Cliby, William A.

BACKGROUND: Learning objectives for gynecologic oncology (GO) fellowships have been created, however a standard curriculum does not exist. There is interest amongst program directors to develop a standardized curriculum with online teaching tools. This study was conducted to determine the learning needs of GO fellows and to assess the use of web-based teaching in this group of learners. METHODS: An 18 minute teaching module on surgical management of vulvar cancer was created and validated by experts. The module was then emailed to fellows with a pre and post-module survey. The survey assessed the learners needs, the learners knowledge and the usefulness of the module. RESULTS: One hundred ninety GO fellows were surveyed, 72 (38%) responses were received. Most participants were in their second year of clinical fellowship (42%). The majority of GO fellowships have a weekly teaching conference with faculty participation. Resources utilized by fellows for learning are textbooks and journal articles, with all responders ranking these as their first or second preferred resource. The teaching module was an effective teaching tool as demonstrated by improved scores across the four content based questions. The webinar was well received by the fellows, with 92% saying they liked this teaching tool and 46/48 (96%) felt that they would view additional presentations if provided. In addition 45/49 (92%) felt that this type of teaching filled a need in GO fellowship. DISCUSSION: Many GO fellowships utilize faculty directed teaching conferences. This online teaching tool improved fellow knowledge and additional modules would be well received in this population of learners.

Purpose To provide guidance to clinicians regarding the use of neoadjuvant chemotherapy and interval cytoreduction among women with stage IIIC or IV epithelial ovarian cancer. Methods The Society of Gynecologic Oncology and the American Society of Clinical Oncology convened an Expert Panel and conducted a systematic review of the literature. Results Four phase III clinical trials form the primary evidence base for the recommendations. The published studies suggest that for selected women with stage IIIC or IV epithelial ovarian cancer, neoadjuvant chemotherapy and interval cytoreduction are noninferior to primary cytoreduction and adjuvant chemotherapy with respect to overall and progression-free survival and are associated with less perioperative morbidity and mortality. Recommendations All women with suspected stage IIIC or IV invasive epithelial ovarian cancer should be evaluated by a gynecologic oncologist prior to initiation of therapy. The primary clinical evaluation should include a CT of the abdomen and pelvis, and chest imaging (CT preferred). Women with a high perioperative risk profile or a low likelihood of achieving cytoreduction to < 1 cm of residual disease (ideally to no visible disease) should receive neoadjuvant chemotherapy. Women who are fit for primary cytoreductive surgery, and with potentially resectable disease, may receive either neoadjuvant chemotherapy or primary cytoreductive surgery. However, primary cytoreductive surgery is preferred if there is a high likelihood of achieving cytoreduction to < 1 cm (ideally to no visible disease) with acceptable morbidity. Before neoadjuvant chemotherapy is delivered, all patients should have confirmation of an invasive ovarian, fallopian tube, or peritoneal cancer. Additional information is available at www.asco.org/NACT-ovarian-guideline and www.asco.org/guidelineswiki .

Abstract Background: In ovarian cancer (OC), the intraperitoneal fibrosis that accompanies metastasis is a common scenario and associated with significant morbidity and gut dysfunction. Accumulating evidences indicate that Transforming Growth Factor β (TGF-β) signaling pathway plays a key role in cancer associated fibrosis and metastasis. Several TGF-β inhibitors, including Galunisertib (LY2157299) which is a TGF-β receptor I inhibitor, are currently in clinical trials for fibrosis-related diseases and cancer. Our hypothesis is that targeted anti-cancer therapies can block the growth and spread of cancer or specifically address the fibrosis accompanying metastatic peritoneal cancer. In this study, we investigated the efficacy of Galunisertib in inhibiting OC fibrosis and metastasis in vitro. Methods: Five OC cell lines, including SKOV3ip, HeyA8, OVCAR8, OV2008, and PEO4, and one cancer-associated fibroblast (CAF) cell line, TRS3, were tested in this study. We utilized a co-culture system that has successfully been used to study the interactions between cancer cells and local environment, including CAFs. Twenty-three candidate TGF-β signaling- and fibrosis-related genes were selected based on previous studies. RNA and protein from both fibroblast cells and OC cells were collected for RT-qPCR and western blot analysis. MTT assay, Wound healing assay and Matrigel invasion assay were used to study OC cell proliferation, migration and invasion. Chou-Talalay assays were performed to study the interactions between Galunisertib and Carboplatin and Paclitaxel. Results: RT-qPCR results showed that Galunisertib treatment suppresses the expression of both TGF-β receptor I and TGF-β1 which is the most abundant isoform of TGF-β in OC. Western blot results showed that Galunisertib treatment reverses the TGF-β1-induced SMAD2/3 phosphorylation, confirming the efficacy of Galunisertib in TGF-β signaling pathway blockage. Intriguingly, Galunisertib treatment inhibits the expression of candidate fibrosis-related genes, like ACTA2, TIMP3, COL5A1, COL11A1, and VCAN in both OC and CAF cells. Would healing and Transwell invasion assay also demonstrated that Galunisertib treatment effectively reduces both basal and TGF-β1-induced cell migration and invasion (p&lt;0.05). MTT assay showed that Galunisertib is able to inhibit the proliferation of both OC and CAFs cells with IC50 values range from 100-400 μm. Additionally, Galunisertib shows strong synergistic effects with both Carboplatin and Paclitaxel in Chou-Talalay assays. Conclusion: Galunisertib treatment suppresses the expression of TGF-β-dependent fibrosis-related genes from OC cell lines and CAFs. Coincident with this inhibition of fibrosis related genes, galunisrtib reduces cell proliferation, migration, and invasion. These data suggest that targeting the TGF-β pathway is a viable therapeutic approach to reduce both symptoms related to OC-related fibrosis and cancer metastasis in OC. Citation Format: Qing Zhang, William A. Cliby. Galunisertib inhibits ovarian cancer cell fibrosis and metastasis in vitro. [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 3026.

Abstract Purpose: Ovarian cancer (OC) patients received maximum benefits when complete dissection with no macroscopic disease is achieved. It has been suggested that surgical outcome is associated with tumor biology and therefore can be predicted from tumor molecular characteristics such as gene expression levels. Noticeably, several debulking-associated genes have been independently reported based on meta-data analysis and further validations in individual center's cohorts. Furthermore, a recent OC study of the cancer genome atlas (TCGA) project revealed the presence of four expression subtypes in high-grade serous ovarian cancer (HGSOC). We have independently confirmed this association with prognosis in our OC cohort. With the awareness that surgical practices and rates of complete resection vary among institutions, we sought to evaluate whether expression changes of previously reported debulking-associated genes are associated with complete dissection in a HGSOC cohort in a center with an aggressive surgical approach. Further, we also tested if the HGSOC four expression subtypes are associated with complete dissection. Experimental Design: We constructed a cohort of 262 stage III/IV HGSOC patient cases diagnosed in Mayo Clinic between 1993 and 2011. Cases were categorized into two groups based upon debulking outcome: 84 complete resection cases with no gross visible residual disease (RD0), 178 cases with residual disease greater than 0 cm (RD1). Tumor mRNA expression was previously measured using Agilent 4x44k platforms. Eight previously published debulking-associated genes were evaluated for their expression differences between RD0 and RD1 patient groups using t-test: FABP4, ADH1B, POSTN, CXCL14, FAP, NUAK1, PTCH1 and TGFBR2. For testing subtype-debulking associations, we first quantified molecular subtype activation scores of individual tumors using single-sample gene set enrichment analysis (ssGSEA), and computed standardized scores after permutation-based scaling adjustments to account for gene set size difference. Then, standardized subtype scores are associated with complete dissection (RD0) vs. other surgical outcome (RD1) using logistic regression. The independent subtype-associations were further evaluated by adjusting known debulking outcome factors, including age, ascites, tumor grade and stage. Results: For eight previously reported debulking-associated genes, only one demonstrated a significant expression difference between RD0 and RD1 groups: CXCL14, t-test p-value = 9.2x10-3. When comparing debulking vs. HGSOC subtypes, we observed a significantly reduced probability of complete resection for the mesenchymal subtype (p-value = 1.1x10-2, OR = 0.56, 95% CI [0.35, 0.87]). Consistent with this observation, we have previously described the mesenchymal subtype as a poor prognosis group. On the other hand, the immunoreactive subtype was associated with a higher likelihood of complete resection (p-value = 9.4 x 10-3, OR=2.19, 95% CI = [1.22, 4.01]). The significant associations between these two subtype activities and complete resection in advanced stage disease remained after adjusting for age, ascites, tumor grade and sub-stage: mesenchymal (p-value = 1.5 x 10-2 ,OR = 0.48, 95% CI = [0.26, 0.85]); immunoreactive subtype (p-value = 4.8 x 10-2 , OR = 2.11, 95% CI = [1.04, 4.53]). Conclusion: This single center HGSOC analysis demonstrates the important of validation of debulking signatures in centers with diverse rates of complete resection. We were only able to validate an association with complete resection for one of eight previously reported debulking-associated genes. We also showed that HGSOC subtypes have significant associations with likelihood of complete dissection. Further studies are warranted for confirming subtype associations in other institutional HGSOC cohorts. Citation Format: Chen Wang, Jamie Bakkum-Gamez, Andrea Mariani, William Cliby, Ellen Goode. Tumor expression subtypes of high-grade serous ovarian cancer demonstrate associations with likelihood of complete resection: a single-center study. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research: Exploiting Vulnerabilities; Oct 17-20, 2015; Orlando, FL. Philadelphia (PA): AACR; Clin Cancer Res 2016;22(2 Suppl):Abstract nr B80.

ObjectiveTo evaluate the effect of body mass index on the surgical outcomes in ovarian cancer patients. In addition, we performed a systematic review to compare our outcomes with the current literature.DesignRetrospective cohort study and a systematic review of the literature.SettingGynaecology department at the Royal Cornwall Hospital Trust.PopulationSurgically managed stage I‐IV ovarian cancer patients between September 2006 and September 2014.MethodsPrimary and secondary outcome measures were evaluated across BMI categories; BMI <25 kg/m², BMI 25–29.9 kg/m², BMI ≥30 kg/m² and BMI ≥40 kg/m². A systematic review was performed according to Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA) guidelines.Main outcome measuresThe primary outcome measure was surgical complications. Secondary outcome measures were other intra‐ and postoperative outcomes.ResultsTwo hundred twenty‐eight women were included in the study, of which 84 had a BMI <25 kg/m², 84 women had a BMI 25–29.9 kg/m², and 60 women were obese (BMI ≥30 kg/m²), 13 of whom were morbidly obese. Morbid obesity was associated with increased rates of wound complications. However, BMI did not show an association with other outcomes. In the review, an increasing BMI was associated with increased rates of wound complications and prolonged hospital stay, but did not impact other surgical outcomes.ConclusionObesity is associated with increased rates of wound complications and a prolonged hospital stay, but does not appear to affect other operative outcomes including cytoreduction status and 30‐day mortality. Therefore, operative management and postoperative care require a multifactorial approach to minimise adverse outcomes.Tweetable abstractObesity is associated with more wound complications and prolonged hospital stay in ovarian cancer surgery.

Abstract Ovarian cancer (OC) is the fifth leading cause of cancer death in women in the US. Müllerian inhibiting substance (MIS) is a glycoprotein hormone that causes Müllerian duct regression through a complex of TGF- β family homologous receptors: a type II ligand-binding receptor (T2R) and a tissue-specific type I receptor (T1R) that initiates downstream signaling. MIS has been proposed as potential therapeutic agent in OC. We have previously shown that specific combination of T2R/T1R receptors are expressed on OC cells, however data is lacking on the MIS-dependent pathways activated in OC cells in a T1R-specific manner. These limitations hinder further development of MIS as a therapy. We sought to determine the downstream signaling pathways activated by MIS in a T1R specific manner. We designed a chimeric OC cell model system in which GM-CSF can function as the ligand to specifically activate candidate T2R/T1R combinations (MISRII with either ALK2, ALK3, or ALK6). RNA-Seq technology was used to identify differentially expressed early and late response genes. Over 15,032 genes were analyzed, restricted to genes in which there were &gt; 32 counts for duplicate samples. Pathway analysis was performed using Ingenuity's Integrative Pathway Analysis Tool (IPA) for genes which were expressed over 2 fold, with an False Discovery Rate (FDR)&lt;0.1 and log (Counts per Million, CPM)&gt;-0.001. We observed 56, 37, and 51 early response (1hr) genes which were up- or down-regulated after stimulation in OC cells engineered to express either ALK2, ALK3, and ALK6, respectively. We identified a subset of 18 of genes (e.g., ID1, SMAD7, FOSB) which were upregulated after treatment in all MISRII/T1R combinations, suggesting redundancy amongst the three T1R partner receptors. These observations will be confirmed by RT-qPCR and immunoblotting. A majority of these redundant genes are known to play roles in TGF-β signaling and cell proliferation pathways. Importantly, as we have previously shown that not all T1R candidates are expressed in OC, we report subsets of genes (e.g., RASSF6, C/EBPBβ, CSMD3) which were uniquely altered after stimulation only in the presence of a specific T1R. This indicates specific pathway activation is dependent upon T1R expression pattern in OC and likely determines response. In addition to previously known TGF- β signaling pathway, we found gene signatures (e.g. FOSB, RASSF6, LRP1B, ID1) suggesting pathways which affect cell proliferation, apoptosis, chemotherapy resistance, and DNA repair in response to MIS. This is the first study to begin to define the specific roles candidate T1R's play in signaling in response to MIS in an OC model. An understanding of these pathways is a necessary prerequisite to examining MIS as a therapy. These preliminary data suggest a role for MIS in apoptosis, cytotoxic drug resistance and DNA repair. This can be used to test combination therapy with currently available drugs and MIS in OC treatment. Citation Format: Qing Zhang, Eati Basal, Jaime I. Davila, Xueqian Yin, Edward B. Leof, William A. Cliby. Comparative RNA-Seq analysis of MIS signaling: Potential relevance as therapeutic strategy in ovarian cancer treatment. [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 3462. doi:10.1158/1538-7445.AM2014-3462