Sir Peter MacCallum Department of Oncology - Theses
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ItemIdentifying heterogenous mechanisms of drug resistance in high grade serous ovarian cancer( 2023-05)Ovarian, fallopian tube and primary peritoneal cancer is the sixth most common cause of cancer death for women in Australia. A diagnosis of ovarian cancer is life-altering with a five-year survival of only 45.7%. While clinical factors such as disease stage are important for prognosis and response to therapy, the underlying genomic, transcriptomic and immune characteristics of the tumour are also key determinants of outcome. High grade serous ovarian cancer (HGSC) is the most common epithelial ovarian cancer subtype, and is characterised by frequent germline, somatic and epigenetic aberrations which result in homologous recombination DNA repair (HR) deficiency. Aneuploidy and frequent somatic copy number aberrations (SCNA) are common features of the genomic landscape of HGSC. Despite often initially responding to therapy, acquired resistance is extremely common, arising through a variety of genomic, transcriptomic, adaptive and microenvironmental mechanisms. Owing to the scarcity of biopsies or surgery in relapsed disease, the frequency and distribution of these acquired resistance mechanisms is only partially known. In particular, there is a paucity of information about resistance mechanisms in late-stage disease following the multiple lines of therapy that a typical patient with HGSC receives. This thesis addressed these important gaps in knowledge by examining resistance mechanisms in a cohort of women with HR deficient HGSC who underwent a research autopsy, providing unique insight into the architecture of end stage disease. Importantly, resistance mechanisms were frequently subclonal, often with more than one mechanism detected within a single metastatic site. Evidence of convergent evolution was also observed, including of reversion mutations and BRCA1-specific mechanisms of HR restoration. An increased frequency of whole genome duplication, an important event in cancer evolution, was noted in the end-stage samples compared to what is known in primary tumours. Following this observation, the transcriptomic differences between tumours with and without WGD were assessed. Examination of the transcriptomic differences in whole genome duplication revealed downregulation of CIITA and other MHC-II genes, highlighting a potential means of immune escape and a potential therapeutic vulnerability. This thesis also examined mechanisms of resistance specifically occurring following receipt of poly-ADP ribose polymerase (PARP) inhibitor therapy, and the natural history and evolution of reversion mutations in HR deficient HGSC, showing that they are in fact not frequently present outside of a progressing or resistant cohort. The findings of this thesis add to the current knowledge of resistance to therapy, demonstrate the need for accessible genomic testing in the clinical management of HGSC and indicate that further exploration of resistance should focus on transcriptomics, epigenetics, and the tumour microenvironment.