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Study Objective To evaluate the role of robotic simulation in training OBGYN residents by determining an optimal number of exercise repetitions prior to clinical debut; To assess whether clinical exposure accelerates proficiency by correlating laparoscopic/robotic experience with simulator skills acquisition Design Prospective cohort study Setting Urban academic center with active COEMIG designation Patients or Participants 2017-2018 Gynecology residents(PGY1-4) Interventions Voluntary participants were instructed to complete 10 repetitions of 5 exercises (pegboard-1, energy dissection-1, energy switching-1, ringr however, after one round, many trainees failed to attain the pre-determined passing score of 80%. Across all participants, mean scores by exercise were 82.5±15.6, 78.0±15.8, 72.6±17.9, 62.7±19.4, 60.1±22.1 (p Conclusion Robotic simulation may be useful for development/maintenance of robotic skills in Gynecology trainees. M-score® may be insufficiently sensitive; additional metrics should be explored. Robotic simulation is valued by trainees, however, not a milestone established by the ACGME. Protected time with incorporation into curricula would be needed to maximize utility.

Objective To evaluate c-erbB2 gene amplification in a series of primary uterine serous carcinoma (USC) cell lines. To assess the efficacy of AZD8055, a novel dual mTORC1/2 inhibitor against primary HER2/neu amplified vs HER2/neu not amplified USC cell lines. Methods Twenty-two primary USC cell lines were evaluated for c-erbB2 oncogene amplification by FISH assays. In vitro sensitivity to AZD8055 was evaluated by flow-cytometry-based viability and proliferation assays. Cell cycle profile and downstream cellular responses to AZD8055 were assessed by measuring the DNA content of cells and by phosphorylation of the S6 protein by flow-cytometry. Results Nine of 22 (40.9%) USC cell lines demonstrated c-erbB2 gene amplification by FISH. AZD8055 caused a strong differential growth inhibition in USC cell lines, with high HER-2/neu-expressors demonstrating significantly higher sensitivity when compared to low HER-2/neu-expressors (AZD-8055 IC 50 mean±SEM=0.27±0.05μM in c-erbB2 amplified versus 1.67±0.68μM in c-erbB2 not amplified tumors, P=0.03). AZD8055 growth-inhibition was associated with a significant and dose-dependent increase in the percentage of cells blocked in the G0/G1 cell cycle phase and a dose-dependent decline in pS6 levels in both c-erbB2 amplified vs c-erbB2 not amplified USC cell lines. Conclusions AZD8055 may represent a novel targeted therapeutic agent in patients harboring advanced/recurrent/refractory USC. c-erbB2 gene amplification may represent a biomarker to identify USC patients who may benefit most from the use of AZD8055.

BACKGROUND Uterine serous carcinoma (USC) is a subtype of endometrial cancer associated with chemoresistance and poor outcome. Overexpression of tubulin-β-III and p-glycoprotein has been linked to paclitaxel resistance in many cancers but has been undercharacterized among USCs. Epothilones have demonstrated activity in certain paclitaxel-resistant malignancies. In this study, relationships are clarified, in USCs relative to ovarian serous carcinomas (OSCs), between tubulin-β-III and p-glycoprotein expression, clinical outcome, and in vitro chemoresponsiveness to epothilone B, ixabepilone, and paclitaxel. METHODS Tubulin-β-III and p-glycoprotein were quantified by real-time polymerase chain reaction in 48 fresh-frozen tissue samples and 13 cell lines. Copy number was correlated with immunohistochemistry and overall survival. Median inhibitory concentration (IC50) was determined using viability and metabolic assays. Impact of tubulin-β-III knockdown on IC50 was assessed with small interfering RNAs. RESULTS USC overexpressed tubulin-β-III but not p-glycoprotein relative to OSC in both fresh-frozen tissues (552.9 ± 106.7 versus 202.0 ± 43.99, P = .01) and cell lines (1701.0 ± 376.4 versus 645.1 ± 157.9, P = .02). Tubulin-β-III immunohistochemistry reflected quantitative real-time polymerase chain reaction copy number and overexpression stratified patients by overall survival (copy number ≤ 400: 615 days; copy number > 400: 165 days, P = .049); p-glycoprotein did not predict clinical outcome. USCs remained exquisitely sensitive to patupilone in vitro despite tubulin-β-III overexpression (IC50,USC 0.245 ± 0.11 nM versus IC50,OSC 1.01 ± 0.13 nM, P = .006). CONCLUSIONS Tubulin-β-III overexpression in USCs discriminates poor prognosis, serves as a marker for sensitivity to epothilones, and may contribute to paclitaxel resistance. Immunohistochemistry reliably identifies tumors with overexpression of tubulin-β-III, and a subset of individuals likely to respond to patupilone and ixabepilone. Epothilones warrant clinical investigation for treatment of USCs. Cancer 2013;119:2582–2592. © 2013 American Cancer Society.

HER2 or ErbB2 is a member of the epidermal growth factor family and is overexpressed in subsets of breast, ovarian, gastric, colorectal, pancreatic and endometrial cancers. HER2 regulates signaling through several pathways (Ras/Raf/mitogen-activated protein kinase and phosphatidylinositol-3 kinase/protein kinase-B/mammalian target of rapamycin pathways) associated with cell survival and proliferation. HER2 overexpressed and/or gene amplified tumors are generally regarded as biologically aggressive neoplasms. In breast, cervical, endometrial and ovarian cancer, there have been several studies linking the amplification of the c-erbB2 gene with chemo-resistance and overall poor survival. Tyrosine kinase inhibitors and immunotherapy with monoclonal antibodies targeting HER2 holds promise for patients harboring these aggressive neoplasms. Trastuzumab combined with cytotoxic chemotherapy agents or conjugated with radioactive isotopes is currently being investigated in clinical trials of several tumor types.

The tubulins are significant players in maintaining microtubule dynamics and have important signaling and apoptotic functions. Alterations in microtubules as a result of changes in tubulin isotype content or polymerization affect the sensitivity of cell lines to tubulin-binding agents (e.g., taxol) in vitro. Epothilones, such as patupilone and ixabepilone, contain a 16-membered macrolide ring and act as competitive inhibitors of taxol. Class III β-tubulin overexpression has been linked to resistance to paclitaxel and correlated with poor survival in ovarian, breast, gastric, non-small-cell lung cancer and unknown primary tumors. Recent data suggest that class III β-tubulin may not only serve as a marker for sensitivity to epothilones, but also as a mediator of a bioaggressive tumor phenotype through activation of multiple cell survival pathways active under stress conditions.

SUMMARY Type II endometrial cancers exhibit distinct histopathology, underlying pathogenesis and clinical behavior. These high-risk cancers are associated with an aggressive clinical course and a relatively poor prognosis that underscores the need for the development of novel rational therapeutic strategies that exploit their distinct underlying molecular pathway alterations. In this review, we describe the extent of disease burden and molecular characterization of type II endometrial cancers, summarize the historical development to support current standards of care and delineate the most recent preclinical and clinical advances in immunotherapy, cytotoxic agents and small-molecule inhibitors for this disease.

Background: We evaluated the expression of CD46, CD55 and CD59 membrane-bound complement-regulatory proteins (mCRPs) in primary uterine serous carcinoma (USC) and the ability of small interfering RNA (siRNA) against these mCRPs to sensitise USC to complement-dependent cytotoxicity (CDC) and antibody (trastuzumab)-dependent cellular cytotoxicity (ADCC) in vitro. Methods: Membrane-bound complement-regulatory proteins expression was evaluated using real-time PCR (RT–PCR) and flow cytometry, whereas Her2/neu expression and c-erbB2 gene amplification were assessed using immunohistochemistry, flow cytometry and fluorescent in-situ hybridisation. The biological effect of siRNA-mediated knockdown of mCRPs on HER2/neu-overexpressing USC cell lines was evaluated in CDC and ADCC 4-h chromium-release assays. Results: High expression of mCRPs was found in USC cell lines when compared with normal endometrial cells (P

Advanced ovarian clear cell carcinoma (OCCC) is associated with a survival disadvantage relative to ovarian serous carcinoma following platinum/taxane-based chemotherapy and optimal cytoreduction. Prostaglandin E2 (PGE2) contributes to disease progression through modulation of several G-protein coupled receptors (EP1-4). Selective EP4 antagonism is preferred over global COX inhibition due to concerns over cardiotoxicity and compensatory upregulation of COX isoenzymes. Class III β-tubulin is a marker for paclitaxel resistance and is widely overexpressed in OCCC. The purpose of this study is to demonstrate that EP4 inhibition may overcome paclitaxel resistance in OCCC that overexpress class III β-tubulin. Expression of EP4 receptor and class III β-tubulin was quantified using immunohistochemistry and Western blot in solid tissues and cell lines. OCCC overexpress class IIIβ-tubulin/EP4 relative to normal ovary. EP4 staining intensity was 2+ in 100% OCCC using an ovarian cancer tissue microarray (62 cores, 13% OCCC); this rate was only 26-56% among other histologies. Standard metabolic growth and migration assays were employed to test the effects of drug treatment and EP4 inhibition. EP4 inhibition reduces growth of paclitaxel resistant cells. Likewise, treatment with EP inhibitors and silencing of EP4 resulted in reduced migration. Selective antagonism of PGE2 through EP4 receptor inhibition may represent a powerful targeted therapy for paclitaxel-resistant OCCC. Further study including simultaneous treatment (EP4 inhibitor + paclitaxel) and larger samples sizes is required. Citation Format: Cong Fan, Jocelyn Reader, Gautam Rao, Paul Staats, Mc Millan Ching, Amy Fulton, Dana Roque. EP4 receptor antagonism in paclitaxel-resistant ovarian clear cell carcinomas. [abstract]. In: Proceedings of the AACR Conference: Addressing Critical Questions in Ovarian Cancer Research and Treatment; Oct 1-4, 2017; Pittsburgh, PA. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(15_Suppl):Abstract nr A50.

Ovarian cancer is the leading cause of death from gynecologic malignancy in the United States. Most cases of ovarian cancer present in late stages, leading to recurrent disease that is incurable and often fatal due to innate or acquired chemoresistance; therefore, new therapies are desperately needed. Cyclo-oygenases, COX-1 and COX-2, are enzymes that catalyze the production of the prostaglandin E2 (PGE2), a lipid mediator that is functionally linked to progression of many cancers including breast and ovarian cancer. PGE2 is exported from the cell via multidrug resistance-associated protein 4 (MRP4) where it acts in a paracrine and autocrine manner by activating a family of four G-protein coupled receptors (EP1-4) that are linked to different intracellular signaling pathways. EP2 and EP4 can activate PKA/cAMP, PI3K, and ERK pathways. COX-1 and COX-2 have been shown to be overexpressed in primary ovarian cancer as well as in many ovarian cancer cell lines. We hypothesized that the EP4 receptor is overexpressed in ovarian cancer; that binding of its cognate ligand, PGE2, will drive ovarian cancer progression; and that inhibition of the EP4-mediated signaling will lead to inhibition of ovarian cancer growth and metastasis. In order to test this hypothesis, we analyzed the expression of the EP4 receptor in a human ovarian cancer tissue microarray (TMA) as well as human ovarian cancer cell lines. Immunohistochemical analysis of EP4 on the TMA composed of varying histologies, including serous, endometrioid, and clear cell, as well as normal ovarian tissue revealed that EP4 was expressed in 38.7% of ovarian cancer patients, whereas EP4 was not expressed in the 10 normal ovarian tissue samples. Additionally, in comparison to immortalized human ovarian surface epithelial (HOSE) cells, EP4 is overexpressed in many of the cell lines analyzed, including OVCAR-3, COAV-3, SKOV3, and Kuramochi cells. Blockade of the EP4 receptor via antagonist or siRNA results in a decrease in proliferation, migration, and invasion in ovarian cancer cell lines. In addition to overexpression of EP4, MRP4 was also found to be overexpressed in ovarian cancer cell lines when compared to HOSE cells. Given the role of MRP4 in exporting PGE2 and affecting drug resistance/ sensitivity in breast cancer cell lines, we hypothesize that MRP4 will similarly play a role in modulating the amount of PGE2 in the microenvironment in ovarian cancer, thereby affecting signaling via of EP4 receptor. Functional testing of dual EP4/ MRP4 inhibition may provide much-needed new therapies for the treatment of ovarian cancer. Citation Format: Mc Millan Ching, Cong Fan, Dana Roque, Gautam Rao, Paul Staats, Amy Fulton, Jocelyn Reader. Functional analysis of PGE2 pathway members EP4 and MRP4 in ovarian cancer. [abstract]. In: Proceedings of the AACR Conference: Addressing Critical Questions in Ovarian Cancer Research and Treatment; Oct 1-4, 2017; Pittsburgh, PA. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(15_Suppl):Abstract nr A22.

Recent advances in next generation sequencing (NRG) have provided compelling evidence that endometrial cancers result from heterogeneous somatic mutations. These findings argue that a catalog of molecular aberrations that cause endometrial cancer is critical for the proper classification of these tumors and for developing novel and more effective targeted therapies against this disease. This chapter summarizes the recent advances made toward the elucidation of underlying pathway aberrations and the development of targeted therapies that exploit the unique molecular characteristics of endometrial cancers.

OBJECTIVES: Advanced ovarian clear cell carcinoma (OCCC) is associated with a survival disadvantage relative to ovarian serous carcinoma following platinum/taxane-based chemotherapy and optimal cytoreduction. Prostaglandin E2 (PGE2) contributes to disease progression through modulation of several G-protein coupled receptors (EP1-4) [Fig.1a]. The addition of upstream COX inhibition to platinum/taxane-based chemotherapy in the first-line phase II setting in ovarian cancer has been disappointing,a possibly due to compensatory upregulation of COX isoenzymes and negation of protective effects of EP1. Selective antagonism of EP4 may therefore pose a more rational strategy than global COX inhibition. Paclitaxel administration has been shown to upregulate components of the COX pathway.b Class III β-tubulin is a marker for paclitaxel resistance and is widely overexpressed in OCCC. The purpose of this study is to demonstrate that EP4 inhibition may overcome paclitaxel resistance in OCCC that overexpress class III β-tubulin. METHODS: Expression of EP4 receptor and class III β-tubulin was quantified using immunohistochemistry and Western blot in solid tissues and cell lines. Standard metabolic growth and migration assays were employed to test the effects of drug treatment (paclitaxel and EP4 inhibitors RQ-15986/AH-23848) with and without EP4 silencing using siRNA. RESULTS: OCCC overexpress class III β-tubulin/EP4 relative to normal ovary [Fig. 1b/c]. EP4 staining intensity was 2+ in 100% OCCC using an ovarian cancer tissue microarray (62 cores, 13% OCCC); this rate was only 26-56% among other histologies. EP4 inhibition reduces growth of paclitaxel-resistant cells [Fig. 1d]. Likewise, treatment with EP inhibitors [Fig.1 e-top] and silencing of EP4 resulted in reduced migration [Fig.1 e-bottom]. CONCLUSIONS: Selective antagonism of PGE2 through EP4 receptor inhibition may represent a powerful targeted therapy for paclitaxel-resistant OCCC. Further study including simultaneous treatment (EP4 inhibitor+paclitaxel) and larger samples sizes is required. REFERENCES: a Reyners et al. A randomized phase II study investigating the addition of the specific COX-2 inhibitor celecoxib to docetaxel plus carboplatin as first-line chemotherapy for stage IC to IV epithelial ovarian cancer, fallopian tube or primary peritoneal carcinomas: the DoCaCel study. Ann Oncol 2012; 23:2986-902. b Moos et al. Effects of taxol/taxotere on gene expression in macrophages: induction of the PGH synthetase-2 isoenzyme. J Immunol 1999;162:476-73. Citation Format: Dana M. Roque, Danielle Meir-Levi, Gautam G. Rao, Paul Staats, Amy Fulton, Jocelyn Reader. EP4 receptor antagonism in paclitaxel-resistant ovarian clear cell carcinomas that overexpress class III β-tubulin [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1179. doi:10.1158/1538-7445.AM2017-1179

Dana M Roque,1 Masoud Azodi1,2 1Division of Gynecologic Oncology, 2Division of Minimally Invasive and Robotic Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, New Haven, CT, USALeonardo da Vinci has been credited with the design in 1495 of the first known robot, which was capable of human-like motions through the manipulation of multiple coordinated pulleys.1 The term "robot" stems from the Czech word "robota", referring to compulsory labor, and was popularized in English vocabulary as early as 1923. Today, the Robotics Institute of America defines "robots" as "reprogrammable, multifunctional manipulators designed to move material, parts, tools, or specialized devices through various programmed functions for the performance of a variety of tasks".2Robotic technology entered the surgical industry as early as 1985, beginning with applications to improve accuracy and precision in neurosurgery during stereotactic brain biopsies3 and in the field of orthopedics for joint alignment.4 Robotic assistance soon emerged as a tool to overcome problematic ergonomics limiting dexterity and the pitfalls of bi-dimensional imaging associated with traditional laparoscopic approaches, with roles quickly expanding to urologic, gastrointestinal, cardiac, maxillofacial, ophthalmologic, and gynecologic subspecialties, among others.5

Context.—In the era of targeted cancer therapy, there is growing interest in developing novel therapeutic strategies against endometrial carcinoma, especially its most biologically aggressive variant, serous adenocarcinoma. Several publications have demonstrated that a significant proportion of uterine serous carcinomas show HER2 overexpression and/or amplification, suggesting that HER2 may be a promising therapeutic target. Case reports have already shown clinical response to trastuzumab, a humanized monoclonal immunoglobulin (Ig) G1 antibody against HER2, and patients are currently being enrolled in a multi-institutional prospective randomized trial to evaluate the therapeutic efficacy of trastuzumab.Objective.—To review current data on HER2 testing and targeted therapy against HER2/neu in endometrial carcinoma.Data Sources.—Review of the literature and personal experience of the authors.Conclusions.—Parallel to the clinical studies, there is a need to develop standardized criteria for HER2 testing in endometrial carcinoma that reflect the unique biological and pathogenetic features of these tumors and correlate with clinical response to therapy. This article presents a comprehensive review of the current state of HER2-based therapy and HER2 testing in endometrial carcinoma.

The use of taxanes in the treatment of gynecologic malignancies has expanded tremendously over the past 30 years. Both paclitaxel and docetaxel have unique microtubule stabilizing, antiangiogenic and radiation sensitizing properties that endow them with remarkable activity as chemotherapeutic agents. As research into the appropriate dose, timing, treatment interval, and response rates have been studied, they have emerged as one of the most active agents available in the treatment of gynecologic cancer. The body of research on taxanes continues to expand especially with regard to the use of taxanes in alternative formulations and in combination with newer treatments or routes of treatment. This review focuses on the development of taxanes as an effective therapy in the treatment of gynecologic cancers and data currently available in the literature regarding their efficacy. Future directions of taxane-based chemotherapy with regards to ovarian, uterine, and cervical cancers are also addressed. There is little doubt that taxane-based chemotherapy will remain an integral part of the treatment of gynecologic cancer for the foreseeable future.

Critics have suggested that neoadjuvant chemotherapy (NACT) followed by interval debulking may select for resistant clones or cancer stem cells when compared to primary cytoreduction. β-tubulins are chemotherapeutic targets of taxanes and epothilones. Class III β-tubulin overexpression has been linked to chemoresistance and hypoxia. Herein, we describe changes in class III β-tubulin in patients with advanced ovarian carcinoma in response to NACT, in relationship to clinical outcome, and between patients who underwent NACT versus primary debulking; we characterize in vitro chemosensitivity to paclitaxel/patupilone of cell lines established from this patient population, and class III β-tubulin expression following repeated exposure to paclitaxel. Using immunohistochemistry, we observed among 22 paired specimens obtained before/after NACT decreased expression of class III β-tubulin following therapy within stroma (p=0.07), but not tumor (p=0.63). Poor median overall survival was predicted by high levels of class III β-tubulin in both tumor (HR 3.66 [1.11,12.05], p=0.03) and stroma (HR 4.53 [1.28,16.1], p=0.02). Class III β-tubulin expression by quantitative-real-time-polymerase-chain-reaction was higher among patients who received NACT (n=12) compared to primary cytoreduction (n=14) (mean±SD fold-change: 491.2±115.9 vs. 224.1±55.66, p=0.037). In vitro subculture with paclitaxel resulted in class III β-tubulin upregulation, however, cell lines that overexpressed class III β-tubulin remained sensitive to patupilone. Overexpression of class III β-tubulin in patients dispositioned to NACT may thus identify an intrinsically aggressive phenotype, and predict poor overall survival and paclitaxel resistance. Decreases in stromal expression may represent normalization of the tumor microenvironment following therapy. Epothilones warrant study for patients who have received neoadjuvant carboplatin and paclitaxel.

Background The aim of the present study was to investigate within ovarian carcinoma and normal ovarian biopsies the gene expression of multiple secretoglobin family members relative to mammaglobin B, which we previously reported as a promising novel ovarian carcinoma prognostic marker. Methods Using quantitative real-time Reverse Transcription PCR we tested 53 ovarian carcinoma and 30 normal ovaries for the expression of 8 genes belonging to the secretoglobin family: mammaglobin A, lipophilin A, lipophilin B, uteroglobin, HIN-1, UGRP-1, RYD5 and IIS. Next, we decided to expand the LipB gene expression analysis to a further 48 ovarian carcinoma samples, for a total of 101 tumor tissues of various histologies and to study its protein expression by immunohistochemistry in formalin-fixed paraffin-embedded tumors and normal ovaries. Finally, we correlated lipophilin B gene and protein expression to conventional patient clinico-pathological features and outcome. Results We found significant mammaglobin A, lipophilin A, lipophilin B and RYD5 gene overexpression in ovarian carcinomas compared to normal ovaries. Lipophilin B mRNA showed a higher presence in tumors (75.4%) compared to normal ovaries (16.6%) and the most significant correlation with mammaglobin B mRNA (rs =0.77, p, This investigation was supported by grants from the Nocivelli Foundation, Brescia, Italy, and by grants from the Istituto Superiore di Sanità (Programma onco-proteomica Italia-USA 527B4/4), Rome, Italy. Dr Elisa Rossi is supported by the JAE-Doc program of CSIC funded by FEDER. Moreover, this work was supported in part by grants from NIH R01 CA122728-01A4 and R01 CA154460-01A1, the Honorable Tina Brozman Foundation and Deborah Bunn Alley Ovarian Cancer Research Foundation to ADS

Uterine serous carcinoma (USC) is a biologically aggressive subtype of endometrial cancer. We analyzed the mutational landscape of USC by whole-exome sequencing of 57 cancers, most of which were matched to normal DNA from the same patients. The distribution of the number of protein-altering somatic mutations revealed that 52 USC tumors had fewer than 100 (median 36), whereas 5 had more than 3,000 somatic mutations. The mutations in these latter tumors showed hallmarks of defects in DNA mismatch repair. Among the remainder, we found a significantly increased burden of mutation in 14 genes. In addition to well-known cancer genes (i.e., TP53 , PIK3CA , PPP2R1A , KRAS , FBXW7 ), there were frequent mutations in CHD4/Mi2b , a member of the NuRD–chromatin-remodeling complex, and TAF1 , an element of the core TFIID transcriptional machinery. Additionally, somatic copy-number variation was found to play an important role in USC, with 13 copy-number gains and 12 copy-number losses that occurred more often than expected by chance. In addition to loss of TP53 , we found frequent deletion of a small segment of chromosome 19 containing MBD3 , also a member of the NuRD–chromatin-modification complex, and frequent amplification of chromosome segments containing PIK3CA , ERBB2 (an upstream activator of PIK3CA), and CCNE1 (a target of FBXW7-mediated ubiquitination). These findings identify frequent mutation of DNA damage, chromatin remodeling, cell cycle, and cell proliferation pathways in USC and suggest potential targets for treatment of this lethal variant of endometrial cancer.

Ovarian cancer is the leading cause of death from gynecologic malignancy in the United States. Most cases of ovarian cancer present in late stages leading to recurrent disease which is incurable. Few effective targeted therapies are available to treat ovarian cancer other than non-specific, toxic chemotherapy. Ovarian cancer is often fatal due to innate or acquired chemoresistance. Lipid mediators are linked to many pathological processes including inflammation and cancer. The lipid prostaglandin E2 (PGE2) is synthesized by cyclooxygenases, COX-1 and COX-2, and elevated expression of COX and increased PGE2 levels are functionally linked to the progression of many cancers. PGE2 is exported from the cell where it acts in a paracrine and autocrine manner by activating a family of four G-protein coupled receptors (EP1-4) which are linked to different intracellular signaling pathways. EP1 is coupled to calcium mobilization and PKC; whereas, EP2 and EP4 activate PKA/cAMP, PI3K and ERK pathways. EP3 generally inhibits cAMP levels. COX-1 has been shown to be overexpressed in primary ovarian cancer as well as in many ovarian cancer cell lines. The EP4 receptor is overexpressed and plays a mechanistic role in various malignancies including breast and colon. Due to toxicity concerns surrounding global inhibition of the COX enzymes and, in an effort to identify new targeted therapies for the treatment of ovarian cancer, our objective was to determine the expression as well as the functional role of the PGE2 receptor EP4 in ovarian cancer. We hypothesized that the EP4 receptor is overexpressed in ovarian cancer and that binding of its cognate ligand, PGE2, will drive ovarian cancer progression and that inhibition of the EP4-mediated signaling will lead to inhibition of ovarian cancer growth and metastasis. In order to test these hypotheses, we analyzed the expression of the EP4 receptor in a human ovarian cancer tissue microarray (TMA) as well as human ovarian cancer cell lines. Immunohistochemical analysis of EP4 on the TMA composed of varying histologies, including serous, endometrioid and clear cell, as well as normal ovarian tissue revealed that EP4 was expressed in 38.7% of ovarian cancer patients; whereas, EP4 was not expressed in the 10 normal ovarian tissue samples. Additionally, in comparison to immortalized human ovarian surface epithelial (HOSE) cells, EP4 is overexpressed in many of the cell lines analyzed, including ES-2, OVCAR-3, COAV-3, SKOV3, OVISE and Kuramochi cells. Treatment of these cell lines with an EP4 antagonist resulted in decreased proliferation and migration compared to vehicle control. Consistent with the pharmacological data, treatment of ovarian cancer cell lines with siRNA directed against the EP4 receptor lead to decreased proliferation and migration. Based on these data, targeting of the PGE2 EP4 receptor should be investigated further for the treatment of ovarian cancer. Citation Format: Joceyln C. Reader, Paul Staats, Olga Goloubeva, Ningbo Jian, Dana M. Roque, Maya E. Matheny, Amy M. Fulton, Gautam G. Rao. Functional studies of the prostaglandin E2 receptor EP4 in ovarian cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 5169.

Purpose of review Uterine serous carcinoma (USC) is a highly aggressive variant of endometrial cancer with distinct molecular pathogenesis. This review summarizes the rationale behind current clinical approaches, as well as advances made in 2012 toward the elucidation of underlying pathway aberrations and development of targeted therapies that exploit these unique characteristics. Recent findings Within the last year, exome-wide analyses have highlighted key mutations to guide rational drug design. The PI3/AKT/mTOR pathway and regulators of cell cycle such as cyclin E/F-box proteins appear to be particularly important. Understanding the epithelial to mesenchymal transition may explain the aggressive pattern of spread frequently observed in this disease. There is heightened evidence for heritable syndromes in association with USC. Conflicting retrospective data continue to emerge regarding optimal therapy, especially for early-stage disease, although prospective studies are underway. Immunotherapies targeting Her2/Neu and vascular endothelial growth factor remain an area of active research. Upregulation of class III β-tubulin observed in paclitaxel-resistant disease may identify candidates for therapy with novel microtubule-stabilizing agents such as epothilones. Summary There is an expanding role for contemporary novel approaches in the treatment of USC. The results of clinical investigations using new target antigens, epothilones, and small molecule inhibitors are eagerly awaited.

To compare the in vitro sensitivity/resistance to patupilone versus paclitaxel in uterine and ovarian carcinosarcomas (CS).Five primary carcinosarcoma cell lines, two from uterine and three of ovarian origin, were evaluated for growth rate and tested for their in vitro sensitivity/resistance to patupilone versus paclitaxel by MTS assays. To identify potential mechanisms underlying the differential sensitivity/resistance to patupilone, expression levels of β-tubulin III (TUBB3) were determined with quantitative-real-time-polymerase-chain-reaction (q-RT-PCR) in primary uterine and ovarian CS cell lines and in 26 uterine and 9 ovarian CS fresh-frozen-tissues.No appreciable difference in sensitivity to patupilone versus paclitaxel was noted in ovarian CS cell lines, or when uterine and ovarian CS cell lines were compared in their response to paclitaxel. In contrast, uterine CS cell lines were found to be significantly more sensitive to patupilone than to paclitaxel (P0.002) and demostrated lower IC(50s) to patupilone (range 0.76-0.93nM) when compared to ovarian CS (range 1.9-3.4 nM, p0.05). Higher levels of TUBB3 were detected in uterine CS cell lines and fresh frozen tissues when compared to ovarian CS (P0.05).Uterine CS cell lines are significantly more sensitive than ovarian CS cell lines to patupilone versus paclitaxel. High expression of TUBB3 is associated with sensitivity to patupilone in primary CS cell lines and may act as a genetic marker to predict chemotherapy efficacy. Patupilone may represent a promising drug in the treatment of this subset of rare but highly aggressive gynecological tumors.

Proteomics embodies a diverse set of platforms devoted to the study of protein structure and function. Mass spectrometry and protein microarrays enable detailed analysis of a diverse set of proteins and their isoforms at the molecular level. These new, high-throughput, and comprehensive proteomic studies can be useful in advancing our understanding of disease processes and have wide potential for integration within clinical trials. Clinical trials incorporating proteomic-based endpoints are geared toward biomarker development, pathway discovery, and target validation. Screening the proteome has the potential to discover a protein biomarker or a signature of markers to predict disease presence, and we have initiated a multi-center clinical trial with the goal of defining a proteomic signature that can predict relapse of ovarian cancer. Serum and tissue proteomics reflect information from the tumor as well as from the tumor microenvironment, as demonstrated in our two recent clinical trials employing these analyses to evaluate effects of targeted agents. Proteomic techniques strengthen the link between bench and bedside by testing existing hypotheses about a disease state or treatment and validating them in the clinical setting. Defining signaling pathways and protein regulatory events in the clinical venue may thus lead to generation of new hypotheses and subsequently to novel treatment strategies.

Dick-Biascoechea. Appearances can be deceiving. Am J Obstet Gynecol 2014. Case notes An 82-year-old patient complained to her gynecologist about 6 months worsening vaginal prolapse, pelvic pressure, and a constant urge to void and defecate. She had used a pessary, which she was unable to replace. Pelvic examination revealed a gaping introitus with an apparent stage 3 posterior vaginal prolapse (Figure 1). Speculum examination was not possible because of a mass displacing the vagina anteriorly. Magnetic resonance imaging showed a 16 8.8 6.5ecm cystic mass anterior to the rectum (Figure 2). The differential diagnosis included a tailgut cyst vs rectal duplication. The patient was taken to the operating room by a team of gynecologic oncologists and colorectal surgeons. They found a large mass in the left ovary, directly contiguous with the uterus and rectosigmoid colon that dissected the rectovaginal septum down to the perineum, ascites, an omental cake that involved the transverse colon, and enlarged periaortic lymph nodes. A total abdominal hysterectomy (bilateral salpingo-oophorectomy [Figure 3], en-bloc resection of the tumor that included the rectosigmoid colon [Figure 4], proctectomy with descending end colostomy omentectomy, periaortic lymphadenectomy, and tumor debulking) was performed. The final pathologic report confirmed a high-grade serous carcinoma that involved the ovaries, fallopian tubes, uterine serosa, rectosigmoid colon, and omentum. Periaortic and mesenteric nodes contained metastatic cancer. The patient was discharged from the hospital to a skilled nursing facility for short-term rehabilitation after 15 days and has just completed adjuvant carboplatin and paclitaxel.

Objective Clear cell carcinoma of the ovary is a distinct subtype of epithelial cancer associated with chemoresistance and poor outcome compared with serous papillary carcinomas. Resistance to paclitaxel has been linked to serous papillary overexpression of class III β-tubulin in several human cancers but inadequately characterized among clear cell carcinoma of the ovary. Chemoresistance has also been variably linked to the drug efflux pump p-glycoprotein. Epothilones are microtubule-stabilizing agents with putative activity in paclitaxel-resistant malignancies. In this study, we clarify the relationship between class III β-tubulin and p-glycoprotein expression in clear cell carcinoma of the ovary, clinical outcome, and in vitro responsiveness to patupilone and paclitaxel. Study Design Class III β-tubulin and p-glycoprotein were quantified by real time polymerase chain reaction in 61 fresh-frozen tissue samples and 11 cell lines. Expression by polymerase chain reaction was correlated with immunohistochemistry and overall survival. IC 50 was determined using viability/metabolic assays. Impact of class III β-tubulin down-regulation on IC 50 was assessed with small interfering RNAs. Results Clear cell carcinoma of the ovary overexpressed class III β-tubulin and p-glycoprotein relative to serous papillary carcinomas carcinomas in fresh-frozen tissues and cell lines. Class III β-tubulin immunohistochemistry reflected real time polymerase chain reaction results and overexpression stratified patients by overall survival. P-glycoprotein correlated with in vitro paclitaxel resistance, but not clinical outcome. Clear cell carcinoma of the ovary were exquisitely sensitive to patupilone in a manner that correlated with class III β-tubulin expression. Conclusion Class III β-tubulin overexpression in clear cell carcinoma of the ovary discriminates poor prognosis, serves as a marker for sensitivity to patupilone, and may contribute to paclitaxel resistance. Immunohistochemistry reliably identifies tumors with overexpression of class III β-tubulin, and accordingly a subset of individuals likely to respond to patupilone.

Recent evidence strongly supports the hypothesis that the capability to sustain tumor formation, growth and resistance to chemotherapy in ovarian cancer exclusively resides in a small proportion of tumor cells termed cancer stem cells (CSC) overexpressing the CD44 marker. If this hypothesis is correct, development of novel, more specific approaches to target and eradicate the CD44+ ovarian CSC population remains a high priority. Our group has recently reported high expression of claudin-4 tight junction protein in CD44+ ovarian CSC. Because this protein is the natural high affinity receptor for Clostridium Perfringens Enterotoxin (CPE), we have evaluated the in vitro targeting potential of fluorescent (i.e. Coumarin 6 loaded) poly(lactic-co-glycolic acid) (PLGA) nanoparticles (NP) conjugated with the C-terminus binding domain of CPE (CPE-peptide) against ovarian CSC and the in vivo biodistribution of these NP after intravenous (IV) injection in SCID mice harboring intraperitoneal CD44+ ovarian CSC tumor. Using flow cytometry, we report a higher time and dose-dependent in vitro uptake of fluorescent PLGA NP conjugated to CPE peptide (CPE-peptide NP) in CD44+ ovarian CSC when compared to unconjugated NP (i.e., control NP, Mean-Fluorescence-Intensity = MFI of 37.1 and 15.0 respectively; p=0.037). Of interest, confocal microcopy images clearly show internalization of CPE-peptide NP within tumor cells after NP exposure. More importantly, when SCID mice harboring claudin-4 overexpressing CD44+ ovarian CSC tumors were injected via the tail vein (IV) with 25 μg/g of CPE-peptide NP or the same concentration of unconjugated NP, a 4 fold increase in fluorescence was detected in tumors excised from mice injected with CPE-peptide NP compared to controls 48 hours after NP administration (mean ± STDV 33159.6 2707 and 6655.8 ±1391 respectively; p Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 364. doi:1538-7445.AM2012-364