitive and specific biomarker for early diagnosis and screening for OC is of utmost importance. Currently, diagnosis is guided by CA125, the patient's menopausal status and imaging features on ultrasound scan. However, emerging evidence suggests that a combination of CA125 and HE4 (another serum biomarker) and patient characteristics in a multivariate index assay may provide a higher specificity and sensitivity than either CA125 and HE4 alone in the early detection of OC. Other attempts at combining various serum biomarkers into one multivariate index assay such as OVA1, ROMA and Overa have all shown promise. However, significant barriers exist before these biomarkers can be implemented in clinical practice. This article aims to provide an up-to-date review of potential biomarkers for screening and early diagnosis of OC which may have the potential to transform its diagnostic landscape.

A predictive and prognostic model for surgical outcome and prognosis in ovarian cancer computed by clinico-pathological and serological parameters (CA125, HE4, mesothelin)

OBJECTIVES

Numerous prognostic models have been proposed for ovarian cancer, extending from single serological factors to complex gene-expression signatures. Nonetheless, these models have not been routinely translated into clinical practice. We constructed a robust and readily calculable model for predicting surgical outcome and prognosis of ovarian cancer patients by exploiting commonly available clinico-pathological factors and three selected serum parameters.

METHODS

Serum CA125, human epididymis protein 4 (HE4) and mesothelin (MSL) were quantified by Lumipulse® G chemiluminescent enzyme immunoassay (Fujirebio) in a total of 342 serum samples from 190 ovarian cancer patients, including 152 paired pre- and post-operative samples.

RESULTS

Detection of pre-operative HE4 and CA125 was the optimal marker combination for blood-based prediction of surgical outcome (AUC=0.86). We constructed a prognostic model, computed by serum levels of pre-operative CA125, post-operative HE4, post-operative MSL and surgical outcome. Prognostic performance of our model was superior to any of these parameters alone and was independent from BRCA1/2 mutational status. We subsequently transformed our model into a prognostic risk index, stratifying patients as "lower risk" or "higher risk". In "higher risk" patients, relapse or death was predicted with an AUC of 0.89 and they had a significantly shorter progression free survival (HR: 9.74; 95 % CI: 5.95-15.93; p<0.0001) and overall survival (HR: 5.62; 95 % CI: 3.16-9.99; p<0.0001) compared to "lower risk" patients.

CONCLUSIONS

We present a robust predictive/prognostic model for ovarian cancer, which could readily be implemented into routine diagnostics in order to identify ovarian cancer patients at high risk of recurrence.

MRI assessment of ovarian masses and correlating with CA-125

BACKGROUND

The combined use of appropriate imaging modalities and serum biomarkers like serum Carcinoembryonic Antigen-125 (CA-125) helps plan treatment strategies and reduce overall mortality.

AIMS AND OBJECTIVES

To assess ovarian masses on Magnetic Resonance Imaging (MRI) and correlate them with serum CA-125 values. To derive a new serum CA-125 cut-off value for differentiating benign from malignant ovarian masses.

MATERIALS AND METHODS

This cross-sectional study was conducted from August 2020 to January 2021 on patients with suspected pelvic masses referred to the department of radio-diagnosis and meeting inclusion and exclusion criteria. Serum CA-125 values and imaging features on MRI were recorded.

RESULTS

A total of 37 ovarian masses were included in the study, of which 14 were malignant and 23 were benign. The mean CA-125 values among benign [35.95 ± 25.42 (mean ± SD) IU/ml] and malignant ovarian masses [444.82 ± 232.9 (mean ± SD) IU/ml] were statistically significant (<0.001). Using the reference serum CA-125 value of 35 IU/ml, specificity and accuracy were 61% and 75.68%. A cut-off value of 80.5 IU/ml recorded specificity and accuracy of 95.7% and 94.59%, respectively, with a sensitivity of 92.86% in differentiating benign from malignant ovarian masses.

CONCLUSION

The serum CA-125 cut-off value of 80.5 IU/ml is a sensitive and specific serum biomarker for ovarian malignancies. A combined approach of MR imaging and serum CA-125 correlation can be used in characterizing ovarian malignancies in routine clinical practice.

Front-line chemo-immunotherapy for treating epithelial ovarian cancer: Part I CA125 and anti-CA125

The current standard therapy of epithelial ovarian cancer (EOC) is the combination of surgery (primary cytoreductive surgery or interval cytoreductive surgery) and platinum-based chemotherapy (mainly using paclitaxel and carboplatin either by neoadjuvant chemotherapy and/or by postoperative adjuvant chemotherapy) with/without adding targeted therapy (mainly using anti-angiogenesis agent- bevacizumab). After front-line chemotherapy, the advanced-stage EOC can be successfully controlled and three-quarters of patients can achieve a complete clinical remission. Unfortunately, nearly all patients will recur and progression-free survival (PFS) of these patients is seldom more than 3 years with a dismal median PFS of 12-18 months. With each recurrence, patients finally develop resistance to standard chemotherapy regimen, contributing to fewer than half of women who survive for more than 5 years after diagnosis with a median overall survival (OS) of 40.7 months. Due to the lower PFS and OS, particularly for those advanced-stage patients, novel therapeutic options during the front-line therapy are desperately needed to decrease the occurrence of recurrence, and the majority of them are still under investigation. It is well-known that overexpression of CA125 has been associated with attenuated cellular apoptosis, platinum chemotherapy resistance, tumor proliferation and disease progression, suggesting that anti-CA125 may play a role in the management of patients with EOC. The current review is a Part I which will focus on development of anti-CA125 monoclonal antibody, hoping that alternation of the front-line therapy by chemo-immunotherapy will be beneficial for prolonged survival of patients with EOC.

Dynamic monitoring of serum tumor markers as prognostic factors in patients with advanced non-small-cell lung cancer treated with first-line immunotherapy: a multicenter retrospective study

Background

To date, no specific studies have reported the use of dynamic serum tumor markers (STMs) as prognostic factors in patients with advanced non-small-cell lung cancer (NSCLC) who receive first-line immunotherapy. Therefore, it is unclear whether STMs can be used as a prognostic factor for first-line immunotherapy in advanced NSCLC.

Objectives

To elucidate the role of STMs in monitoring immunotherapy response in advanced NSCLC. Patients were treated with first-line programmed cell death-1/programmed cell death ligand-1 inhibitors at four Chinese centers.

Design

This was a multicenter retrospective study.

Methods

Blood samples were collected at baseline and after 6-8 weeks of treatment. Computed tomography scans were used to evaluate treatment efficacy according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1. Post-treatment drops in STMs [Serum carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), cytokeratin fragment 19 (CYFRA21-1), carbohydrate antigen 19-9 (CA19-9), and carbohydrate antigen 125 (CA125)] were decreased ⩾20% (Group C) over baseline was used as cutoff level for defining a marker response. If STMs were increased by ⩾20% after treatment, the therapeutic effect was limited (Group A). Patients with STM changes between a 20% increase or decrease were enrolled in Group B. In univariate and multivariate stepwise Cox regression analyses, STMs and RECIST responses were analyzed for their impact on progression-free survival (PFS) and overall survival (OS).

Results

The analysis included 716 patients. By multivariate analysis, CEA, NSE, CYFRA21-1, CA19-9, and CA125 (Group A versus Group B and Group A versus Group C) were associated with significant differences in PFS. Similar results were observed in the OS analysis. Similar results were observed in the adenocarcinoma subgroup analyses. In squamous cell carcinoma subgroup analyses, there was no statistical difference in PFS (p = 0.147) or OS (p = 0.068) between Group A and Group B for CA125.

Conclusion

The increase and decrease in serum levels of STMs might be reliable prognostic factors for immunotherapy efficacy in NSCLC patients.

Baseline serum tumor markers predict the survival of patients with advanced non-small cell lung cancer receiving first-line immunotherapy: a multicenter retrospective study

BACKGROUND

This study aimed to investigate the association between baseline serum tumor markers (STMs) (carcinoembryonic antigen [CEA], neuron-specific enolase [NSE], cytokeratin-19 fragment [CYFRA21-1], carbohydrate antigen 19-9 [CA19-9], and carbohydrate antigen 125 [CA125]) and the efficacy of first-line immunotherapy in patients with advanced non-small cell lung cancer.

METHODS

This multicenter retrospective study evaluated patients who received first-line immunotherapy between July 2017 and July 2022. The endpoints were progression-free survival (PFS) and overall survival (OS), as defined by the Response Evaluation Criteria in Solid Tumors version 1.1. We divided the patients into three groups based on STM levels: Group A ≥ threefold upper limit of normal, threefold upper limit of normal > Group B > upper limit of normal, and Group C ≤ upper limit of normal.

RESULTS

In total, 716 patients were included in this study. In Cox proportional hazards analyses, the STM levels in Group C were independently associated with superior PFS and OS in patients with lung adenocarcinoma (LUAD). Except for CA19-9 level, the STM levels in Group C were independently associated with superior PFS and OS in patients with lung squamous carcinoma (LUSC). Except for CEA and CA19-9 levels, the levels in Group A were independently associated with inferior PFS and OS in patients with LUAD and LUSC.

CONCLUSIONS

Serum CEA, NSE, CYFRA21-1, and CA125 levels can predict PFS and OS in patients with LUAD and LUSC, and serum CA19-9 levels can predict PFS and OS in patients with LUAD. The higher the serum NSE, CYFRA21-1, and CA125 levels, the worse the PFS and OS in patients with LUAD and LUSC. In addition, the higher the serum CA19-9 level, the worse the OS in patients with LUAD.

Comparison of the diagnostic accuracy of HE4 with CA125 and validation of the ROMA index in differentiating malignant and benign epithelial ovarian tumours among patients in Lagos, Nigeria

This prospective cross-sectional study compared the diagnostic accuracy of human epididymal protein 4 (HE4) with cancer antigen 125 (CA 125) and validates the risk of malignancy algorithm (ROMA) in differentiating benign from malignant ovarian tumours. The study population included 112 women with an ultrasound diagnosis of an adnexal mass, out of whom 49 women had a diagnosis of ovarian cancer following optimal debulking surgery, and 63 women had a diagnosis of benign ovarian tumour. All diagnosis was confirmed by histopathological analysis. Serum HE4 and CA 125 were assessed preoperatively according to the manufacturer's instructions. CA 125 and HE4 cut-offs were 35 U/mL and 70 pM/L respectively. Serum CA 125 and HE4 were significantly higher in ovarian cancer patients compared to those with benign ovarian tumours (p < 0.001 and p < 0.000, respectively). HE4 had higher sensitivity (77.5% versus 69.4%), specificity (96.8% versus 82.5%), positive predictive value (PPV) (95% versus 75.6%) and negative predictive value (84.7% versus 77.6%) than CA 125. When the two markers were combined with each other in the ROMA index, Specificity and PPV reached 100% each. In the receiver operative characteristics analysis, the area under the curve for CA 125 was 0.679 (95% CI 0.566-0.791, p = 0.001), HE4 was 0.845 (95% CI 0.760-0.930, p = 0.000) and ROMA was 0.902 (95% CI 0.851-0.998, p = 0.000) and this was statistically significant (p < 0.001). Conclusively, HE4 performed better than CA 125 in differentiating benign from malignant ovarian tumours and the combination of the two biomarkers improved the detection of ovarian cancer. In addition, the cut off values corresponding to the highest accuracy for CA 125 and HE4 were 126 U/mL and 42 pM/L respectively in this study. The value for CA 125 is much higher while that of HE4 is much lower than the reference values obtained predominantly from the white population.

Mass Spectrometry-based Proteomics of Epithelial Ovarian Cancers: a Clinical Perspective

Increasing proteomic studies focused on epithelial ovarian cancer (EOC) have attempted to identify early disease biomarkers, establish molecular stratification, and discover novel druggable targets. Here we review these recent studies from a clinical perspective. Multiple blood proteins have been used clinically as diagnostic markers. The ROMA test integrates CA125 and HE4, while the OVA1 and OVA2 tests analyze multiple proteins identified by proteomics. Targeted proteomics has been widely used to identify and validate potential diagnostic biomarkers in EOCs, but none has yet been approved for clinical adoption. Discovery proteomic characterization of bulk EOC tissue specimens has uncovered a large number of dysregulated proteins, proposed new stratification schemes, and revealed novel targets of therapeutic potential. A major hurdle facing clinical translation of these stratification schemes based on bulk proteomic profiling is intra-tumor heterogeneity, namely that single tumor specimens may harbor molecular features of multiple subtypes. We reviewed over 2500 interventional clinical trials of ovarian cancers since 1990, and cataloged 22 types of interventions adopted in these trials. Among 1418 clinical trials which have been completed or are not recruiting new patients, about 50% investigated chemotherapies. Thirty-seven clinical trials are at phase 3 or 4, of which 12 focus on PARP, 10 on VEGFR, 9 on conventional anti-cancer agents, and the remaining on sex hormones, MEK1/2, PD-L1, ERBB, and FRα. Although none of the foregoing therapeutic targets were discovered by proteomics, newer targets discovered by proteomics, including HSP90 and cancer/testis antigens, are being tested also in clinical trials. To accelerate the translation of proteomic findings to clinical practice, future studies need to be designed and executed to the stringent standards of practice-changing clinical trials. We anticipate that the rapidly evolving technology of spatial and single-cell proteomics will deconvolute the intra-tumor heterogeneity of EOCs, further facilitating their precise stratification and superior treatment outcomes.

Metastases to Meningiomas: A Comprehensive Literature Review Including Mediating Proteins

Approximately 5-15% of solid tumors metastasizing to the central nervous system metastasize to the leptomeninges. Less common, is metastasis to leptomeningeal meningiomas. These are primarily carcinomas of the breast and lung. Awareness of this phenomenon is critical to the evaluation of meningiomas, especially since the metastases may be the first indication of an occult tumor elsewhere in the body. Lack of clear demarcation between the metastasis and meningioma parenchyma, as well as histological features similar to the meningioma, may hinder recognition. The mechanisms underlying metastases anchoring and spread along the leptomeninges are not established. However, several cell adhesion molecules are thought to contribute to this phenomenon. E cadherin is a cell adhesion molecule present in meningioma cells. Binding to endothelium by adhesion molecules such as ICAM, B1 integrin, P-selectin, PECAM-1, CXCL12 and SDF-1 have also been proposed as part of the mechanisms underlying breast carcinoma metastases. In addition, the leptomeninges and meningiomas express mesothelin that acts as an anchoring protein coupling with mucin-16. Consequently, metastatic tumor cell mucin and mesothelin may also facilitate the anchoring of metastases to meningiomas.

Circular RNAs in Epithelial Ovarian Cancer: From Biomarkers to Therapeutic Targets

Epithelial ovarian cancer (EOC) is the most lethal gynecological cancer, and more than 70% of patients are diagnosed at advanced stages. Despite the application of surgery and chemotherapy, the prognosis remains poor due to the high relapse rate. It is urgent to identify novel biomarkers and develop novel therapeutic strategies for EOC. Circular RNAs (circRNAs) are a class of noncoding RNAs generated from the "back-splicing" of precursor mRNA. CircRNAs exert their functions via several mechanisms, including acting as miRNA sponges, interacting with proteins, regulating transcription, and encoding functional proteins. Recent studies have identified many circRNAs that are dysregulated in EOC and may be used as diagnostic and prognostic markers. Increasing evidence has revealed that circRNAs play a critical role in ovarian cancer progression by regulating various cellular processes, including proliferation, apoptosis, metastasis, and chemosensitivity. The circRNA-based therapy may be a novel strategy that is worth exploring in the future. Here, we provide an overview of EOC and circRNA biogenesis and functions. We then discuss the dysregulations of circRNAs in EOC and the possibility of using them as diagnostic/prognostic markers. We also summarize the role of circRNAs in regulating ovarian cancer development and speculate their potential as therapeutic targets.

Translational proteomics and phosphoproteomics: Tissue to extracellular vesicles

We are currently experiencing a rapidly developing era in terms of translational and clinical medical sciences. The relatively mature state of nucleic acid examination has significantly improved our understanding of disease mechanism and therapeutic potential of personalized treatment, but misses a large portion of phenotypic disease information. Proteins, in particular phosphorylation events that regulates many cellular functions, could provide real-time information for disease onset, progression and treatment efficacy. The technical advances in liquid chromatography and mass spectrometry have realized large-scale and unbiased proteome and phosphoproteome analyses with disease relevant samples such as tissues. However, tissue biopsy still has multiple shortcomings, such as invasiveness of sample collection, potential health risk for patients, difficulty in protein preservation and extreme heterogeneity. Recently, extracellular vesicles (EVs) have offered a great promise as a unique source of protein biomarkers for non-invasive liquid biopsy. Membranous EVs provide stable preservation of internal proteins and especially labile phosphoproteins, which is essential for effective routine biomarker detection. To aid efficient EV proteomic and phosphoproteomic analyses, recent developments showcase clinically-friendly EV techniques, facilitating diagnostic and therapeutic applications. Ultimately, we envision that with streamlined sample preparation from tissues and EVs proteomics and phosphoproteomics analysis will become routine in clinical settings.

CT imaging phenotypes linked to CA125 and HE4 biomarkers are highly predictive in discriminating between hereditary and sporadic ovarian cancer patients

BACKGROUND: Hereditary ovarian cancers (HOC) represent about 23% of ovarian cancer (OC) cases: they are most frequently related to germline mutations in the BRCA genes. OBJECTIVE: We aimed to compare CA125/HE4 serum levels and Computed Tomography (CT) features at time of ovarian cancer (OC) diagnosis in two populations: BRCA mutant and BRCA wild-type (WT) OC, and to investigate the relationship between this laboratory and radiological biomarker and BRCA mutation status. METHODS: This retrospective study included 60 newly diagnosed OC patients with FIGO stage IIIC-IV disease, tested for BRCA1/2 germline mutation status of which preoperative CT scan and serum tumor marker assay were available. RESULTS: The median level of CA125 (708 U/mL) was significantly higher (p < 0.002) in BRCA1/2 mutated patients than in WT patients (176 U/mL), whereas the median level of HE4 (492 pmol/L) was significantly higher (p < 0.002) in WT than in BRCA-mutated patients (252 pmol/L). BRCA mutation carriers showed a higher incidence of bilateral ovarian masses (p = 0.0303) characterized by solid structures (p < 0.00001), higher peritoneal tumor load, macronodular implants >2 cm (p = 0.000099), increased frequency of lymphadenopathies (p = 0.019), and metastasis (p = 0.052) compared to patients with BRCA WT. CONCLUSIONS: Tumor markers and CT patterns may help in identifying BRCA mutation status in OC directing patients towards a personalized treatment.

Human Malignant Rhabdoid Tumor Antigens as Biomarkers and Potential Therapeutic Targets

Simple Summary

Atypical teratoid rhabdoid tumor (ATRT) is a deadly type of human pediatric brain cancer without effective treatments. ATRT is mainly linked to the inactivation of a tumor suppressor gene, SMARCB1; however, additional biomarkers remain to be identified to develop novel therapeutic strategies. Therefore, different tumor antigens and extracellular matrix modulators were investigated in two human ATRT and one kidney malignant rhabdoid tumor cell lines and compared with the nonmalignant HEK293 cell line. Alpha-fetoprotein (AFP), mucin-16 (MUC16 or cancer antigen 125/CA125), osteopontin (OPN), and mesothelin (MSLN) are highly expressed in these human malignant rhabdoid cancer cell lines. Inhibiting MMPs using a small-molecule inhibitor decreased cell survival. This biomarker discovery process may lead to the identification of novel diagnostic and therapeutic strategies, such as the development of targeted and immunotherapies against cancer biomarkers, to treat cancer patients.

Abstract

Introduction: Atypical teratoid rhabdoid tumor (ATRT) is a lethal type of malignant rhabdoid tumor in the brain, seen mostly in children under two years old. ATRT is mainly linked to the biallelic inactivation of the SMARCB1 gene. To understand the deadly characteristics of ATRT and develop novel diagnostic and immunotherapy strategies for the treatment of ATRT, this study investigated tumor antigens, such as alpha-fetoprotein (AFP), mucin-16 (MUC16/CA125), and osteopontin (OPN), and extracellular matrix modulators, such as matrix metalloproteinases (MMPs), in different human malignant rhabdoid tumor cell lines. In addition, the roles of MMPs were also examined. Materials and methods: Five human cell lines were chosen for this study, including two ATRT cell lines, CHLA-02-ATRT and CHLA-05-ATRT; a kidney malignant rhabdoid tumor cell line, G401; and two control cell lines, human embryonic kidney HEK293 and HEK293T. Both ATRT cell lines were treated with a broad-spectrum MMP inhibitor, GM6001, to investigate the effect of MMPs on cell proliferation, viability, and expression of tumor antigens and biomarkers. Gene expression was examined using a reverse transcription polymerase chain reaction (RT-PCR), and protein expression was characterized by immunocytochemistry and flow cytometry. Results: All the rhabdoid tumor cell lines tested had high gene expression levels of MUC16, OPN, AFP, and MSLN. Low expression levels of neuron-specific enolase (ENO2) by the two ATRT cell lines demonstrated their lack of neuronal genotype. Membrane-type 1 matrix metalloproteinase (MT1-MMP/MMP-14) and tissue inhibitor of metalloproteinases-2 (TIMP-2) were highly expressed in these malignant rhabdoid tumor cells, indicating their invasive phenotypes. GM6001 significantly decreased ATRT cell proliferation and the gene expression of MSLN, OPN, and several mesenchymal markers, suggesting that inhibition of MMPs may reduce the aggressiveness of rhabdoid cancer cells. Conclusion: The results obtained from this study may advance our knowledge of the molecular landscapes of human malignant rhabdoid tumors and their biomarkers for effective diagnosis and treatment. This work analyzed the expression of human malignant rhabdoid tumor antigens that may serve as biomarkers for the development of novel therapeutic strategies, such as cancer vaccines and targeted and immunotherapies targeting osteopontin and mesothelin, for the treatment of patients with ATRT and other malignant rhabdoid tumors.

Current Advances in PD-1/PD-L1 Blockade in Recurrent Epithelial Ovarian Cancer

Immunotherapies have revolutionized the treatment of a variety of cancers. Epithelial ovarian cancer is the most lethal gynecologic malignancy, and the rate of advanced tumor progression or recurrence is as high as 80%. Current salvage strategies for patients with recurrent ovarian cancer are rarely curative. Recurrent ovarian cancer is a “cold tumor”, predominantly due to a lack of tumor antigens and an immunosuppressive tumor microenvironment. In trials testing programmed death-1 (PD-1)/programmed death ligand 1 (PD-L1) blockade as a monotherapy, the response rate was only 8.0-22.2%. In this review, we illustrate the status of cold tumors in ovarian cancer and summarize the existing clinical trials investigating PD-1/PD-L1 blockade in recurrent ovarian cancer. Increasing numbers of immunotherapy combination trials have been set up to improve the response rate of EOC. The current preclinical and clinical development of immunotherapy combination therapy to convert an immune cold tumor into a hot tumor and their underlying mechanisms are also reviewed. The combination of anti-PD-1/PD-L1 with other immunomodulatory drugs or therapies, such as chemotherapy, antiangiogenic therapies, poly (ADP-ribose) polymerase inhibitors, adoptive cell therapy, and oncolytic therapy, could be beneficial. Further efforts are merited to transfer these results to a broader clinical application.

A risk prediction model for acute kidney injury in patients with pulmonary tuberculosis during anti-tuberculosis treatment

Background

Acute kidney injury (AKI) is not a rare complication during anti-tuberculosis treatment in some patients with pulmonary tuberculosis (PTB). We aimed to develop a risk prediction model for early recognition of patients with PTB at high risk for AKI during anti-TB treatment.

Methods

This retrospective cohort study assessed the clinical baseline, and laboratory test data of 315 inpatients with active PTB who were screened for predictive factors from January 2019 to June 2020. The elements were analyzed by logistic regression analysis. A nomogram was established by the results of the logistic regression analysis. The prediction model discrimination and calibration were evaluated by the concordance index (C-index), ROC curve, and Hosmer-Lemeshow analysis.

Results

A total of 315 patients with PTB were enrolled (67 patients with AKI and 248 patients without AKI). Seven factors, including microalbuminuria, hematuria, cystatin-C (CYS-C), albumin (ALB), creatinine-based estimated glomerular filtration rates (eGFRs), body mass index (BMI), and CA-125 were acquired to develop the predictive model. According to the logistic regression, microalbuminuria (OR = 3.038, 95%CI 1.168–7.904), hematuria (OR = 3.656, 95%CI 1.325–10.083), CYS-C (OR = 4.416, 95%CI 2.296–8.491), and CA-125 (OR = 3.93, 95%CI 1.436–10.756) were risk parameter, while ALB (OR = 0.741, 95%CI 0.650–0.844) was protective parameter. The nomogram demonstrated good prediction in estimating AKI (C-index= 0.967, AUC = 0.967, 95%CI (0.941–0.984), sensitivity = 91.04%, specificity = 93.95%, Hosmer-Lemeshow analysis SD = 0.00054, and quantile of absolute error = 0.049).

Conclusions

Microalbuminuria, hematuria, ALB reduction, elevated CYS-C, and CA-125 are predictive factors for the development of AKI in patients with PTB during anti-TB treatments. The predictive nomogram based on five predictive factors is achieved good risk prediction for AKI during anti-TB treatments.

Temporal trends of healthcare system use between symptomatic presentation and ovarian cancer diagnosis in the United States

OBJECTIVE

To describe trends in healthcare system use over time between onset of classic ovarian cancer symptoms and ovarian cancer diagnosis in the United States.

METHODS

A population-based study of the Surveillance, Epidemiology, and End Results-Medicare database was conducted on patients aged ≥66 years with stage II-IV epithelial ovarian cancer between 1992 and 2015 with at least one of the following diagnosis codes: abdominal pain, bloating, difficulty eating, and/or urinary symptoms. The outcomes were frequency of visit type, frequency of diagnostic modality, and Medicare reimbursement between first symptomatic claim and cancer diagnosis. Jonckheere-Terpstra and Cochran-Armitage tests were used to evaluate trends over time.

RESULTS

Among 13 872 women, 13 541 (97.6%) had outpatient, 6466 (46.6%) had inpatient, and 4906 (35.4%) had emergency room visits. The frequency of outpatient (p<0.001) and emergency room visits (p<0.001) increased while the frequency of inpatient visits (p<0.001) decreased between 1992 and 2015. The median number of outpatient visits (p<0.001) and physician specialties seen (p<0.001) increased over time. The median hospital length of stay decreased from 10 days in 1992 to 5 days in 2015 (p<0.001). Between 1992 and 2015, the frequency of ultrasound decreased (p<0.001) while the frequency of computed tomography, magnetic resonance imaging, positron emission tomography imaging, and cancer antigen 125 tumor immunoassay increased (p<0.001). Median monthly total (p<0.001), inpatient (p<0.001), and outpatient (p=0.006) reimbursements decreased while emergency room reimbursements increased (p<0.001) over time.

CONCLUSION

Healthcare reimbursement between symptomatic presentation and ovarian cancer diagnosis has decreased over time and may reflect the trends in fewer and shorter hospitalizations and increased use of emergency and outpatient management during the evaluation of symptoms of women with ovarian cancer.

Fertility in multiple recurrent bilateral ovarian teratomas: A case report

Very few cases of bilateral and recurrent teratomas have been reported. We present the case of a 21-year-old nulliparous female who presented to an outside facility complaining of left flank pain and was found to have bilateral ovarian teratomas. The physician proceeded with a laparotomy. Five years later, the patient presented to our facility complaining of abdominal pain. Imaging revealed a second incidence of bilateral dermoid cysts for which she underwent a bilateral laparoscopic cystectomy. The patient retained her fertility and was able to deliver a newborn 2 years later. At the age of 31, and during a regular check-up, the patient was found again to have a third incidence of bilateral dermoid cysts for which she underwent bilateral laparoscopic cystectomy with preservation of her ovaries. In conclusion, laparoscopic removal of dermoid cysts is of utmost importance to retain the fertility of young patients. Regular check-up by ultrasound post-operatively is necessary to screen for recurrences and prevent painful presentations.

Predicting miscarriage using systemic immune-inflammation index

AIM

To evaluate the clinical significance of the systemic immune-inflammation index (SII) for patients who had miscarriages.

MATERIALS

The retrospective study included 709 pregnant women who had a miscarriage (nonviable intrauterine pregnancy up to 20 weeks of gestation) and 676 women who carried a viable intrauterine pregnancy up to 20 weeks of gestation-serving as the control group. The study and the control group were compared in terms of demographic characteristics, laboratory test results, and SII values. Furthermore, laboratory test results and SII values were compared between patients in the study group and the control group with a history of genital bleeding (threatened abortion).

RESULTS

The mean gestational week of pregnancy was 9.5 ± 3 for the control group and 8.3 ± 2.5 for the study group (p = 0.150). The SII values were higher in the study group than in the control group (p = 0.030). In all participants with a clinical history of genital bleeding, the leukocyte count, neutrophil count, neutrophil-to-lymphocyte ratio (NLR), and SII values were higher in the miscarriage group than the group with viable fetus (p = 0.031, p = 0.003, p = 0.002, p < 0.001). Based on a receiver operating characteristic (ROC) curve analysis, the SII cutoff value for miscarriage was 883.95 (10⁹ /L) (62.6% sensitivity, 62% specificity) in patients with a clinical history of threatened abortion.

CONCLUSION

High SII values in early pregnancy may be used as an additional marker for the prediction of miscarriage, in pregnant women with threatened abortion. Further prediction models including maternal risk factors and multiple markers may be more valuable for clinical practice.

Plasma circN4BP2L2 is a promising novel diagnostic biomarker for epithelial ovarian cancer

BACKGROUND

Circular RNAs (circRNAs) are more stable than linear RNA molecules, which makes them promising diagnostic biomarkers for diseases. By circRNA-sequencing analysis, we previously found that circN4BP2L2 was significantly decreased in epithelial ovarian cancer (EOC) tissues, and was predictive of disease progression. The aim of this study was to evaluate the diagnostic value of plasma circN4BP2L2 in EOC.

METHODS

Three hundred seventy-eight plasma samples were acquired prior to surgery. Samples were obtained from 126 EOC patients, 126 benign ovarian cyst patients, and 126 healthy volunteers. CircN4BP2L2 was assessed using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Cancer antigen 125 (CA125) and human epididymis protein 4 (HE4) were assessed using enzyme-linked immunosorbent assay (ELISA). EOC cells were transfected with small interference RNAs (siRNAs) and cell proliferation, migration, invasion, cell cycle and cell apoptosis were performed to assess the effect of circN4BP2L2 in EOC. Receiver operating curve (ROC), the area under the curve (AUC), sensitivity and specificity were estimated.

RESULTS

Plasma circN4BP2L2 was significantly downregulated in EOC patients. Decreased circN4BP2L2 was significantly associated with advanced tumor stage, worse histological grade, lymph node metastasis and distant metastasis in EOC. CircN4BP2L2 inhibited tumor cell migration and invasion in vitro. CircN4BP2L2 could significantly separate EOC from benign (AUC = 0.82, P <  0.01) or normal (AUC = 0.90, P <  0.01) cohort. Early stage EOC vs benign (AUC = 0.81, P <  0.01) or normal (AUC = 0.90, P <  0.01) cohort could also be distinguished by circN4BP2L2. In discrimination between EOC cohort and benign or normal cohort, circN4BP2L2 performed equally well in both pre- and post-menopausal women. The combination of circN4BP2L2, CA125 and HE4 showed high sensitivity and specificity in detecting EOC cases.

CONCLUSIONS

Plasma circN4BP2L2 is significantly downregulated in EOC and might serve as a promising novel diagnostic biomarker for EOC patients, especially in early stage EOC cases. CircN4BP2L2 might act as an adjunct to CA125 and HE4 in detecting EOC. Further large-scale studies are warranted to verify our results.

Human iPSC-derived fallopian tube organoids with BRCA1 mutation recapitulate early-stage carcinogenesis

Germline pathogenic mutations in BReast CAncer (BRCA1) genes are thought to drive normal fallopian tube epithelial (FTE) cell transformation to high-grade serous ovarian cancer. No human models capture the sequence of events for disease initiation and progression. Here, we generate induced pluripotent stem cells (iPSCs) from healthy individuals and young ovarian cancer patients with germline pathogenic BRCA1 mutations (BRCA1^mut). Following differentiation into FTE organoids, BRCA1^mut lines exhibit cellular abnormalities consistent with neoplastic transformation compared to controls. BRCA1^mut organoids show an increased production of cancer-specific proteins and survival following transplantation into mice. Organoids from women with the most aggressive ovarian cancer show the greatest pathology, indicating the potential value to predict clinical severity prior to disease onset. These human FTE organoids from BRCA1^mut carriers provide a faithful physiological in vitro model of FTE lesion generation and early carcinogenesis. This platform can be used for personalized mechanistic and drug screening studies.

Yucer et al. generate a human BRCA1 mutant iPSC-derived fallopian tube organoid model, which recapitulates BRCA1 mutant ovarian carcinogenesis in vitro and shows tumors in vivo. This model provides a biologically relevant platform to validate drugs and a basis for personalized early detection and preventative strategies for women carrying BRCA1 mutations.

Biomarkers in Ovarian Pathology: From Screening to Diagnosis. Review of the Literature

Background: Ovarian cancer has a low incidence, but high mortality due to a habitual diagnosis in advanced cancer stages. Currently, used biomarkers have good sensitivity, but low specificity. Aim: To determine the usefulness of the biomarkers and algorithms used up to now in the screening, diagnosis, response to treatments and identification of recurrence in patients with ovarian masses. Methodology: Systematic search of publications in English in the Medline-PubMed database with the terms: “biomarkers”, “tumour”, “tumour biomarkers”, “marker”, “tumour marker”, “ovarian cancer”, “ovarian”, “Neoplasms”, “cancer”, CA-125 Antigen; Human Epididymis-specific Protein E4; Risk of Malignancy Index (RMI); Risk of Ovarian Malignancy Algorithm (ROMA); Ovarian Neoplasms. Original articles, clinical trials, reviews, systematic reviews and meta-analyses, published between January 2000 and November 2020, were selected to determine the usefulness (among others) of CA 125 and HE4 antigen in ovarian cancer. Results: Finally, 39 transcendental publications were selected to write this article to determine the usefulness of tumour markers and algorithms in ovarian cancer. Conclusions: The usefulness of the tumour markers antigen CA125 and antigen HE4 individually or as a basis for decision-making algorithms has low specificity; however, there is little evidence that confirms their usefulness as markers in ovarian cancer screening.

Salvaging Detection of Early-Stage Ovarian Malignancies When CA125 Is Not Informative

Background: Ovarian cancer is the deadliest gynecologic cancer, with no recommended screening test to assist with early detection. Cancer antigen 125 (CA125) is a serum biomarker commonly used by clinicians to assess preoperative cancer risk, but it underperforms in premenopausal women, early-stage malignancies, and several histologic subtypes. OVA1 is a multivariate index assay that combines CA125 and four other serum proteins to assess the malignant risk of an adnexal mass. Objective: To evaluate the performance of OVA1 in a cohort of patients with low-risk serum CA125 values. Study Design: We analyzed patient data from previous collections (N = 2305, prevalence = 4.5%) where CA125 levels were at or below 67 units/milliliter (U/mL) for pre-menopausal women and 35 U/mL for post-menopausal women. We compare the performance of OVA1 to CA125 in classifying the risk of malignancy in this cohort, including sensitivity, specificity, positive and negative predictive values. Results: The overall sensitivity of OVA1 in patients with a low-risk serum CA125 was 59% with a false-positive rate of 30%. OVA1 detected over 50% of ovarian malignancies in premenopausal women despite a low-risk serum CA125. OVA1 also correctly identified 63% of early-stage cancers missed by CA125. The most common epithelial ovarian cancer subtypes in the study population were mucinous (25%) and serous (23%) carcinomas. Despite a low-risk CA125, OVA1 successfully detected 83% of serous, 58% of mucinous, and 50% of clear cell ovarian cancers. Conclusions: As a standalone test, CA125 misses a significant number of ovarian malignancies that can be detected by OVA1. This is particularly important for premenopausal women and early-stage cancers, which have a much better long-term survival than late-stage malignancies. Using OVA1 in the setting of a normal serum CA125 can help identify at-risk ovarian tumors for referral to a gynecologic oncologist, potentially improving overall survival.

The evolving role of MUC16 (CA125) in the transformation of ovarian cells and the progression of neoplasia

MUC16 (the cancer antigen CA125) is the most commonly used serum biomarker in epithelial ovarian cancer, with increasing levels reflecting disease progression. It is a transmembrane glycoprotein with multiple isoforms, undergoing significant changes through the metastatic process. Aberrant glycosylation and cleavage with overexpression of a small membrane-bound fragment consist MUC16-related mechanisms that enhance malignant potential. Even MUC16 knockdown can induce an aggressive phenotype but can also increase susceptibility to chemotherapy. Variable MUC16 functions help ovarian cancer cells avoid immune cytotoxicity, survive inside ascites and form metastases. This review provides a comprehensive insight into MUC16 transformations and interactions, with description of activated oncogenic signalling pathways, and adds new elements on the role of its differential glycosylation. By following the journey of the molecule from pre-malignant states to advanced stages of disease it demonstrates its behaviour, in relation to the phenotypic shifts and progression of ovarian cancer. Additionally, it presents proposed differences of MUC16 structure in normal/benign conditions and epithelial ovarian malignancy.

Bispecific T-Cell Engaging Antibodies Against MUC16 Demonstrate Efficacy Against Ovarian Cancer in Monotherapy and in Combination With PD-1 and VEGF Inhibition

Immunotherapy for ovarian cancer is an area of intense investigation since the majority of women with relapsed disease develop resistance to conventional cytotoxic therapy. The paucity of safe and validated target antigens has limited the development of clinically relevant antibody-based immunotherapeutics for this disease. Although MUC16 expression is almost universal in High Grade Serous Ovarian Cancers, engagement of the shed circulating MUC16 antigen (CA-125) presents a theoretical risk of systemic activation and toxicity. We designed and evaluated a series of bispecific tandem single-chain variable fragments specific to the retained portion of human MUC16 ectodomain (MUC16^ecto) and human CD3. These MUC16^ecto- BiTEDs retain binding in the presence of soluble MUC16 (CA-125) and show cytotoxicity against a panel of ovarian cancer cells in vitro. MUC16^ecto- BiTEDs delay tumor progression in vivo and significantly prolong survival in a xenograft model of ovarian peritoneal carcinomatosis. This effect was significantly enhanced by antiangiogenic (anti-VEGF) therapy and immune checkpoint inhibition (anti-PD1). However, the combination of BiTEDs with anti-VEGF was superior to combination with anti-PD1, based on findings of decreased peritoneal tumor burden and ascites with the former. This study shows the feasibility and efficacy of MUC16^ecto- specific BiTEDs and provides a basis for the combination with anti-VEGF therapy for ovarian cancer.

Abdominopelvic leiomyoma with large ascites: A case report and review of the literature

BACKGROUND

Leiomyoma of the uterus is relatively common, but uterine leiomyoma of the greater omentum is rare.

CASE SUMMARY

Here, we report the case of a 22-year-old woman who presented with a 3 mo history of progressive abdominal distension and a hypervascular abdominopelvic mass. Due to a high serum concentration of CA125, the preoperative diagnosis was unclear. During surgery, 5 L of ascites was removed. An 18.8 cm solid mass, which was pedunculated from the uterine fundus and exhibited complex adhesion to the greater omentum, was removed. The CA125 level was reduced postoperatively, and a pathologic study confirmed that the mass was a leiomyoma that originated in the uterus.

CONCLUSION

Uterine leiomyoma can share vessels with the greater omentum. This case highlights the difficulty of diagnosing pseudo-Meigs syndrome and the importance of imaging and laboratory examinations.

Incidence of and risk factors associated with lung metastases in newly diagnosed epithelial ovarian cancer with a look on prognosis after diagnosis: a population-based cohort study of the SEER database

PURPOSE

Patients with lung metastases (LM) from epithelial ovarian cancer (EOC) (EOCLM) usually have a poor prognosis. However, there is no consensus on the optimal management of these patients. In this study, we aimed to take a look at the incidence of LM and factors associated with its occurrence as well as the prognosis in newly diagnosed EOC with LM on a population level.

METHODS

EOC patients diagnosed between the years 2010 and 2016 were identified from the Surveillance, Epidemiology, and End Results (SEER) program database. Multivariable logistic regression and multivariable Cox regression were used to investigate the factors that could predict the occurrence of and prognosis after diagnosis of EOC with LM.

RESULTS

Of the 33,418 qualified EOC patients, 2240 (6.7%) were noted to have LMs at the time of EOC diagnosis. Higher T stage, N1 stage, advanced tumor grade, and elevated cancer antigen-125 levels were found to be associated with a higher risk of having LM at the time of EOC diagnosis. The median survival time after diagnosis with EOCLM was found to be 13.0 months (interquartile range: 3.0-34.0 months). Being unmarried and having mucinous histology were both associated with increased all-cause death risk from EOCLM. However, the primary tumor originated from the midline of ovaries, surgical management, and whether patient received chemotherapy or not predicted improved overall survival. The median survival time of patients was significantly longer for EOCLM cases managed surgically (31.0 months) versus those who did not have surgery (4.0 months), as well as EOCLM cases received chemotherapy (23.0 months) versus those who did not have chemotherapy (2.0 months).

CONCLUSION

This retrospective cohort study showed that de novo LM was infrequent in EOC patients overall and when present predicted poor prognosis. The findings can be potentially useful in formulating for follow-up strategies, screening tools, and personalized interventions.

Targeting eukaryotic elongation factor-2 kinase suppresses the growth and peritoneal metastasis of ovarian cancer

Ovarian cancer (OC) is the deadliest gynecological cancer and is currently incurable with standard treatment regimens. Early invasion, intraperitoneal metastasis, and an aggressive course are the hallmarks of OC. The major reason for poor prognosis is a lack of molecular targets and highly effective targeted therapies. Therefore, identification of novel molecular targets and therapeutic strategies is urgently needed to improve OC survival. Herein we report that eukaryotic elongation factor-2 kinase (EF2K) is highly upregulated in primary and drug-resistant OC cells and its expresssion associated with progression free survival TCGA database) and promotes cell proliferation, survival, and invasion. Downregulation of EF2K reduced expression of integrin β1 and cyclin D1 and the activity of the Src, phosphoinositide 3-kinase/AKT, and nuclear factor-κB signaling pathways. Also, in vivo, therapeutic targeting of EF2K by using single-lipid nanoparticles containing siRNA led to substantial inhibition of ovarian tumor growth and peritoneal metastasis in nude mouse models. Furthermore, EF2K inhibition led to robust apoptosis and markedly reduced intratumoral proliferation in vivo in ovarian tumor xenografts and intraperitoneal metastatic models. Collectively, our data suggest for the first time that EF2K plays an important role in OC growth, metastasis, and progression and may serve as a novel therapeutic target in OCs.

Evaluation of the potential of Pap test fluid and cervical swabs to serve as clinical diagnostic biospecimens for the detection of ovarian cancer by mass spectrometry-based proteomics

BACKGROUND

The purpose of this study was to determine whether the residual fixative from a liquid-based Pap test or a swab of the cervix contained proteins that were also found in the primary tumor of a woman with high grade serous ovarian cancer. This study is the first step in determining the feasibility of using the liquid-based Pap test or a cervical swab for the detection of ovarian cancer protein biomarkers.

METHODS

Proteins were concentrated by acetone precipitation from the cell-free supernatant of the liquid-based Pap test fixative or eluted from the cervical swab. Protein was also extracted from the patient's tumor tissue. The protein samples were digested into peptides with trypsin, then the peptides were run on 2D-liquid chromatography mass spectrometry (2D-LCMS). The data was searched against a human protein database for the identification of peptides and proteins in each biospecimen. The proteins that were identified were classified for cellular localization and molecular function by bioinformatics integration.

RESULTS

We identified almost 5000 proteins total in the three matched biospecimens. More than 2000 proteins were expressed in each of the three biospecimens, including several known ovarian cancer biomarkers such as CA125, HE4, and mesothelin. By Scaffold analysis of the protein Gene Ontology categories and functional analysis using PANTHER, the proteins were classified by cellular localization and molecular function, demonstrating that the Pap test fluid and cervical swab proteins are similar to each other, and also to the tumor extract.

CONCLUSIONS

Our results suggest that Pap test fixatives and cervical swabs are a rich source of tumor-specific biomarkers for ovarian cancer, which could be developed as a test for ovarian cancer detection.

Insights into Bioinformatic Applications for Glycosylation: Instigating an Awakening towards Applying Glycoinformatic Resources for Cancer Diagnosis and Therapy

Glycosylation plays a crucial role in various diseases and their etiology. This has led to a clear understanding on the functions of carbohydrates in cell communication, which eventually will result in novel therapeutic approaches for treatment of various disease. Glycomics has now become one among the top ten technologies that will change the future. The direct implication of glycosylation as a hallmark of cancer and for cancer therapy is well established. As in proteomics, where bioinformatics tools have led to revolutionary achievements, bioinformatics resources for glycosylation have improved its practical implication. Bioinformatics tools, algorithms and databases are a mandatory requirement to manage and successfully analyze large amount of glycobiological data generated from glycosylation studies. This review consolidates all the available tools and their applications in glycosylation research. The achievements made through the use of bioinformatics into glycosylation studies are also presented. The importance of glycosylation in cancer diagnosis and therapy is discussed and the gap in the application of widely available glyco-informatic tools for cancer research is highlighted. This review is expected to bring an awakening amongst glyco-informaticians as well as cancer biologists to bridge this gap, to exploit the available glyco-informatic tools for cancer.

HE4 in the evaluation of tumor load and prognostic stratification of high grade serous ovarian carcinoma

OBJECTIVE

Human epididymis protein 4 (HE4) is a validated, complementary biomarker to cancer antigen 125 (CA125) for high grade serous ovarian carcinoma (HGSC). Currently, there are insufficient data on the utility of longitudinal HE4 measurement during HGSC treatment and follow up. We set to provide a comprehensive analysis on the kinetics and prognostic performance of HE4 with serial measurements during HGSC treatment and follow up.

METHODS

This prospective study included 143 patients with advanced HGSC (ClinicalTrials.gov identifier: NCT01276574). Serum CA125 and HE4 were measured at baseline, before each cycle of chemotherapy and during follow up until first progression. Baseline biomarker values were compared to the tumor load assessed during surgery and to residual disease. Biomarker nadir values and concentrations at progression were correlated to survival.

RESULTS

The baseline HE4 concentration distinguished patients with a high tumor load from patients with a low tumor load assessed during surgery (p<.0001). The baseline CA125 level was not associated with tumor load to a similar extent (p=.067). At progression, the HE4 level was an independent predictor of worse survival in the multivariate analysis (p=.002). All patients that were alive 3 years post-progression had a serum HE4 concentration below 199.20 pmol/l at the 1st recurrence.

CONCLUSION

HE4 is a feasible biomarker in the treatment monitoring and prognostic stratification of patients with HGSC. Specifically, the serum level of HE4 at first relapse was associated with the survival of patients and it may be a useful complementary tool in the selection of second line treatments. This is to the best of our knowledge the first time this finding has been reported.

Soluble heat-shock protein 27 in blood serum is a non-invasive prognostic biomarker for ovarian cancer

OBJECTIVES

Ovarian cancer (OC) is the leading cause of death in gynecological oncology, primarily caused by limited prognostic and therapeutic options. The heat shock protein 27 (HSP27) is recognized as a prominent factor in OC, playing a pivotal role in cancer progression machinery such as treatment resistance. Thus, HSP27 may represent an appropriate biomarker for OC diagnosis, prognosis, and therapy response.

MATERIALS & METHODS

Extracellular HSP27 levels were measured by enzyme-linked immunosorbent assay (ELISA) in serum samples of OC patients (n = 242) and compared to a non-malignant control group without any history of cancer (n = 200). Correlations between serum levels of HSP27 and clinical pathological parameters were analyzed by bivariate analysis. Survival analyses were carried out by Kaplan-Meier test.

RESULTS

This study demonstrated that protein levels of HSP27 are comparable in the blood serum of healthy women and OC patients. However, HSP27 levels are significantly correlated with the volume of ascites, residual tumor mass, and age at first diagnosis in OC patients. Notably, elevated levels of HSP27 demonstrate significantly higher overall survival.

CONCLUSION

Taken together, our findings demonstrate that high levels of circulating HSP27 in serum are associated with improved overall survival of OC patients. Even though functionality of secreted HSP27 is still unclear, serum levels of HSP27 represent a putative non-invasive prognostic biomarker candidate for OC progression.

Integrated Proteomic and Glycoproteomic Characterization of Human High-Grade Serous Ovarian Carcinoma

Many gene products exhibit great structural heterogeneity because of an array of modifications. These modifications are not directly encoded in the genomic template but often affect the functionality of proteins. Protein glycosylation plays a vital role in proper protein functions. However, the analysis of glycoproteins has been challenging compared with other protein modifications, such as phosphorylation. Here, we perform an integrated proteomic and glycoproteomic analysis of 83 prospectively collected high-grade serous ovarian carcinoma (HGSC) and 23 non-tumor tissues. Integration of the expression data from global proteomics and glycoproteomics reveals tumor-specific glycosylation, uncovers different glycosylation associated with three tumor clusters, and identifies glycosylation enzymes that were correlated with the altered glycosylation. In addition to providing a valuable resource, these results provide insights into the potential roles of glycosylation in the pathogenesis of HGSC, with the possibility of distinguishing pathological outcomes of ovarian tumors from non-tumors, as well as classifying tumor clusters.

SJI 2020 special issue: A catalogue of Ovarian Cancer targets for CAR therapy

Ovarian Cancer (OC) is currently difficult to cure, mainly due to its late detection and the advanced state of the disease at the time of diagnosis. Therefore, conventional treatments such as debulking surgery and combination chemotherapy are rarely able to control progression of the tumour, and relapses are frequent. Alternative therapies are currently being evaluated, including immunotherapy and advanced T cell-based therapy. In the present review, we will focus on a description of those Chimeric Antigen Receptors (CARs) that have been validated in the laboratory or are being tested in the clinic. Numerous target antigens have been defined due to the identification of OC biomarkers, and many are being used as CAR targets. We provide an exhaustive list of these constructs and their current status. Despite being innovative and efficient, the OC-specific CARs face a barrier to their clinical efficacy: the tumour microenvironment (TME). Indeed, effector cells expressing CARs have been shown to be severely inhibited, rendering the CAR T cells useless once at the tumour site. Herein, we give a thorough description of the highly immunosuppressive OC TME and present recent studies and innovations that have enabled CAR T cells to counteract this negative environment and to destroy tumours.

Circ-0001068 is a novel biomarker for ovarian cancer and inducer of PD1 expression in T cells

Ovarian cancer is a primary gynecological malignancy with a global 5-year survival rate of 44%. The majority of patients present with advanced disease at initial diagnosis because of the lack of an effective early detection screening test. Circular RNAs (circRNAs) within exosomes in the circulatory system are effective diagnostic and therapeutic biomarkers for many diseases, especially tumors. In this study, we used microarrays to identify 6 circRNAs that were upregulated and 37 circRNAs that were downregulated in exosomes from ovarian cancer patients as compared to healthy volunteers. We validated the accumulation trends for the 6 upregulated circRNAs in the training set using qRT-PCR and found that circ-0001068 was significantly higher in the serum exosomes from the ovarian cancer patients as than healthy volunteers. Circ-0001068 was next evaluated further in a larger cohort. As with the training set, results from the larger cohort revealed that levels of circ-0001068 in the exosomes were significantly higher in ovarian cancer patients than healthy volunteers. Circ-0001068 was also delivered into T cells and induced PD1 expression by acting as a competing endogenous RNA (ceRNA) for miR-28-5p through the exosomes.

Elevated CA 125 level in a mucinous cystadenoma and a teratoma: a case report

Background

The presence of a suspicious ovarian cyst with elevated cancer antigen 125 level in a woman of reproductive age poses a serious therapeutic dilemma. Mature cystic teratomas and mucinous cystadenomas may also cause an increase in cancer antigen 125.

Case presentation

A 43-year-old Sinhalese woman with a history of anovulatory subfertility for 5 years presented with heavy menstrual bleeding and secondary dysmenorrhea of 6 months’ duration. Imaging (pelvic ultrasound and computed tomography of the abdomen and pelvis) revealed a hemorrhagic cyst (6 × 4 cm) on the right side and a multilocular cyst with solid areas (10 × 7 cm) on the left side. Her cancer antigen 125 level was 2715 U/ml. Following a multidisciplinary team meeting, a fertility-sparing staging laparotomy was performed, which included right cystectomy, left oophorectomy, infracolic omentectomy, and peritoneal washings. Histology revealed a mucinous cystadenoma of the right ovary and a mature cystic teratoma on the left ovary. No malignant cells were observed in peritoneal washings. The patient’s cancer antigen 125 level dropped to 74.8 U/ml 1 month after surgery.

Conclusion

Rarely, teratomas and mucinous cystadenomas may also give rise to an extremely high cancer antigen 125 level. The risk of malignancy index and risk of malignancy algorithm may both be misleading in these instances. Therefore, multidisciplinary input, fertility-sparing surgery, and follow-up are paramount to achieve optimal treatment and patient satisfaction.

Challenges and Opportunities in Clinical Applications of Blood-Based Proteomics in Cancer

Simple Summary

The traditional approach in identifying cancer related protein biomarkers has focused on evaluation of a single peptide/protein in tissue or circulation. At best, this approach has had limited success for clinical applications, since multiple pathological tumor pathways may be involved during initiation or progression of cancer which diminishes the significance of a single candidate protein/peptide. Emerging sensitive proteomic based technologies like liquid chromatography mass spectrometry (LC-MS)-based quantitative proteomics can provide a platform for evaluating serial serum or plasma samples to interrogate secreted products of tumor–host interactions, thereby revealing a more “complete” repertoire of biological variables encompassing heterogeneous tumor biology. However, several challenges need to be met for successful application of serum/plasma based proteomics. These include uniform pre-analyte processing of specimens, sensitive and specific proteomic analytical platforms and adequate attention to study design during discovery phase followed by validation of discovery-level signatures for prognostic, predictive, and diagnostic cancer biomarker applications.

Abstract

Blood is a readily accessible biofluid containing a plethora of important proteins, nucleic acids, and metabolites that can be used as clinical diagnostic tools in diseases, including cancer. Like the on-going efforts for cancer biomarker discovery using the liquid biopsy detection of circulating cell-free and cell-based tumor nucleic acids, the circulatory proteome has been underexplored for clinical cancer biomarker applications. A comprehensive proteome analysis of human serum/plasma with high-quality data and compelling interpretation can potentially provide opportunities for understanding disease mechanisms, although several challenges will have to be met. Serum/plasma proteome biomarkers are present in very low abundance, and there is high complexity involved due to the heterogeneity of cancers, for which there is a compelling need to develop sensitive and specific proteomic technologies and analytical platforms. To date, liquid chromatography mass spectrometry (LC-MS)-based quantitative proteomics has been a dominant analytical workflow to discover new potential cancer biomarkers in serum/plasma. This review will summarize the opportunities of serum proteomics for clinical applications; the challenges in the discovery of novel biomarkers in serum/plasma; and current proteomic strategies in cancer research for the application of serum/plasma proteomics for clinical prognostic, predictive, and diagnostic applications, as well as for monitoring minimal residual disease after treatments. We will highlight some of the recent advances in MS-based proteomics technologies with appropriate sample collection, processing uniformity, study design, and data analysis, focusing on how these integrated workflows can identify novel potential cancer biomarkers for clinical applications.

BIRC5/Survivin Expression as a Non-Invasive Biomarker of Endometriosis

The etiology of endometriosis is highly complex, and although it is a benign disease, it has several biological behaviors similar to malignant lesions, including cell invasion, neo-angiogenesis, and decreased apoptosis. Survivin is a protein encoded by the BIRC5 gene that plays a role in cell division by inhibiting apoptosis and regulating the process of mitosis in embryonic and cancer cells. Therefore, we aimed to evaluate the expression of BIRC5 in samples of peripheral blood of women with and without endometriosis. This study comprised of 40 women with endometriosis and 10 healthy women as controls. Peripheral blood samples were collected in the three phases of the menstrual cycle (follicular, ovulatory, and luteal). The expression of the BIRC5 gene was evaluated by RT-qPCR using the TaqMan methodology. The BIRC5 expression was significantly higher in all phases of the menstrual cycle in women with endometriosis, regardless of the disease stage. The accuracy of BIRC5 expression in the peripheral blood for the diagnosis endometriosis presented AUC of 0.887 (p < 0.001), with 97.2% of sensitivity and specificity of 65.5% considering the overall endometriosis group. Regarding the minimal/mild endometriosis group, the AUC presented a value of 0.925 (p < 0.001), with 100% of sensitivity and 79.3% of specificity, whereas in the moderate/severe endometriosis group the AUC was 0.868 (p < 0.001), with a sensitivity of 95.8% and specificity of 65.5%. These findings suggest that the expression of BIRC5 may be a potential noninvasive biomarker for the diagnosis of endometriosis.

Salivary biomarkers in breast cancer: a cross-sectional study

AIM

The objective was to evaluate the diagnostic value of salivary biomarkers in breast cancer.

MATERIALS AND METHODS

A prospective study was carried out of 91 consecutive breast cancer patients and 60 controls without neoplastic disease. Demographic data were recorded, along with the Hospital Anxiety Depression (HAD), risk for development periodontal diseases questionnaire and Mini-Nutritional Assessment (MNA) scores, and the TNM classification and stage of the primary tumor. Unstimulated basal saliva samples were collected and stored at - 80 °C until analysis.

RESULTS

The mean salivary CA125 concentration was 102.1 pg/ml in the control group and 267.6 pg/ml in the breast cancer group (p = 0.005). The soluble Fas (sFas) concentration in turn was 84.1 pg/ml and 145.9 pg/ml, respectively (p = 0.008). None of the biomarkers was related to questionnaire-assessed risk for development of periodontal diseases. The area under the ROC curve was 0.68 for CA125 (95% CI, 0.05-0.56) and 0.67 for sFas (95% CI, 0.08-0.55).

CONCLUSIONS

The salivary biomarkers CA125 and sFas appear to be promising tools in the diagnosis of breast cancer.

Clinical significance of CD38 and CD101 expression in PD-1+CD8+ T cells in patients with epithelial ovarian cancer

Previous studies using mouse liver tumor models have indicated that coexpression of CD38 and CD101 in programmed cell death-1 (PD-1)⁺CD8⁺ T cells may reflect fixed dysregulation of CD8⁺ T cells and thus indicate a poor response to anti-PD-1 immunotherapy. However, whether CD38 and CD101 expression in PD-1⁺CD8⁺ T cells can predict the clinical status and efficacy of chemotherapy for various cancer types, including ovarian cancer (OC), remains unclear. In the present study, peripheral blood mononuclear cells (PBMCs) were obtained by Ficoll-Hypaque gradient centrifugation from 96 fresh samples from healthy adult volunteers and patients with epithelial OC, aged 55.21±9.91 years. Additionally, tumor-infiltrating lymphocytes (TILs) were separated using a combination of mechanical, chemical and enzymatic digestion from fresh surgically removed tumor tissues from 15 patients with epithelial OC. The expression of CD38 and CD101 in PD-1⁺CD8⁺ T cells or TILs was detected by flow cytometry or immunofluorescence (IF) staining, respectively. The association between the level of CD38/CD101 expression and clinicopathological parameters or postoperative chemotherapy in patients with OC was statistically analyzed. The levels of CD38/CD101-coexpressing PD-1⁺CD8⁺ T cells were significantly increased in PBMCs and TILs of patients with OC compared with those of healthy volunteers. The frequency of PD-1⁺CD38⁺CD101⁺CD8⁺ T cells among the total PD-1⁺CD8⁺ T cell subpopulation was negatively associated with clinical stage, lymph node metastasis and postoperative chemotherapy prognosis in patients with OC. Furthermore, IF staining confirmed colocalization of CD38 and CD101 on the majority of TILs in OC tissues. Thus, the present study suggests that coexpression of CD38 and CD101 in peripheral PD-1⁺CD8⁺ T cells and TILs may serve as a new indicator for diagnosis and treatment efficacy in patients with epithelial OC.

Recent advancements in fabrication of nanomaterial based biosensors for diagnosis of ovarian cancer: a comprehensive review

Ovarian cancer is commonly diagnosed via determination of biomarkers like CA125, Mucin 1, HE4, and prostasin that can be present in the blood. However, there is a substantial need for less expensive, simpler, and portable diagnostic tools, both for timely diagnosis and management of ovarian cancer. This review (with 101 refs.) discusses various kinds of nanomaterial-based biosensors for tumor markers. Following an introduction into the field, a first section covers different kinds of biomarkers for ovarian cancer including CA125 (MUC16), mucin 1 (MUC1), human epididymis protein 4 (HE4), and prostasin. This is followed by a short overview on conventional diagnostic approaches. A large section is then presented on biosensors for determination of ovarian cancer, with subsections on optical biosensors (fluorimetric, colorimetric, surface plasmon resonance, chemiluminescence, electrochemiluminescence), on electrochemical sensors, molecularly imprinted sensors, paper-based biosensors, microfluidic (lab-on-a-chip) assays, chemiresistive and field effect transistor-based sensors, and giant magnetoresistive sensors. Tables are presented that give an overview on the wealth of methods and materials. A concluding section summarizes the current status, addresses current challenges, and gives an outlook on potential future trends. Graphical abstract Schematic representation of the review covering the advancements in the fabrication of various nanomaterial based biosensors for diagnosis of ovarian cancer.

Comparison of the clinicopathological features and prognoses of patients with schistosomal and nonschistosomal colorectal cancer

Patients with schistosomal colorectal cancer (CRC) and nonschistosomal CRC have different clinicopathological features, laboratory test results and survival rates. Long-term infection with schistosomiasis in patients with CRC may affect the pathogenesis and subsequently change the mechanisms of CRC in these patients, resulting in changes in the survival rates of patients with schistosomal and nonschistosomal CRC. In China, the most common type of schistosomiasis is S. japonicum. The present study aimed to investigate the clinicopathological features and prognostic factors of schistosomal and nonschistosomal CRC. A total of 253 patients with schistosomal CRC and 2,885 patients with nonschistosomal CRC were analyzed and their symptoms, clinicopathological features and laboratory test results were retrospectively evaluated. Patients with CRC in the present study underwent radical resection at The First Affiliated Yijishan Hospital of Wannan Medical College between January 2012 and December 2018. A total of 3,138 patients with CRC were enrolled, 253 of whom were patients with schistosomal CRC. Patients were followed-up to examine differences in the 5-year survival rates between patients with schistosomal and nonschistosomal CRC to determine whether schistosomiasis impacted the prognosis of CRC. There were significant differences in age, sex, fecal occult blood positive, pathological T stage, and CA19-9, WBC, RBC and PLT levels between patients with schistosomal CRC and nonschistosomal CRC. For residents in areas with higher levels of schistosomiasis infections, especially middle-aged and elderly males, serum tumor markers and digestive tract endoscopy should be regularly evaluated to detect the presence of digestive tract tumors as early as possible.

Aptamers in nanostructure-based electrochemical biosensors for cardiac biomarkers and cancer biomarkers: A review

Heart disease (especially myocardial infarction (MI)) and cancer are major causes of death. Recently, aptasensors with the applying of different nanostructures have been able to provide new windows for the early and inexpensive detection of these deadly diseases. Early, inexpensive, and accurate diagnosis by portable devices, especially aptasensors can increase the likelihood of survival as well as significantly reduce the cost of treatment. In this review, recent studies based on the designed aptasensors for the diagnosis of these diseases were collected, ordered, and reviewed. The biomarkers for the diagnosis of each disease were discussed separately. The primary constituent elements of these aptasensors including, analyte, aptamer sequence, type of nanostructure, diagnostic technique, analyte detection range, and limit of detection (LOD), were evaluated and compared.

A longitudinal analysis of CA125 glycoforms in the monitoring and follow up of high grade serous ovarian cancer

OBJECTIVE

Cancer antigen 125 (CA125) is generally considered the gold standard of biomarkers in the diagnosis and monitoring of high grade serous ovarian carcinoma (HGSC). We recently reported, that two CA125 glycoforms (CA125-STn and CA125-MGL) have a high specificity to HGSC and further hypothesized, that these cancer specific glycoforms are feasible candidates as biomarkers in HGSC treatment and follow up.

METHODS

Our cohort consisted of 122 patients diagnosed with HGSC. Serum samples were collected longitudinally at the time of diagnosis, during treatment and follow up. Serum levels of CA125, CA125-STn and CA125-MGL were determined and compared or correlated with different end points (tumor load assessed intraoperatively, residual disease, treatment response, progression free survival).

RESULTS

Serum CA125-STn levels at diagnosis differentiated patients with low tumor load and high tumor load (p = 0,030), indicating a favorable detection of tumor volume. Similarly, the CA125-STn levels at diagnosis were significantly lower in patients with subsequent complete cytoreduction than in patients with suboptimal cytoreduction (p = 0,025). Conventional CA125 did not differentiate these patients (p = 0,363 and p = 0,154). The CA125-STn nadir value predicted the progression free survival of patients. The detection of disease relapse was improved with CA125-STn, which presented higher fold increase in 80,0% of patients and earlier increase in 37,0% of patients.

CONCLUSIONS

CA125-STn showed promise as a useful biomarker in the monitoring and follow up of patients with HGSC utilizing a robust and affordable technique. Our findings are topical as a suitable indicator of tumor load facilitates patient selection in an era of new targeted therapies.

Promoter hypermethylation of the CFTR gene as a novel diagnostic and prognostic marker of breast cancer

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer-related deaths among women. New biomarkers with definite diagnostic and prognostic efficacy are urgently needed. Here, we showed that the promoter of the cystic fibrosis transmembrane conductance regulator (CFTR) was hypermethylated in breast cancer. The messenger RNA level of CFTR was downregulated in breast cancer. Notably, all 19 breast cancer patients with hypermethylated CFTR were diagnosed with invasive carcinoma. Moreover, CFTR was upregulated in decitabine (10 μM) treated breast cancer cells. Overexpression of CFTR inhibited cell growth whereas knockdown of CFTR promoted cell invasion. In the tissue array analysis, the CFTR protein level decreased significantly in breast cancer and low CFTR protein level correlated with poor survival with a P-value of 0.034. Thus, promoter hypermethylation of the CFTR gene might be a novel diagnostic marker of breast cancer.

Utility Of Plasma circBNC2 As A Diagnostic Biomarker In Epithelial Ovarian Cancer

BACKGROUND

Epithelial ovarian cancer (EOC) is the fifth most common cause of cancer death in women. Due to a lacking of early detection method, its five-year survival rate is only 30%. Nevertheless, novel biomarkers for diagnosis remain to be discovered. The potential of microRNA signatures in the diagnosis of EOC has been especially described in recent years. In our previous experiments, we identified that circBNC2 was downregulated in EOC specimens, and was associated with advanced tumor stage and lymph node metastasis (LNM) by performing circRNA-sequencing analysis. The aim of this study was to explore the diagnostic value of circBNC2 in patients with epithelial ovarian cancer (EOC).

METHODS

Plasma from 249 age and menopause-matched women (83 with EOC; 83 with benign ovarian cyst; 83 were healthy volunteers) was collected prior to surgery. CircBNC2 was analyzed using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Cancer antigen 125 (CA125) and human epididymis protein 4 (HE4) were analyzed using enzyme-linked immunosorbent assay (ELISA). Receiver operating curve (ROC), the area under the curve (AUC), sensitivity and specificity were estimated.

RESULTS

CircBNC2 was downregulated in EOC and had higher ROC AUC in comparing EOC to benign (ROC AUC 0.879, sensitivity 96.4%, specificity 80.7%) or healthy (ROC AUC 0.923, sensitivity 95.2%, specificity 85.5%) cohorts than HE4 (ROC AUC: 0.742, benign cohort; 0.779, healthy cohort) and CA125 (ROC AUC: 0.373, benign cohort; 0.713, healthy cohort). Early stage EOC vs benign (ROC AUC 0.864, sensitivity 92.0%, specificity 80.7%) and healthy (ROC AUC 0.908, sensitivity 92.0%, specificity 85.5%) cohorts could be significantly separated by circBNC2. CircBNC2 performed alike in pre- and postmenopausal women, within EOC compared to the benign or healthy cohort.

CONCLUSION

CircBNC2 is downregulated in EOC (both in tissue and plasma samples) and might present promising novel biomarker for EOC. Further studies are needed to verify our results.

IMPACT

CircBNC2 is downregulated in EOC and warrants investigation in a screening study in females at risk for EOC.

Real-World Impact of Survival by Period of Diagnosis in Epithelial Ovarian Cancer Between 1990 and 2014

Introduction: Although advances in surgical and chemotherapeutic approaches have improved management of epithelial ovarian cancer (EOC) in recent decades. The mortality of EOC over time remains controversial. The aim of this study was to assess the survival trends of EOC according to period of diagnosis using real-world data. Methods: Patients with EOC diagnosed from 1990 to 2014 were included from the Surveillance, Epidemiology, and End Results database. The Kaplan-Meier method and multivariate Cox regression models were used to evaluate the trends in survival over time. Results: We identified 59,763 patients diagnosed with EOC as follows: 6,586 (11.0%) in 1990-1994, 7,408 (12.4%) in 1995-1999, 15,348 (25.7%) in 2000-2004, 14,908 (24.9%) in 2005-2009, and 15,513 (26.0%) in 2010-2014. In the distant stage, the use of surgery decreased from 92.0% in 1990-1994 to 88.9% in 2010-2014. The use of chemotherapy increased from 67.4% in 1990-1994 to 75.0% in 2010-2014. The 5-year cause-specific survival (CSS) increased from 48.6% in 1990-1994 to 57.4% in 2010-2014 (P < 0.001). The 5-year overall survival (OS) increased from 42.7% in 1990-1994 to 51.7% in 2010-2014 (P < 0.001). The 5-year CSS and OS showed slight improvement in the localized stage (CSS, 91.9 vs. 93.1%; OS, 85.6 vs. 88.5%), and largely improved in the distant stage (CSS, 31.4 vs. 42.7%; OS, 26.7 vs. 37.4%) between 1990-1994 and 2010-2014. The multivariate analysis indicated that being diagnosed in the later years was related to better CSS and OS of EOC. Conclusion: The trends in survival of EOC have improved over time, but net survival remains poor overall in distant-stage EOC.