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Endometrial cancer (EC) is the fourth most common cancer in women, and half of the endometrioid EC (EEC) cases are attributable to obesity. However, the underlying mechanism(s) of obesity-driven EEC remain(s) unclear. In this study, we examined whether LIF signaling plays a role in the obesity-driven progression of EEC. RNA-seq analysis of EEC cells stimulated by adipose conditioned medium (ADP-CM) showed upregulation of LIF/LIFR-mediated signaling pathways including JAK/STAT and interleukin pathways. Immunohistochemistry analysis of normal and EEC tissues collected from obese patients revealed that LIF expression is upregulated in EEC tissues compared to the normal endometrium. Treatment of both primary and established EEC cells with ADP-CM increased the expression of LIF and its receptor LIFR and enhanced proliferation of EEC cells. Treatment of EEC cells with the LIFR inhibitor EC359 abolished ADP-CM induced colony formation andcell viability and decreased growth of EEC organoids. Mechanistic studies using Western blotting, RT-qPCR and reporter assays confirmed that ADP-CM activated LIF/LIFR downstream signaling, which can be effectively attenuated by the addition of EC359. In xenograft assays, co-implantation of adipocytes significantly enhanced EEC xenograft tumor growth. Further, treatment with EC359 significantly attenuated adipocyte-induced EEC progression in vivo. Collectively, our data support the premise that LIF/LIFR signaling plays an important role in obesity-driven EEC progression and the LIFR inhibitor EC359 has the potential to suppress adipocyte-driven tumor progression.

Ovarian cancer (OCa) is the deadliest gynecologic cancer. Emerging studies suggest ovarian cancer stem cells (OCSCs) contribute to chemotherapy resistance and tumor relapse. Recent studies demonstrated estrogen receptor beta (ERβ) exerts tumor suppressor functions in OCa. However, the status of ERβ expression in OCSCs and the therapeutic utility of the ERβ agonist LY500307 for targeting OCSCs remain unknown. OCSCs were enriched from ES2, OV90, SKOV3, OVSAHO, and A2780 cells using ALDEFLUOR kit. RT-qPCR results showed ERβ, particularly ERβ isoform 1, is highly expressed in OCSCs and that ERβ agonist LY500307 significantly reduced the viability of OCSCs. Treatment of OCSCs with LY500307 significantly reduced sphere formation, self-renewal, and invasion, while also promoting apoptosis and G2/M cell cycle arrest. Mechanistic studies using RNA-seq analysis demonstrated that LY500307 treatment resulted in modulation of pathways related to cell cycle and apoptosis. Western blot and RT-qPCR assays demonstrated the upregulation of apoptosis and cell cycle arrest genes such as FDXR, p21/CDKN1A, cleaved PARP, and caspase 3, and the downregulation of stemness markers SOX2, Oct4, and Nanog. Importantly, treatment of LY500307 significantly attenuated the tumor-initiating capacity of OCSCs in orthotopic OCa murine xenograft models. Our results demonstrate that ERβ agonist LY500307 is highly efficacious in reducing the stemness and promoting apoptosis of OCSCs and shows significant promise as a novel therapeutic agent in treating OCa.

Background: Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer (BC) that accounts for a disproportionate amount of BC mortality. The relationship(s) between obesity and the TNBC is crucial because the obesity prevalence in the USA is on the rise. Obese patients are generally diagnosed with large primary tumors, more lymph node metastases, and obesity effects on tumor microenvironment (TME) are suspected to accelerate the development of TNBC, but the exact mechanism(s) by which this occurs remain unknown. The goal of this study is to investigate the hypothesis that obesity enhances leukemia inhibitory factor receptor (LIFR) oncogenic signaling in TNBC and to test the utility of LIFR inhibitor in blocking obesity driven progression of TNBC. Methods: Established TNBC cell lines were co-cultured with human primary adipocytes, incubated with adipocyte conditioned media, or exposed to high glucose (HG), then treated with the LIFR inhibitor EC359. Cell viability, colony formation, and invasion assays were used to analyze the impact of obesity on TNBC cells and to test utility of EC359. RT-qPCR, Western blotting, reporter gene assays, and RNA-seq analyses were used in the mechanistic studies. Xenografts and patient-derived organoid (PDO) models were used to evaluate the effectiveness of the EC359. Results: The cell proliferation and invasion of TNBC cells were accelerated by adipocyte conditioned media or when exposed to HG. RNA-seq and RT-qPCR analysis revealed a correlation between elevated LIFR expression and downstream LIFR signaling, including STAT3, as well as the subsequent activation of STAT3 target genes. The cell viability, colony formation, and invasion of TNBC cells under HG and adipose conditions were all markedly decreased after treatment with LIFR inhibitor EC359. Results from Western blotting demonstrated that co-culture with adipocytes or incubation with HG dramatically increased LIFR downstream signaling in TNBC model cells, and that this signaling is effectively suppressed by EC359 therapy. In addition, administration of EC359 prevented organoid proliferation that was mediated by the adipose conditioned media. Importantly, co-implantation of adipocytes greatly increased the growth of the TNBC xenograft tumor; however, therapy with EC359 significantly reduced the growth of TNBC caused by adipocyte co-implantation. Conclusions: Collectively, these findings suggest that obesity conditions promote the activation of LIF/LIFR pathway, which in turn enhances TNBC cell proliferation. The LIFR inhibitor EC359 may be employed as a new therapeutic drug to treat obesity driven TNBC and LIF/LIFR axis represents a potential therapeutic target for obesity driven TNBC. Citation Format: Lois Randolph, Alondra Rodriguez Sanchez, Logan Blankenship, Uday P. Pratap, Xue Yang, Durga Meenakshi Panneerdoss, Swapna Konda, Bindu Santhamma, Gangadhara R. Sareddy, Manjeet K. Rao, Edward R. Kost, Rajeshwar R. Tekmal, Hareesh B. Nair, Ratna K. Vadlamudi, Suryavathi Viswanadhapalli. The role of obesity in promoting the LIF/LIFR signaling in triple negative breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3408.

BACKGROUND: Ovarian cancer (OCa) is the deadliest of all gynecologic cancers in the United States. Currently approved therapies have improved OCa survival for clinically localized disease, however, the majority (~90%) of patients with high-grade serous OCa (HGSOC) experience relapse with incurable metastases. There is a dire need for new therapeutic approaches. We hypothesized that the high basal endoplasmic reticulum stress (ERS) in OCa represents a critical and targetable vulnerability and may overcome the tumor heterogeneity. The objective of this project is to exploit increased ERS in ovarian cancer cells by engaging the novel target LIPA using the unique compound ERX-41. METHODS: The utility of ERX-41 as a new therapy was evaluated using MTT and CellTiter-Glo Cell Viability Assays. We used multiple established and patient derived OCa cell lines. The effect of ERX-41 on the Cell viability of patient-derived organoids (PDO) was measured using CellTiter-Glo 3D Assay. Long term effects of ERX-41 on cell survival were measured using colony formation assays. Apoptosis was measured using Annexin V and Caspase-Glo® 3/7 Assays. Cell cycle analysis was analyzed by Flow Cytometry. Mechanistic studies were done using LIPA knockout (KO) cells, RT-qPCR, and western blotting. Status of LIPA in OCa was determined using TNMplot database. In vivo efficacy of ERX-41 was tested using both cell line derived (CDX) and patient derived (PDXs) xenografts. RESULTS: TNM plot results showed that LIPA is highly expressed in OCa tumors compared to normal tissues and LIPA expression correlated with clinical grade. Kaplan-Meier plotter analyses of TCGA data revealed that LIPA expression is negatively correlated with overall survival in OCa patients. MTT and CellTitre-Glo assay results showed that ERX-41 significantly reduced the cell viability of both established and primary OCa cells, and PDO’s with an IC50 of ~500nM. ERX-41 treatment also significantly reduced the cell survival, increased S-phase arrest, and promoted apoptosis of OCa cells. A time course study revealed a robust and consistent induction of ERS markers (CHOP and sXBP1) in OCa cells by ERX-41 within 4h. Western blotting analyses also confirmed increased expression of ERS markers including CHOP, elF2α, PERK, and ATF4 upon ERX-41 treatment confirming that ERX-41 induces ERS. In xenograft studies, ERX-41 treatment resulted in ~66% reduction of tumor volume measured by Xenogen-IVIS. Further, in studies using PDX tumors, treatment with ERX-41 resulted in a significant reduction (~60%) of tumor volume and tumor weight. CONCLUSION: Collectively, our results suggest that ERX-41 is a novel therapeutic agent that targets the LIPA with a unique mechanism of action and implicate ERX-41 binding to LIPA induces ER stress, and apoptosis of OCa cells. Further molecular characterization of how ERX-41 binding to LIPA induces ER stress in OCa cells is ongoing. Citation Format: Alexia B. Collier, Suryavathi Viswanadhapalli, Tae-Kyung Lee, Kara Kassees, Karla Parra, Gaurav Sharma, Tanner Reese, Michael Hsieh, Xihui Liu, Xue Yang, Behnam Ebrahimi, Uday P. Pratap, Rahul Gopalam, Chia Yuan Chen, Scott Terry Elmore, Gangadhara Reddy Sareddy, Edward R. Kost, Jung-Mo Ahn, Ganesh V. Raj, Ratna K. Vadlamudi. Novel LIPA targeted therapy for treating ovarian cancer. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3986.

Background: Of all gynecologic cancers, ovarian cancer (OCa) has the highest mortality rates. Nearly 90% of patients who receive standard surgical and cytotoxic treatment experience disease recurrence. Leukemia inhibitory factor (LIF) and its receptor LIFR are implicated in the progression of several cancers. A knowledge gap exists on whether LIF/LIFR plays a role in the evolution of OCa. We recently developed EC359, a first-in-class LIFR inhibitor. Here, we examined whether autocrine loops of LIF/LIFR contribute to OCa progression and tested the utility of EC359 as a potential targeted therapy. Methods: Eighteen different OCa model cells, both established and primary, were used to profile the expression of LIF and LIFR. Cell viability, colony formation, apoptosis, and reporter assays were used to assess EC359 impact on OCa cells. Mechanistic studies were carried out using RNA-seq and RT-qPCR analysis. Using cell-based xenografts, syngeneic xenografts, patient derived organoids (PDO), and patient derived xenograft (PDX) models, the effectiveness of LIFR inhibitor EC359 as a targeted therapy was examined. Results: Kaplan-Meier survival analysis (KMplot) revealed increased expression of LIF and LIFR was linked to poor progression-free survival in OCa patients. The levels of LIF and LIFR were considerably greater in OCa chemotherapy non-responders than responders. We validated the existence of LIF/LIFR autocrine signaling using 18 distinct OCa cells. Treatment with the LIFR inhibitor EC359 dramatically decreased OCa cell viability, cell survival and increased apoptosis, with an IC50 of 5 to 50 nM. The activation of STAT3, mTOR, AKT, and p42/44 MAPKs as well as other downstream LIFR signaling was markedly decreased by EC359 treatment. Treatment with EC359 also decreased the stemness of OCa cells, slowed PDO development, and sensitized chemotherapy-resistant OCa cells to chemotherapy. One of the significant pathways elevated by EC359, according to RNA-seq data, is the regulation of apoptosis. In six different cell-based xenografts and PDX tumors, we demonstrated that the EC359 at 5mg/kg dose significantly reduced the OCa xenograft growth. In comparison to the vehicle control, the tumor volume was significantly reduced by EC359 treatment of murine ID8 xenografts in C57BL6 mice. Our findings indicated that EC359 had both intrinsic and extrinsic effects on tumors. Tumor-associated macrophages (TAMs) with a significant M1 polarity (CD11b+Gr1-CD68high/phosphoSTAT1+/cMAF-) and robust tumor infiltration by (CD45+) leukocytes were enhanced with EC359 therapy of ID8 xenograft tumors. Importantly, normal T, B, and other immune cells in the blood demonstrated that EC359 had no effect on immune cell homeostasis. Conclusions: Together, our findings support the existence of LIF/LIFR autocrine loops, and EC359 is a viable treatment option for OCa. Citation Format: Behnam Ebrahimi, Suryavathi Viswanadhapalli, Uday P. Pratap, Rahul Gopalam, Xue Yang, Bindhu Santhamma, Swapna Konda, Xiaonan Li, Hui Yan, Gangadhara R. Sareddy, Zhenming Xu, Edward R. Kost, Rajeshwar R. Tekmal, Hareesh B. Nair, Ratna K. Vadlamudi. Targeting LIF/LIFR autocrine loops with EC359 in ovarian cancer: A novel LIFR targeted therapy. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4966.

Endometrial cancer (EC) is the fourth most common cancer in women. Advanced-stage EC has limited treatment options with a poor prognosis. There is an unmet need for the identification of actionable drivers for the development of targeted therapies in EC. Leukemia inhibitory factor receptor (LIFR) and its ligand LIF play a major role in cancer progression, metastasis, stemness, and therapy resistance. However, little is known about the functional significance of the LIF/LIFR axis in EC progression. In this study using endometrial tumor tissue arrays, we identified that expression of LIF, LIFR is upregulated in EC. Knockout of LIFR using CRISPR/Cas9 in two different EC cells resulted in a significant reduction of their cell viability and cell survival. In vivo studies demonstrated that LIFR-KO significantly reduced EC xenograft tumor growth. Treatment of established and primary patient-derived EC cells with a novel LIFR inhibitor, EC359 resulted in the reduction of cell viability with an IC50 in the range of 20–100 nM and induction of apoptosis. Further, treatment with EC359 reduced the spheroid formation of EC cancer stem cells and reduced the levels of cancer stem cell markers SOX2, OCT4, NANOG, and Axin2. Mechanistic studies demonstrated that EC359 treatment attenuated the activation of LIF-LIFR driven pathways, including STAT3 and AKT/mTOR signaling in EC cells. Importantly, EC359 treatment resulted in a significant reduction of the growth of EC patient-derived explants ex vivo, EC cell line-derived xenografts, and patient-derived xenografts in vivo. Collectively, our work revealed the oncogenic potential of the LIF/LIFR axis in EC and support the utility of LIFR inhibitor, EC359, as a novel targeted therapy for EC via the inhibition of LIF/LIFR oncogenic signaling.

Endometrial cancer (EC) often exhibit aberrant activation of PI3K/Akt/mTOR signaling and targeted therapies using mTOR inhibitors showed limited success. The epigenetic modifier, lysine-specific histone demethylase-1A (KDM1A/LSD1) is overexpressed in EC, however, the mechanistic and therapeutic implications of KDM1A in EC are poorly understood. Here, using 119 FDA-approved drugs screen, we identified that KDM1A inhibition is highly synergistic with mTOR inhibitors. Combination therapy of KDM1A and mTOR inhibitors potently reduced the cell viability, survival, and migration of EC cells. Mechanistic studies demonstrated that KDM1A inhibition attenuated the activation of mTOR signaling cascade and abolished rapamycin induced feedback activation of Akt. RNA-seq analysis identified that KDM1A inhibition downregulated the expression of genes involved in rapamycin induced activation of Akt, including the mTORC2 complex. Chromatin immunoprecipitation experiments confirmed KDM1A recruitment to the promoter regions of mTORC2 complex genes and that KDM1A inhibition promoted enrichment of repressive H3K9me2 marks at their promoters. Combination therapy of KDM1A inhibitor and rapamycin reduced the tumor growth in EC xenograft and patient derived xenograft models in vivo and patient derived tumor explants ex vivo. Importantly, in silico analysis of TCGA EC patients data sets revealed that KDM1A expression positively correlated with the levels of PI3K/Akt/mTOR genes. Collectively, our results provide compelling evidence that KDM1A inhibition potentiates the activity of mTOR inhibitors by attenuating the feedback activation of Akt survival signaling. Furthermore, the use of concurrent KDM1A and mTOR inhibitors may be an attractive targeted therapy for EC patients.

Emerging evidence indicates that adipose stromal cells (ASC) are recruited to enhance cancer development. In this study, we examined the role these adipocyte progenitors play relating to intercellular communication in obesity-associated endometrial cancer. This is particularly relevant given that gap junctions have been implicated in tumor suppression. Examining the effects of ASCs on the transcriptome of endometrial epithelial cells (EEC) in an in vitro coculture system revealed transcriptional repression of GJA1 (encoding the gap junction protein Cx43) and other genes related to intercellular communication. This repression was recapitulated in an obesity mouse model of endometrial cancer. Furthermore, inhibition of plasminogen activator inhibitor 1 (PAI-1), which was the most abundant ASC adipokine, led to reversal of cellular distribution associated with the GJA1 repression profile, suggesting that PAI-1 may mediate actions of ASC on transcriptional regulation in EEC. In an endometrial cancer cohort (n = 141), DNA hypermethylation of GJA1 and related loci TJP2 and PRKCA was observed in primary endometrial endometrioid tumors and was associated with obesity. Pharmacologic reversal of DNA methylation enhanced gap-junction intercellular communication and cell–cell interactions in vitro. Restoring Cx43 expression in endometrial cancer cells reduced cellular migration; conversely, depletion of Cx43 increased cell migration in immortalized normal EEC. Our data suggest that persistent repression by ASC adipokines leads to promoter hypermethylation of GJA1 and related genes in the endometrium, triggering long-term silencing of these loci in endometrial tumors of obese patients. Significance: Studies reveal that adipose-derived stem cells in endometrial cancer pathogenesis influence epigenetic repression of gap junction loci, which suggests targeting of gap junction activity as a preventive strategy for obesity-associated endometrial cancer.

Ovarian cancer is the deadliest of all gynecologic cancers. Despite success with initial chemotherapy, the majority of patients relapse with an incurable disease. Development of chemotherapy resistance is a major factor for poor long-term survival in ovarian cancer. The biological effects of estrogens are mediated by estrogen receptor alpha (ERα) and estrogen receptor beta (ERβ). Emerging evidence suggests that ovarian cancer cells express ERβ that functions as a tumor suppressor; however, the clinical utility of ERβ agonists in ovarian cancer remains elusive. We tested the utility of two natural ERβ agonists liquiritigenin (Liq), which is isolated from Glycyrrhiza uralensis and S-equol, which is isolated from soy isoflavone daidzein, for treating ovarian cancer. Both natural ERβ ligands had significant growth inhibition in cell viability and survival assays, reduced migration and invasion, and promoted apoptosis. Further, ERβ agonists showed tumor suppressive functions in therapy-resistant ovarian cancer model cells and sensitized ovarian cancer cells to cisplatin and paclitaxel treatment. Global RNA-Seq analysis revealed that ERβ agonists modulate several tumor suppressive pathways, including downregulation of the NF-κB pathway. Immunoprecipitation assays revealed that ERβ interacts with p65 subunit of NF-κB and ERβ overexpression reduced the expression of NF-κB target genes. In xenograft assays, ERβ agonists reduced tumor growth and promoted apoptosis. Collectively, our findings demonstrated that natural ERβ agonists have the potential to significantly inhibit ovarian cancer cell growth by anti-inflammatory and pro-apoptotic actions, and natural ERβ agonists represent novel therapeutic agents for the management of ovarian cancer.

Objectives: The incidence of endometrial cancer (EC) is estimated to increase by 1-2% annually. More than half of all EC diagnoses are currently attributable to obesity, which is an independent risk factor for this cancer. Obesity is suspected to function as a potent inducer of leukemia inhibitory factor (LIF), the most pleiotropic member of the interleukin-6 family of cytokines. Our recent studies utilizing public databases revealed high levels of LIF and its receptor LIFR are associated with poor survival in EC patients (KM plotter). The objective of this study is to determine whether alterations in the LIF/LIFR signal cascade occur in EC cells under conditions of adiposity; and whether this pathway could be a target for therapy. Methods: All patient samples, EC tissue, serum, and adipose tissue, were collected through the UT Health San Antonio tumor registry under IRB approval. Expression of LIF in EC patient samples was analyzed using immunohistochemistry (IHC) using a UT Health generated tumor tissue array (TMA) and scored by UT Health Pathology. Primary EC tissue derived cells and established EC cell lines were treated with primary adipocyte conditioned medium and non-obese patient serum or obese patient serum. The effect of adiposity on EC cells was determined using MTT cell viability assay and colony formation assay, in addition to utilization of organoids derived from primary EC tissue. Mechanistic studies were conducted using Western blotting, RT-qPCR, and reporter assays thus confirming the activation of LIF/LIFR downstream pathways including STAT3, mTOR, Akt, and MAPK. The recently developed LIFR inhibitor, EC359, was used to elucidate the therapeutic utility of targeting the enhanced LIF/LIFR pathway generated by high adiposity. Results: Treatment of established and primary EC cells with adipose environment increased the expression of LIFR protein, enhanced LIFR reporter activity, and increased cellular proliferation. Western blot and RT-qPCR analyses confirmed that increased expression of LIFR correlated with enhanced downstream LIFR signaling and subsequent activation of LIFR target genes. Treatment of EC cells with the LIFR inhibitor EC359 significantly reduced cell viability under adipose conditions. EC359 treatment also decreased adipose environment mediated organoid growth. IHC results using TMA that contained normal tissue (n=33) and EC tumors (n=45) with BMI >30 showed significantly increased expression of LIF in EC compared to normal endometrium. Further, LIF expression was upregulated in EC from obese patients compared to non-obese EC control patients. Conclusions: Collectively, our results suggest that increased adiposity contributes to accelerated EC cell growth via upregulation of the LIF/LIFR pathway. The LIF/LIFR axis represents a potential therapeutic target for adiposity driven EC and the LIFR inhibitor EC359 may be useful in modulating LIF/LIFR signaling in obese EC patients.

Objectives: Our goal was to evaluate if Hispanic ethnicity is a risk factor for developing Type I Endometrial Cancer (EC) at an earlier age than Non-Hispanic White women. Methods: Patients diagnosed with Type I endometrial cancer based on surgical pathology at University Hospital between 2008-2018 were included in this study. The variables we examined were age, race, insurance status, race and ethnicity, stage, grade, and year of diagnosis. Fisher's exact t-test, chi-square analysis, and relative risk calculations were used to determine the association between Hispanic ethnicity and age of diagnosis, body mass index, and stage. Results: We identified 548 patients that were diagnosed with Type I Endometrial cancer based on surgical pathology. Overall, 62% (N=340) of these patients were Hispanic, 33.5% (N=184) were Non-Hispanic White, 3.2% (N=18) were Non-Hispanic Black, 0.4% (N=2) were Asian American, and 0.7% (N=4) were unknown ethnicity. The mean age of diagnosis for Hispanic patients was 52.2 years (95% CI 50.9-53.5) and 56.8 years (95% CI 55-58.6) (P Download : Download high-res image (85KB) Download : Download full-size image Conclusions: Hispanic women were likely to be significantly younger when diagnosed with Type I Endometrial Cancer and more likely to be premenopausal. However, there was no significant difference in mean body mass index between the two groups. Hispanic race should be considered a risk factor for Type I Endometrial cancer, specifically in premenopausal patients.

Background: Endometrial cancer (EC) is the fourth most common cancer in women. Approximately 80% of EC belong to the endometroid-EC subtype and are driven by estrogen signaling. Advanced-stage EC has limited treatment options with poor prognosis. There is an urgent need for the identification of actionable drivers as new targets for treating advance stage EC. Leukemia inhibitory factor receptor (LIFR) and its ligand LIF plays a major role in cancer progression, metastasis, stemness, and therapy resistance. Published and our preliminary data suggest a critical role of the LIF-LIFR signaling axis in EC progression. The objective of this study is to test the utility of targeting the LIF/LIFR axis using a novel LIFR inhibitor, EC359. Methods: We used multiple established and primary EC cells to test the utility LIFR inhibitor, EC359 in treating EC. CRISPR/Cas9 system was used to generate LIFR KO EC cells. In vitro activity was tested using Cell-Titer Glo, MTT, invasion, and apoptosis assays. Mechanistic studies were conducted using Western blot, reporter gene assays, and RNA-seq analysis. EC cell-derived xenograft (CDX) and patient-derived explant (PDEX) models were used for preclinical evaluation and toxicity. Results: EC359 treatment of seven EC cells showed anti-proliferative effects in MTT cell viability assays with an IC50 of 25-100 nM. Further, EC359 treatment reduced invasiveness, stemness, and promoted apoptosis of EC cells. The activity of EC359 is dependent on LIF/LIFR expression in EC cells. CRISPR mediated knockout of LIFR significantly abolished EC359 activity. In vivo xenograft studies using Ishikawa-vector or LIFR-KO cells demonstrated that LIFR-KO significantly reduced EC tumor growth, and tumor weights. Further, EC359 treatment attenuated the activation of LIF/LIFR driven pathways, including STAT3, AKT-mTOR signaling. Mechanistic studies using RNA-seq revealed that EC359 significantly upregulated 213 genes and down regulated 126 genes. Pathway analyses of differential genes revealed enrichment in the apoptotic pathways upon EC359 treatment. EC359 (5mg/kg body weight) treatment significantly reduced CDX tumor progression and reduced proliferation in PDEX models. Conclusions: Collectively, these data support EC359 as a novel targeted therapy for EC by inhibiting LIF/LIFR oncogenic signaling pathway. Citation Format: Weiwei Tang, Kumaraguruparan Ramasamy, Sureshkumar M. Pillai, Bindu Santhamma, Swapna Konda, Prabhakar P. Vekata, Logan Blankenship, Junhao Liu, Zexuan Liu, Kristin A. Altwegg, Behnam Ebrahimi, Uday P. Pratap, Xiaonan Li, Edward Kost, Gangadhara R. Sareddy, Ratna K. Vadlamudi, Hareesh B. Nair, Rajeshwar R. Tekmal, Suryavathi Viswanadhapalli. Therapeutic targeting of endometrial cancer with novel LIFR inhibitor EC359 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1253.

ObjectivesApproximately 3% to 5% of endometrial cancers (EC) are associated with Lynch syndrome (LS). The clinical characteristics and prevalence of LS have not been well studied in the US Hispanic population. Hispanics are the largest and fastest growing ethnic minority group in the United States. We sought to characterize the demographics, tumor characteristics, and prevalence of loss of mismatch repair (MMR) protein expression in a large Hispanic population with EC.MethodsFrom January 1, 2005, to August 1, 2012, 83 women of Hispanic ethnicity diagnosed with EC 50 years and younger were identified. Clinical and pathologic data were abstracted from the electronic medical record. Tumor studies included immunohistochemistry of MLH1, MSH2, MSH6, and PMS2 and methylation of the MLH1 promoter.ResultsNinety-five percent of patients were overweight or obese. The mean body mass index was 40.1 kg/m2, 75% had irregular menses, 36% had diabetes, 46% were nulliparous, and 95% had endometrioid histology. Thirteen patients (15.7%) had tumor MMR deficiency due to a presumed germline mutation (9 MSH6, 3 MSH2, and 1 MLH1). The pattern of MMR protein loss was consistent with the expected binding properties of the MMR heterodimer complexes. No significant difference was found in clinical or pathological variables between patients with and without MMR deficient tumors.ConclusionsThe prevalence of molecular findings consistent with LS was at least as high as other populations of varied geography, race, and ethnicity. We found no reliable factors to include body mass index, family history, synchronous tumors, or pathologic tumor features to serve as triage markers for which ECs should be screened for MMR protein loss. Our findings support a recommendation for universal screening of ECs utilizing 2-antibody testing with MLH1 promoter methylation testing as indicated up to 60 years or older. Our recommendations should be generalizable to other Hispanic populations in the Southern United States.

SUMMARY While plasminogen activator inhibitor-1 (PAI-1) is known to potentiate cellular migration via proteolytic regulation, this adipokine is implicated as an oncogenic ligand in the tumor microenvironment. To understand the underlying paracrine mechanism, here, we conduct transcriptomic analysis of 1,898 endometrial epithelial cells (EECs) exposed and unexposed to PAI-1-secreting adipose stromal cells. The PAI-1-dependent action deregulates crosstalk among tumor-promoting and tumor-repressing pathways, including transforming growth factor β (TGF-β). When PAI-1 is tethered to lipoprotein receptor-related protein 1 (LRP1), the internalized signaling causes downregulation of SMAD4 at the transcriptional and post-translational levels that attenuates TGF-β-related transcription programs. Repression of genes encoding the junction and adhesion complex preferentially occurs in SMAD4-underexpressed EECs of persons with obesity. The findings highlight a role of PAI-1 signaling that renders ineffective intercellular communication for the development of adiposity-associated endometrial cancer., Graphical Abstract, In Brief Lin et al. demonstrate that PAI-1 secreted by adipose stromal cells interacts with LRP1 to repress TGF-β/SMAD4-regulated genes linked to cellular junction and adhesion complexes. This action disrupts cell-cell communication and facilitates the development of obesity-driven endometrial cancer.

Background: Ovarian cancer (OCa) is the deadliest gynecologic cancer. Recent studies suggest that OCa cells express estrogen receptor beta (ESR2), which functions as a tumor suppressor. However, ESR2 expression decreases during tumor progression and under the selection pressure of chemotherapy; this decrease occurs via epigenetic mechanisms. The lysine-specific histone demethylase 1A (KDM1A), an epigenetic regulator, is overexpressed in OCa. We reason that agents that restore the expression/functions of ESR2 may provide a novel therapeutic opportunity for suppression of OCa. In this study we tested the hypothesis that KDM1A suppresses ESR2 expression/functions and that inhibition of KDM1A potentiates ESR2 mediated tumor suppression. Methods: We examined the utility of combination therapy of KDM1A inhibitor and ESR2 agonist on established and patient derived OCa cells using cell viability, survival, apoptosis and invasion assays. KDM1A knockout (KDM1A-KO) cells were generated using the CRISPR/Cas9 system. Mechanistic studies were conducted using RNA-seq, ERE-Luc reporter assays, RT-qPCR, co-IP, ChIP and Western blot analysis. The efficacy of combination therapy on primary ovarian tumors was examined using patient derived explant (PDEx) models. In vivo efficacy of KDM1A inhibitor and ESR2 agonist was studied using orthotopic OCa and patient derived xenograft models. Results: Analysis of the gene expression profiles of OCa patients showed that KDM1A negatively correlates with ESR2. Combination of KDM1A inhibitor NCD-38 and ESR2 agonist LY500307 synergistically reduced cell viability, survival and invasion and increased apoptosis of established and patient derived primary OCa cells. Inhibition or knockout of KDM1A sensitized OCa cells to ESR2 agonist treatment and significantly increased the expression of ESR2 and its target genes. Further, we found that KDM1A is recruited to the ESR2 0N promoter and interacts with ESR2. In addition, inhibition of KDM1A increased the active histone methylation mark H3K4-me2 at the ESR2 0N promoter. RNA-seq analysis demonstrated that ESR2 agonist treatment resulted in modulation of pathways related to cell cycle, apoptosis and DNA damage. Importantly, combination treatment significantly reduced the tumor growth in orthotopic and patient derived xenograft models and reduced the proliferation of OCa cells in PDEx models. Conclusions: Our results demonstrate that KDM1A inhibition enhances ESR2 expression/functions and combination therapy of KDM1A inhibitor and ESR2 agonist is an attractive therapy for treating OCa. Citation Format: Prabhakar Pitta Venkata, Bridgitte E. Palacios, Yihong Chen, Salvador Alejo, Yi He, Ilanna Loeffel, Uday Pratap, Kristin Altwegg, Suryavathi Viswanadhapalli, Takayoshi Suzuki, Rajeshwar Tekmal, Edward Kost, Gangadhara Sareddy. KDM1A inhibition activates estrogen receptor beta pathway to suppress ovarian cancer progression [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1764.

Emerging evidence indicates that adipose stromal cells (ASC) are recruited to enhance cancer development. In this study, we examined the role these adipocyte progenitors play relating to intercellular communication in obesity-associated endometrial cancer. This is particularly relevant given that gap junctions have been implicated in tumor suppression. Examining the effects of ASCs on the transcriptome of endometrial epithelial cells (EEC) in an in vitro co-culture system revealed transcriptional repression of GJA1 (encoding the gap junction protein Cx43) and other genes related to intercellular communication. This repression was recapitulated in an obesity mouse model of endometrial cancer. Furthermore, inhibition of plasminogen activator inhibitor 1 (PAI-1), which was the most abundant ASC adipokine, led to reversal of cellular distribution associated with the GJA1 repression profile, suggesting that PAI-1 may mediate actions of ASC on transcriptional regulation in EEC. In an endometrial cancer cohort (n=141), DNA hypermethylation of GJA1 and related loci TJP2 and PRKCA was observed in primary endometrial endometrioid tumors and was associated with obesity. Pharmacologic reversal of DNA methylation enhanced gap junction intercellular communication and cell-cell interactions in vitro. Restoring Cx43 expression in endometrial cancer cells reduced cellular migration; conversely, depletion of Cx43 increased cell migration in immortalized normal EEC. Our data suggest that persistent repression by ASC adipokines leads to promoter hypermethylation of GJA1 and related genes in the endometrium, triggering long-term silencing of these loci in endometrial tumors of obese patients.

PURPOSE OF INVESTIGATION Pain control and early ambulation are two important postoperative goals. Strategies that decrease morphine use while increasing ambulation have the potential to decrease postoperative complications. In this study the authors sought to determine the effect of an abdominopelvic binder on postoperative morphine use, pain, and ambulation in the first day after surgery. MATERIALS AND METHODS The authors randomly assigned 75 patients undergoing abdominal gynecologic surgery to either binder or not after surgery. Demographic data and surgical characteristics were collected. Outcome variables included morphine use, pain score, time to ambulation, and number of ambulations. RESULTS A group at high risk for decreased mobility was identified and the binder increased the number of ambulatory events by 300%, 260%, and 240% in patients with vertical incisions, age over 50 years, and complex surgeries, respectively. Morphine use and pain scores were not significantly different. CONCLUSION The binder increased ambulations in the subset of patients at the highest risk for postoperative complications: elderly, cancer patients, and vertical incisions. Routine use of the binder may benefit particularly high-risk gynecologic surgical patients.

Endometrial cancer is the most common gynecologic cancer. It is divided into two major types, a less aggressive endometrioid type and a more aggressive serous type. Recent clinical observations underscore obesity as a major risk factor for endometrial cancer. In this study, we hypothesized that obesity can result in long term epigenetic modifications in the endometrial compartment, leading to the promotion of endometrial cancer. We examined the role of adipose-derived stem cells (ASCs), which are adipocyte progenitors, in the endometrial tumor microenvironment. By staining for ASCs in a tumor tissue microarray, we observed ASC infiltration that was specific to samples from obese patients, correlating with body mass index (R2=0.77, p Citation Format: Li-Ling Lin, Srikanth Polusani, Guangcun Huang, Chun-Lin Lin, Chiou-Miin Wang, Nicholas Lucio, Mikhail Kolonin, Alexes Daquinag, Pawel Osmulski, Bruce Nicholson, Edward Kost, Tim Huang, Nameer B. Kirma. Adipose-derived stem cell disruption of gap junction intercellular communication in obesity-associated endometrial cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5150.

Highlights • STUMPs are rare smooth muscle tumors with an overall favorable prognosis. • Pregnancy is possible after diagnosis of STUMP treated with myomectomy • Management of patients desiring fertility with STUMPs requires a multidisciplinary approach.

Background: Ovarian cancer (OCa) is the deadliest of all gynecologic cancers. OCa patients initially respond to standard combinations of surgical and cytotoxic therapy; however, ~80% will develop recurrence and inevitably succumb to chemotherapy-resistant disease. OCa stem cells are implicated in the tumor initiation and therapy resistance. LIFR signaling plays a critical role in OCa progression and stemness. Further, high circulating LIF levels correlate with tumor recurrence and chemoresistance. The autocrine loop involving LIF, LIFR and STAT3 axis drives sustained fibroblast production of inflammatory mediators. This represents a significant problem and a critical need exists for development of novel therapies targeting the LIFR axis for treating OCa. Methods: We have rationally designed and synthesized a small organic molecule (EC359) that emulates the LIF-LIFR binding site and functions as a LIFR inhibitor from a library of compounds. In silico docking studies were used to identify the putative interaction of the EC359 and LIF/LIFR complex. Binding of EC359 to LIFR was confirmed using surface plasmon resonance (SPR) and IP assays. Mechanistic studies were conducted using Western, RT-qPCR, and RNA-Seq analysis. Xenograft models were used for preclinical evaluation and toxicity. The efficacy of EC359 was tested using Patient-Derived eXplants (PDeX). Results: Global analysis of online databases revealed negative correlation of OCa survival with LIFR expression. Molecular docking studies showed EC359 interacts at the LIF-LIFR binding interface. SPR studies confirmed interaction of EC359 to LIFR. Western analysis of eight cells that represent four subtypes of OCa confirmed higher expression of LIF and LIFR. EC359 reduced the growth of eight OCa cells with high potency (IC50 10-50 nM) and promoted apoptosis. EC359 treatment reduced stemness of OCa cells. EC359 activity is dependent on the level of expression of LIFR with little activity on cells that do not express LIFR. EC359 significantly reduced the viability of carboplatin- and taxol-resistant OCa cells. Mechanistic studies showed EC359 interacts with LIFR and block its interaction with LIF. EC359 treatment reduced the STAT3 phosphorylation, mTOR and downstream survival signaling cascades. RNA sequencing revealed unique pathways blocked by EC359. Treatment of xenograft tumors with EC359 significantly reduced the tumor volume compared to control. Further, using PDeX of OCa, we demonstrated that EC359 has potential to reduce the proliferation. Pharmacologically, EC359 exhibited high oral bioavailability and long half-life with a wide therapeutic window. Conclusions: EC359 is a novel agent that targets LIF-LIFR axis and has activity against chemotherapy-resistant and primary OCa tumors. EC359 has the distinct pharmacologic advantages of oral bioavailability, in vivo stability, and is associated with minimal systemic side effects. Citation Format: Suryavathi Viswanadhapalli, Hareesh B Nair, Bindu Santhamma, Gangadhara R Sareddy, Yiliao Luo, Xinlei Pan, Edward R Kost, Ramachandran Murali, Rajeshwar Rao Tekmal, Klaus J Nickisch, Ratna K Vadlamudi. Development of LIFR inhibitor EC359 as a novel therapeutic for ovarian cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5875.

The current study sought to determine if endometrial adenocarcinomas express human leukocyte antigen-G (HLA-G), an immune-regulatory protein, and if degree of expression correlates with the stage of carcinoma.Forty-four primary endometrial adenocarcinomas were tested using immunohistochemical staining with the 4H84 anti-HLA-G monoclonal antibody. Metastatic implants were not included. A subset of 10 samples was tested using RNA in situ hybridization to confirm the presence of HLA-G transcript. Results of staining were analyzed with respect to grade, tumor histology, and stage of disease. Spearman rank correlation was used to assess tumor grade, histology, and disease stage as a function of HLA-G protein staining. Receiver-operator characteristic (ROC) curve analysis was used to determine the feasibility of HLA-G protein staining as a clinical marker for advanced stage disease.Immunohistochemical staining for HLA-G protein was seen in 55% (24/44) of primary site endometrial adenocarcinomas and localized to glandular but not stromal epithelium. RNA in situ hybridization confirmed the presence of transcript in the majority of samples tested and also localized to glandular epithelium. A significant correlation was seen with increasing HLA-G protein staining and increasing stage of endometrial cancer, P0.01. HLA-G was found to be a fair discriminator as a test for metastatic disease with an area under the ROC curve of 0.75 for metastatic versus non-metastatic disease.HLA-G protein is expressed in a significant number of endometrial adenocarcinomas, in which it is localized to the glandular epithelium. HLA-G may serve as a clinical marker for the preoperative prediction of metastatic endometrial cancer.

Objective The Department of Defense health care system provides access to care without respect to age, race, or socioeconomic status. We sought to determine the effect of race as a predictor of survival in patients with endometrial cancer treated in the Department of Defense medical system. Methods Information on patients with endometrial carcinoma was extracted from the Department of Defense centralized tumor registry for the period 1988 to 1995. Data included age at diagnosis, military status, race, tumor histology, grade, FIGO surgical stage, adjuvant therapies, and disease-free survival. The χ 2 test was used for analysis of prognostic factors and adjuvant treatments between racial groups. Actuarial survival curves were calculated by using the method of Kaplan and Meier and compared by the log-rank test. Variables found to be significant on univariate analysis ( P Results Of 1811 patients meeting criteria for the study, racial distribution was 90% Caucasian, 4.4% African-American, and 5.5% Asian-Pacific Islander. African-Americans had more advanced stages of disease compared to Caucasians ( P P P = 0.007). Additional poor prognostic factors included age >60 years, grade, unfavorable histology, and stage. On multivariate analysis age >60 years, stage, and Asian-Pacific Islander race remained significant prognostic factors. Conclusion African-Americans and Asian-Pacific Islanders had worse survivals than Caucasians. After controlling for imbalances in clinicopathologic factors, Asian-Pacific Islander race was found to be a newly identified poor prognostic factor.

BACKGROUND The objective of this study was to compare survival between patients with adenocarcinoma and patients with adenosquamous carcinoma of the cervix. METHODS Patients who were diagnosed with invasive cervical carcinoma from 1988 to 1999 were identified from the Automated Central Tumor Registry for the United States Military Health Care System. Clinical data, including race, age at diagnosis, histology, tumor grade, disease stage, lymph node status, treatment modality, and survival, were collected. Survival analysis was performed with Kaplan–Meier survival curves and compared using the log-rank test. RESULTS A total of 273 women were identified, 185 women with a histologic diagnosis of adenocarcinoma (AC) and 88 women with a diagnosis of adenosquamous carcinoma (ASC). Among the women with ASC, only 5% had Grade 1 tumors, and 66% had Grade 3 tumors. By comparison, among the women with AC, 37% had Grade 1 tumors, and 26% had Grade 3 tumors (P < 0.001). There was no difference in the incidence of positive lymph nodes or in the number of patients who underwent radical hysterectomy as primary treatment between patients with ASC and patients with AC. More patients with ASC received radiation therapy (51% vs. 28%) or chemotherapy (29% vs. 12%) as treatment (P < 0.001). Patients who had tumors with ASC histology had a significantly decreased 5-year survival rate compared with patients who had tumors with AC histology (65% vs. 83%; P < 0.002). When patients with early-stage cervical carcinoma (International Federation of Gynecology and Obstetrics [FIGO] Stage I) were examined separately, there was no statistically significant difference in the 5-year survival rate (AC, 89%; ASC, 86%; P = 0.644). However, when patients with advanced-stage disease (FIGO Stages II–IV) were analyzed, ASC was associated with a significant decrease in median and overall survival (P = 0.01). When the results were analyzed by grade, patients who had tumors with ASC histology had a shorter survival compared with patients who had AC histology of any grade; however, this was a significant difference only for patients with Grade 1 tumors: The 5-year survival rate for patients with Grade 1 AC was 93%, compared with 50% for patients with Grade 1 ASC (P < 0.01). CONCLUSIONS ASC histology appears to be an independent predictor of poor outcome in women with cervical carcinoma compared with their counterparts who have pure AC. The significant decrease in survival was observed only in patients with advanced-stage cervical carcinoma. This decreased survival may be related mainly to the grade of ASC. Cancer 2003;97:2196–202. Published 2003 American Cancer Society. DOI 10.1002/cncr.11371

Ovarian cancer (OCa) is the deadliest of all gynecologic cancers in the United States. Although patients with OCa respond initially to standard combinations of surgical and cytotoxic therapy, nearly 90% will develop recurrence and inevitably succumb to chemotherapy-resistant disease. Estrogen mediates its effects through the estrogen receptor α (ESR1) and estrogen receptor β (ESR2). Recent studies suggest that OCa cells and OCa stem cells express ESR2, which functions as a tumor suppressor and identified synthetic compound LY500307 as a potent ESR2 specific agonist. However, ESR2 expression decreases during tumor progression and under the selection pressure of chemotherapy; this decrease occurs via epigenetic mechanisms. The lysine-specific histone demethylase 1A (KDM1A/LSD1) is overexpressed in OCa and plays a vital role in metastasis and cancer stemness. Our group recently developed a novel KDM1A-specific inhibitor (NCD-38) based on an innovative concept of direct delivery of phenylcyclopropylamine to the KDM1A active site. We reason that agents that restore the expression and functions of ESR2 by increasing active histone marks may provide a novel therapeutic opportunity to reactivate ESR2 for suppression of OCa. The objective of this study is to test whether KDM1A inhibitor could enhance the expression and tumor suppressive functions of ESR2 and to test the combination of KDM1A inhibitor along with ESR2 agonist using in vitro and in vivo preclinical models. Our results demonstrated that combination of ESR2 agonist and KDM1A inhibitor reduces the cell viability of OCa cells synergistically. Further caspase-3/7 activity and Annexin V assays showed synergistic induction of apoptosis upon combination therapy. Matrigel invasion assays revealed reduction in cell invasion of OCa cell lines following ESR2 agonist and KDM1A inhibitor treatment. RT-qPCR analysis demonstrated that KDM1A inhibitor treatment significantly increases the expression of ESR2 and its target genes leading to increased tumor suppression. Further, co-immunoprecipitation analysis revealed that KDM1A interacts with ESR2 and Chromatin immunoprecipitation assays demonstrated that KDM1A inhibition increases the recruitment of active histone methylation mark H3K4-me2 at ESR2 0N promoter. RNA-sequencing analysis demonstrated that ESR2 agonist treatment modulates the several pathways related to cell cycle, apoptosis and DNA damage check point regulation. Finally, ESR2 agonist and KDM1A inhibitor treatment significantly reduced the in vivo tumor growth in orthotopic models. Since ESR2 agonists and KDM1A inhibitors are currently in clinical trials for other clinical indications and are well tolerated, identification of KDM1A inhibitor and ESR2 agonist combination therapy as a novel therapeutic can be readily transferred to clinical use for enhancing survival in OCa patients. Citation Format: Gangadhara Reddy R. Sareddy, Jinyou Liu, Lauren Garcia, Suryavathi Viswanadhapalli, Mei Zhou, Takayoshi Suzuki, Edward Kost, Ratna K. Vadlamudi. Enhancing estrogen receptor beta mediated tumor suppression by lysine specific demethylase 1A inhibitor for the treatment of ovarian cancer [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 4052. doi:10.1158/1538-7445.AM2017-4052

Objective: The aim of this study was to determine the rates of recurrent dysplasia with longer follow-up durations and to determine whether margin status and other variables were associated with recurrence. Study Design: A retrospective chart review was performed for all women who underwent a loop electrosurgical excision procedure at Wilford Hall Medical Center, Lackland Air Force Base, Texas, between January 1993 and December 1994. Extracted information included age, parity, indication for the loop electrosurgical excision procedure, histologic classification of the loop electrosurgical excision procedure specimen, margin status, and whether a "deep" (endocervical) pass had been performed. Follow-up data included findings of repeated cytologic examination, colposcopy, and biopsy if performed. Results: The mean duration of follow-up for all women was 24 months. Margins were positive in 28%, with 73% of these being endocervical. The overall recurrent dysplasia rate was 31%, with a mean time to recurrence of 11.9 months. Participants with any positive margins had a higher recurrence rate than did those with negative margins (47% vs 26%; P =.009). High-grade lesions at the margin were more commonly associated with recurrence than were low-grade lesions relative to those with clear margins (high-grade lesion vs negative margins, 55% vs 26%; P =.003; low-grade lesion vs negative margins, 36% vs 26%; P =.34). Recurrence was not associated either with the performance of an endocervical pass or with the histologic diagnosis of the loop electrosurgical excision procedure specimen. Conclusion: With comprehensive long-term follow-up, positive margins on loop electrosurgical excision procedure specimens were shown to be a risk factor for recurrence of cervical dysplasia, particularly when high-grade lesions were seen at the margin. Recurrence was also considerable among women with negative margins. Women should be counseled regarding this risk, and the importance of follow-up should be emphasized. (Am J Obstet Gynecol 2001;184:315-21.)

BACKGOUND. It was the purpose of this study to investigate whether race is an independent prognostic factor in the survival of patients with cervical carcinoma in a health care system with minimal racial bias, and few barriers to access to care. METHODS Records for patients with a diagnosis of invasive cervical carcinoma from 1988 to 1999 were obtained from the Automated Central Tumor Registry for the United States Military Health Care System. Clinical data including race, age at diagnosis, histology, grade, stage, socioeconomic status, treatment modality, and survival also were obtained. Survival analysis was performed with Kaplan–Meier survival curves. RESULTS One thousand five hundred fifty-three patients were obtained for review. Sixty-five percent of patients were Caucasian, and 35% were minorities. Of the minorities, 29% were African Americans (AAs). Mean age of diagnosis was similar among AAs and Caucasians, 44 and 42 years, respectively. There was no statistically significant difference between the distribution of age, stage, grade, or histology between Caucasians and AAs. Forty-six percent of patients were treated with surgery and 56% with radiation therapy, with no difference in type of treatment between the Caucasian and AA groups. Five- and 10-year survival rates for Caucasians and AAs were 75%, and 76%, and 64% 65% (P = 0.59), respectively. CONCLUSIONS In an equal access, unbiased, nonracial environment, race is not an independent predictor of survival for patients with cervical carcinoma. This study has shown, for the first time to the authors' knowledge, that when they receive equal treatment for cervical carcinoma, AA women's survival can approach that of their nonminority counterparts (75% at 10 years). Cancer 2001;91:869–73. © 2001 American Cancer Society.

Objectives. We set out to determine the clinical significance of atypical immature squamous metaplasia (AIM). Methods. We performed in a military, hospital-based colposcopy clinic a descriptive, retrospective review of patients who had a diagnosis of AIM. Patients were examined at 3- to 4-month intervals for at least 1 year after a diagnosis of AIM was established. A gynecological pathologist reviewed all histological and cytological specimens. Initial histological or cytological specimens were tested for the presence of HPV DNA using in situ hybridization. Results. High-risk HPV DNA types 16 or 18 were detected in 3% of patients with AIM. Concurrent cervical intraepithelial neoplasia 3 (CIN3) was noted in 3% of patients with AIM. One-third of patients with initially diagnosed AIM had complete resolution of this lesion after 1 year of follow-up. Conclusions. This descriptive, retrospective review shows that AIM does not appear to be associated with high-risk HPV DNA or with CIN3. In this limited study, a concurrent diagnosis of AIM likely does not influence the 1-year behavior of CIN. The degree of CIN should dictate treatment recommendations. A larger prospective trial is needed.

We report on a case of a suburethral erosion of transobturator tape tracking into the right thigh with abscess formation 20 months from surgery resulting in necrotizing fasciitis. A 64-year-old woman presented with new onset of severe right thigh pain. Physical exam was concerning for a right thigh abscess and she was admitted to general surgery for evaluation. Gynecology was consulted secondary to a complaint of foul vaginal discharge. The patient was noted to have a vaginal mass on the anterior vaginal wall. A computed tomography scan showed a large right medial thigh abscess. The patient was taken for emergency exploratory surgery where an ObTape® (Mentor, Santa Barbara, CA, USA) TOT was found eroding through the anterior vaginal wall, extending into the thigh abscess. During removal of the ObTape® from her thigh, the entire gracilis muscle was removed due to necrotizing fasciitis and extensive tissue debridement was performed. A wound vac was placed and the patient had an uneventful recovery.

BACKGROUND: Extremity compartment syndrome is a rare surgical complication in which increased intracompartmental pressure threatens the viability of the muscular and nervous tissue. We report a case of a delivery complicated by postpartum hemorrhage and a lower extremity compartment syndrome. CASE: A multigravida in her late 20s was admitted for induction of labor at 41 weeks of gestation. She underwent a cesarean delivery for a nonreassuring fetal heart rate tracing. The delivery was complicated by severe postpartum hemorrhage due to uterine atony, resulting in a cesarean hysterectomy. The patient developed a lower extremity compartment syndrome and underwent an emergent anterior tibial fasciotomy. CONCLUSION: Extremity compartment syndrome is rarely encountered in obstetric care; however, there may be an association with severe postpartum hemorrhage.

Objective: The familial clustering of ovarian, breast, endometrial, colon, and prostate cancer was compared in first-degree relatives of probands with invasive and borderline ovarian cancer to determine coaggregation. Methods: Probands ( n = 392), who had been patients in the Division of Gynecologic Oncology at Washington University, were ascertained consecutively. Family history on 2192 first-degree relatives was collected by personal interviews of the probands and other family members. Estimates of prevalence of cancers in first-degree relatives of the two proband groups were compared. Survival analysis was used to examine the age-at-onset distribution of each cancer in relatives of invasive probands versus relatives of borderline probands. Results: Among the relatives were 24 cases of ovarian cancer, 46 cases of breast cancer, 13 cases of endometrial cancer, and 25 and 28 cases of colon and prostate cancer, respectively. There were no significant differences in the prevalence of any of these cancers in relatives of the invasive and borderline probands. Cumulative lifetime risk estimates did not differ between the relatives of the two groups for any cancers. Age-at-onset of ovarian cancer did not differ between probands with positive family histories of the five cancers and those with negative histories. The inability to reject the null hypothesis of no differences in the first-degree relatives of our two study groups might be from insufficient power to detect small differences, given our sample size. Conclusion: These results suggest that relatives of patients with invasive and borderline ovarian cancer might share similar cancer risks and age-at-onset distributions.

OBJECTIVE: Our purpose was to define the expression of tumor necrosis factor receptors on ovarian cancer cells and determine what role these receptors play in tumor necrosis factor-α - mediated cytolysis. STUDY DESIGN: Cell surface expression of tumor necrosis factor-α receptors was determined on ovarian cancer cell lines Caov-3, SK-OV-3, NIH : OVCAR-3, and A2780 by a tumor necrosis factor-α binding assay that used iodine 125 - labeled tumor necrosis factor-α. Monoclonal antibodies specific for the 55 to 60 kd (TR60) and 75 to 80 kd (TR80) tumor necrosis factor receptors were used to determine the relative density of each receptor type. To elucidate which receptor(s) was responsible for mediating the signal for cytolysis, 24-hour MTT cytolytic assays that used tumor necrosis factor-α and emetine were performed in the presence or absence of receptor-specific monoclonal antibodies. RESULTS: The four ovarian cell lines expressed a similar number of surface receptors, 4500 to 7000 per cell, had similar dissociation constants, 0.3 to 0.6 nmol/L, and expressed predominately the TR60 receptor subtype. Receptor function studies showed that the presence of the monoclonal antibody to the TR60 receptor completely inhibited tumor necrosis factor-α - mediated cytolysis, whereas the monoclonal antibody to the TR80 receptor only partially blocked cytolysis. CONCLUSIONS: Ovarian cancer cell lines express both tumor necrosis factor receptors, with the TR60 receptor being the dominant subtype. Tumor necrosis factor-α - mediated cytolysis appears to be dependent on the presence of a functional TR60 receptor. The TR80 receptor does not appear requisite for cytolysis; however, a complementary role cannot be excluded. Manipulation of tumor necrosis factor receptor subtypes on ovarian cancer cells may enhance the cytotoxic effects, thus improving the therapeutic efficacy of tumor necrosis factor-α. (AM J OBSTET GYNECOL 1996;174:145-53.)

BACKGROUND: Dissemination of coccidioidomycosis to the abdominal cavity is rare. No previous case of peritoneal coccidioidomycosis has presented as an adnexal mass. CASE: We report a case of peritoneal coccidioidomycosis mimicking ovarian carcinoma. The patient presented with a complex ovarian mass, ascites, omental caking, and an elevated CA 125. The ultimate diagnosis was not made until frozen section histopathology was performed at staging laparotomy. CONCLUSION: Peritoneal coccidioidomycosis can present with the clinical, radiographic, and serologic features of ovarian cancer. Although essential for diagnosis and staging, radiographic studies and tumor markers have limited specificity. Coccidioidomycosis now joins other benign conditions that comprise the differential diagnosis of patients who present with what seems to be advanced ovarian carcinoma. Infectious diseases consultation is recommended for the management of peritoneal coccidioidomycosis.

BACKGROUND: Hysteroscopy to evaluate abnormal uterine bleeding is gaining popularity. The standard methods of evaluation, endocervical curettage, and endometrial biopsy frequently diagnose adenocarcinoma without determining location. Because the treatments of endometrial and endocervical cancers are different, knowing the neoplastic origin is desirable. CASES: Two postmenopausal women were referred for abnormal uterine bleeding. Endometrial biopsies were consistent with mucinous adenocarcinoma without distinction between cervical and endometrial sites. Endocervical curettages were inconclusive. Both patients underwent hysteroscopy at the time of exploratory laparotomy, which revealed the location of the adenocarcinomas, one in the endocervix and one in the uterine fundus. CONCLUSION: The location of adenocarcinoma may be further clarified by the use of intraoperative hysteroscopy, which can aid in determining surgical treatment.

Objective To evaluate the relationship between the E 2 response during the clomiphene citrate (CC) challenge test and ovarian responsiveness to exogenous gonadotropins. Design Performance of a CC challenge test followed by ovulation induction with exogenous gonadotropins as part of participation in an assisted reproduction program. Setting Assisted reproduction program in a large military tertiary care center. Patients Two hundred forty-seven women between the ages of 24 and 39 years with normal CC challenge tests within 1 year of their assisted reproduction cycle. Interventions Performance of CC challenge tests and ovulation induction with exogenous gonadotropins as a component of an assisted reproduction cycle. Main Outcome Measures Correlation of the E 2 response during the CC challenge test and peak E 2 , the duration of stimulation, number of ampules of exogenous gonadotropins, number of mature follicles, number of mature oocytes recovered, and fertilization and pregnancy rates in an assisted reproduction program. Results No correlation exists between the E 2 response during the CC challenge test and any of the parameters evaluated. Conclusion Monitoring of the E 2 response during the CC challenge test did not predict ovarian responsiveness or pregnancy rates in patients participating in an assisted reproduction program and one may choose not to include it in routine testing.

The hypercoagulability status of women with and without gynecologic malignancies was compared using the thromboelastograph coagulation analyzer. Blood specimens from 25 women with newly diagnosed gynecologic malignancies and from 21 age-matched controls were analyzed. Hypercoagulability is defined by a short R value (min), a short K value (min), an elevated maximum amplitude (MA) value (mm), and a broad alpha-angle (degrees). A two-tailed, two-sample t-test was used for statistical analysis. When compared with specimens from age-matched controls, specimens from women with gynecologic malignancies demonstrated values consistent with hypercoagulability. The specific parameters are presented as a mean (+/- SD). Patients with gynecologic malignancies were found to have a short R value (7.1 +/- 2.1 vs. 11.8 +/- 1.8 min; P0.001), a short K value (3.1 +/- 0.9 vs. 4.6 +/- 0.9 min; P0.001), a prolonged MA value (64.7 +/- 5.4 vs. 58.8 +/- 6.1 mm; P = 0.001), and a greater alpha-angle (70.6 +/- 5.3 vs. 61.6 +/- 4.9 degrees ; P0.001). Detection of hypercoagulability as measured by thromboelastography is statistically more common among women with gynecologic malignancies compared with age-matched controls. Future studies may address the use of thromboelastography to identify patients at risk for gynecologic malignancies.

Background : Up to 20% of ovarian epithelial tumors are classified as being of low malignant potential. Most of these low malignant potential tumors are detected at an early stage and have an excellent prognosis. This is a report of a woman with cardiac metastasis from an ovarian low malignant potential tumor. Case : This case describes a 53-year-old woman who presented with congestive heart failure and was found to have a recurrent stage III ovarian tumor of low malignant potential. A transesophageal echocardiogram revealed compression of the inferior vena cava and a mass encompassing the right atrium. Findings at autopsy confirmed a low malignant potential ovarian tumor thrombus involving the inferior vena cava and right atrium. Conclusion : Ovarian low malignant potential tumors can metastasize in an aggressive manner. A transesophageal echocardiogram may be useful when the diagnosis of cardiac tumor thrombus is considered.

This review describes three cases of human immunodeficiency virus-infected women who were diagnosed with vulvar cancer before age 40 years. A retrospective chart review was performed for three patients who were younger than 40 years of age and who had histologically confirmed invasive squamous cell carcinoma of the vulva diagnosed between 1999 and 2002. Demographic, clinical, and laboratory data were recorded. Three human immunodeficiency virus-seropositive women were diagnosed with invasive squamous cell carcinoma of the vulva, stages IA, IB1, and III. All cases were characterized by extensive surrounding vulvar, vaginal, and cervical intraepithelial neoplasia. CD4 cell counts were 250, 330, and 900 cells/uL. Two patients experienced previous acquired immune deficiency syndrome-defining illnesses: toxoplasmosis and cervical cancer. Vulvar cancer in young human immunodeficiency virus-seropositive women may be associated with other human papillomavirus-related diseases and immunosuppression, as evidenced by low CD4 counts and the presence of antecedent acquired immune deficiency syndrome-defining illnesses.

The Department of Defense health care system provides access to care without respect to age, race, or socioeconomic status. We sought to determine the effect of race as a predictor of survival in patients with endometrial cancer treated in the Department of Defense medical system.Information on patients with endometrial carcinoma was extracted from the Department of Defense centralized tumor registry for the period 1988 to 1995. Data included age at diagnosis, military status, race, tumor histology, grade, FIGO surgical stage, adjuvant therapies, and disease-free survival. The chi(2) test was used for analysis of prognostic factors and adjuvant treatments between racial groups. Actuarial survival curves were calculated by using the method of Kaplan and Meier and compared by the log-rank test. Variables found to be significant on univariate analysis (P0.05) were entered into a multivariate Cox regression analysis.Of 1811 patients meeting criteria for the study, racial distribution was 90% Caucasian, 4.4% African-American, and 5.5% Asian-Pacific Islander. African-Americans had more advanced stages of disease compared to Caucasians (P0.001). Both African-Americans and Asian-Pacific Islanders had higher grade tumors and less favorable histologic types than Caucasians (P0.05). The extent of adjuvant therapies was similar for racial groups. African-Americans and Asian-Pacific Islanders had significantly worse 5-year disease-free survivals than Caucasians (P = 0.007). Additional poor prognostic factors included age60 years, grade, unfavorable histology, and stage. On multivariate analysis age60 years, stage, and Asian-Pacific Islander race remained significant prognostic factors.African-Americans and Asian-Pacific Islanders had worse survivals than Caucasians. After controlling for imbalances in clinicopathologic factors, Asian-Pacific Islander race was found to be a newly identified poor prognostic factor.

Ovarian cancer (OC) is the deadliest of all gynecologic cancers in the United States. Despite success with initial chemotherapy, 70% of patients relapse with incurable disease. Development of chemotherapy resistance is the main factor for poor long-term survival in OC. OC stem cells are implicated in tumor initiation and therapy resistance and their elimination is critical for the development of efficient therapeutic strategies. The biological effects of estrogens are mediated through their cognate receptors: estrogen receptor alpha (ERα) and ER beta (ERβ). Emerging evidence suggests that OC cells express ERβ that functions as a tumor suppressor; however, the clinical utility of ERβ agonists in OC remains elusive. Here, we have tested the utility of ERβ to inhibit OC progression by employing ERβ specific agonists. We have used three different ERβ agonists: liquiritigenin (LIQ) isolated from the plant Glycyrrhiza uralensis, S-equol from soy isoflavone daidzein, and the synthetic compound LY500307 (Eli Lilly). Western analysis revealed detectable expression of ERβ in all OC models tested (SKOV3, BG1 and OVCAR3). Using ERβ reporter gene assay and ERβ specific target gene expression, we confirmed functionality of the ERβ pathway in OC cells. All three ERβ ligands showed significant growth inhibition in MTT and colony formation assays, and ERβ agonists promoted apoptosis. Treatment with ERβ agonists significantly upregulated the expression of ERβ via autocrine signaling. Mechanistic studies revealed ERβ mediated non-classical signaling via AP1 and SP1 as playing a critical role in ERβ mediated tumor suppression. Of the three ligands tested, LY500307 showed more potent growth inhibitory activity (IC50: 3μM). ERβ knockdown using shRNA significantly reduced the ERβ agonist mediated growth inhibition. Interestingly, we found that OC stem cells express ERβ and ERβ agonists significantly decrease the sphere formation by OC stem cells. Additional assays revealed that ERβ agonists reduced the stemness of OC stem cells and enhanced their sensitivity to chemotherapy. Accordingly, ERβ agonists significantly reduced the growth of chemotherapy resistant ovarian cancer model cells (cisplatin-resistant ES2, paclitaxel resistant SKOV-3TR cells) and sensitized them to apoptosis. Collectively, our findings show that ERβ agonists have the potential to significantly inhibit ovarian cancer cell growth and reduce stemness; therefore, ERβ agonists represent novel therapeutic agents for the management of ovarian cancer. Citation Format: Gangadhara Reddy Sareddy, Javier E. Chavez, Humberto Salazar, Monica Mann, Jocelyn Hernandez, Samaya Rajeshwari Krishnan, Edward Kost, Rajeshwar Rao Tekmal, Ratna K. Vadlamudi. Therapeutic efficacy of ERβ agonists on ovarian cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 606. doi:10.1158/1538-7445.AM2014-606