The -124C>T mutation of TERT promoter indicated a favorable prognosis in OCCC: a monoinstitutional study in China

The -124C>T mutation of TERT promoter indicated a favorable prognosis in OCCC: a monoinstitutional study in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The -124C>T mutation of TERT promoter indicated a favorable prognosis in OCCC: a monoinstitutional study in China Xiaonan Zhou, Yifei Liu, Jue Hu, Jing Zhang, Min Ren, Gang Ji, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3909705/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Ovarian clear cell carcinoma (OCCC) is the second most common type of epithelial ovarian cancer. Patients with advanced or recurrent OCCC were resistant to chemotherapy and had poor prognosis. The purpose of this study was to identify specific prognostic markers in ovarian clear cell carcinoma. Methods A cohort of 169 patients with OCCC were enrolled, and their clinicopathological features were reviewed. Mutations in the TERT promoter and PIK3CA gene were detected by Sanger sequencing in 87 and 109 cases, respectively. Immunohistochemical markers for ARID1A, HDAC6, Cyclin E1, and p53 were stained on the tissue microarrays. Kaplan-Meier curves and Cox regression analysis were used to assess the correlation between these parameters and prognosis. Results The overall survival (OS) and progression-free survival (PFS) of patients with the − 124 C > T mutation in the TERT promoter were significantly longer than those of wild-type patients. The − 124 C > T mutation was an independent factor associated with a favorable OS. Patients with the − 124 C > T mutation were more likely to have a normal preoperative serum CA125 level (P = 0.017), a higher prevalence of single nucleotide polymorphism (SNP) (P = 0.014), and a lower probability of relapse (P = 0.025) than wild-type patients. No correlation between other factors and prognosis was observed in this cohort. Conclusion Our results suggest that the − 124C > T mutation in the TERT promoter may serve as a favorable prognostic factor for overall survival in patients with OCCC. Ovarian clear cell carcinoma prognosis clinicopathological features TERT promotor mutation Figures Figure 1 Figure 2 1. Introduction Ovarian cancer is the leading cause of death from gynecologic cancers and the fifth leading cause of cancer death in women.(Siegel, Miller et al., 2023 ) Ovarian clear cell carcinoma (OCCC) is the second most common epithelial ovarian cancer and has increased significantly in the Southeast Asian population in recent years, with an incidence of 30% in Japan.. (Machida, Matsuo et al., 2019 , Tan, Ye et al., 2019 ) OCCC presents unique clinicopathological features and molecular alterations with frequent ARID1A , PIK3CA and TERT promoter ( TERT p) somatic alterations and usually coexist with endometriosis.(Bolton, Chen et al., 2022 , Zhu, Xu et al., 2021 ) Consistent with the standard treatment for high-grade serous ovarian cancer, staging surgery or optimal cytoreduction combined with chemotherapy is a major therapeutic approach for treating OCCC.(Armstrong, Alvarez et al., 2022 ) Despite favorable clinical outcomes in early-stage cases, patients with advanced or recurrent OCCC were resistant to chemotherapy and had a poor prognoses.(Iida, Okamoto et al., 2021 ) However, specific prognostic markers for OCCC are currently lacking. The prognostic significance of high-frequency mutations remains controversial.(Huang, Chiang et al., 2015 , Katagiri, Nakayama et al., 2012 , Rahman, Nakayama et al., 2012 ) Previous studies have suggested adverse effects on patient outcomes associated with abnormal expression of HDAC6, Cyclin E1, and p53.(Ayhan, Kuhn et al., 2017 , Parra-Herran, Bassiouny et al., 2019 , Yano, Katoh et al., 2019 ) However, these findings require further research. To search for prognostic markers, we conducted a relatively comprehensive study of commonly mutated genes and clinicopathological factors in OCCC to evaluate their clinical significance and prognostic value. 2. Materials and methods Patients and Tissue Samples This study included 176 patients of ovarian clear cell carcinoma who received treatment at Fudan University Shanghai Cancer Center (FUSCC) between 2000 and 2015. Finally, 169 patients were analyzed after the follow-up until May 2023. The following clinical information were extracted from the medical history and examination records: age, tumor size, lateral, ascites, preoperative serum CA125 level and Federation of Gynecology and Obstetrics (FIGO) stage. All international FIGO stages were reclassified according to the 2014 FIGO guidelines.(Mutch & Prat, 2014 ) We also examined the all slides of each case, and defined that the association of endometriosis was the endometriosis presented in any specimen not limited in the ovary. Tissue microarray (TMA) construction The TMA was prepared using 1mm triplicate core samples from 169 OCCCs to achieve a high level of standardization for immunohistochemical analysis as we have constructed and reported.(Ge, Xiao et al., 2021 ) Immunohistochemistry Immunohistochemical staining was performed using a TMA with protocols as previously described.(Ge et al., 2021 ) We performed the immunohistochemical staining for ARID1A, p53, HDAC6 (histone deacetylase6) and Cyclin E1. The details of the antibody were summarized in Supplementary Table 1. All staining results were reviewed by Dr Rui Bi. Expression of the stained markers was scored using a histologic score (H score) as previously described. (McCarty, Szabo et al., 1986 ) In briefly, the deficient ARID1A was interpreted as loss of expression that no tumor cells were stained.(Katagiri et al., 2012 ) HDAC6 was scored as 0 (0%), 1+ (1–50%), 2+ (51–80%), 3+ (81–100%).(Yano et al., 2019 ) Cyclin E1 overexpression defined diffuse and intense immunoreactivity in > 80% of tumor cells.(Ayhan et al., 2017 ) Abnormal p53 expression refers to overexpression (strong nuclear expression involving > 80% of tumor cell nuclei), complete absence of expression in tumor cell nuclei with retained internal control, or unequivocal cytoplasmic expression. DNA Extraction and Mutation Analysis We also extracted DNA from 3-um sections by QIAGEN DNA FFPE Tissue Kit (Qiagen, Shanghai, CA) according to the protocol of the manufacturer. The annealing temperature for all pairs of primers was 56°C. Sanger DNA sequencing was performed by Shenggong Bioengineering Co. Ltd (Shanghai, China) and sequencing data was analyzed using SnapGene version 6.0.2 software. All mutations detected were confirmed by re-sequencing. The primers of PIK3CA exon 9 and 20, and TERT p were summarized in Supplementary Table 2. Statistical Analysis Age and diameter were summarized as medians and interquartile ranges (IQRs), and other factors were summarized as numbers and percentages using the R package tableone. Comparisons between groups were made using the chi-squared test or Fisher's exact test (categorical data) and the Mann-Whitney test or Kruskal-Wallis test (continuous data). To identify independent prognostic factors, all significant variables in univariate Cox regression analysis ( P < 0.05) were subjected to multivariate Cox regression analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. Progression-free survival (PFS) and overall survival (OS) rates were calculated using the Kaplan-Meier method, followed by the log-rank test to determine significance. P < 0.05 was considered significant for all tests. All statistical analyses were performed with SPSS v25 and R v4.2.2. 3. Results 3.1 Patient characteristics and clinicopathological factors The clinicopathological features of the 169 OCCCs from FUSCC were summarized in Table 1 . Overall, the median age of our cohort was 53 years (range, 26 to 83 years) and the median maximal diameter was 11 cm (range, 2 to 35cm). Most tumors were FIGO stage I/II (67%) and unilateral (79%). One third (37%) of the patients had a history of endometriosis and half of the patients (50%) had ascites. Preoperative serum CA125 concentration was higher than normal in almost 80% (116/169) of patients. ARID1A deficiency was present in 54% (70/129) of cases. Abnormal expression of p53 occurred in 15% (25/165) of cases. HDAC6 expression was scored as 0, 1+, 2 + and 3 + and distributed in 36% (59/166), 22% (37/166), 24% (40/166) and 18% (30/166), respectively. Cyclin E1 overexpressed in 23% (38/167) OCCC. The rate of PIK3CA mutations was 56% (61/109), in which the exon9 and exon20 mutation rates were 48% (51/107) and 18% (20/109), respectively. We examined the − 124, -138, -146 hot mutation sites in the TERT p with mutation rates of 22% (19/87), 1% (1/87) and 5% (4/87), respectively. The single nucleotide polymorphism (SNP) (rs2853669) at -245 bp of the TERT p region was also genotyped in 81 patients of our cohort, in which 62% (50/81) of patients carried the allelic variant. Table 1 The clinicopathological characteristics of 169 OCCCs. Variables Overall Age (median [IQR]) 53 [48, 58] Diameter (median [IQR]) 11 [7, 15] FIGO Stage (%) I/II 113 (67) III/IV 56 (33) Lateral (%) Bilateral 35 (21) Unilateral 134 (79) Endometriosis (%) absent 107 (63) present 62 (37) Ascites (%) absent 85 (50) present 84 (50) CA125 (%) normal 30 (20) abnormal 116 (80) ARID1A (%) Intact 59 (46) Deficient 70 (54) p53 (%) Negative 140 (85) Positive 25 (15) HDAC6(%) 0 59 (36) 1 37 (22) 2 40 (24) 3 30 (18) Cyclin E1 (%) Negative 129 (77) Positive 38 (23) PIK3CA (%) Wild-type 48 (44) Mutated 61 (56) Exon9 (%) Wild-type 56 (52) Mutated 51 (48) Exon20 (%) Wild-type 89 (82) Mutated 20 (18) TERT p(%) Wild-type 64 (74) Mutated 23 (26) -124C > T (%) Wild-type 68 (78) Mutated 19 (22) -138C > T (%) Wild-type 86 (99) Mutated 1 (1) -146C > T (%) Wild-type 83 (95) Mutated 4 (5) rs2853669 SNP (%) Noncarrier 31 (38) Carrier 50 (62) 3.2 Prognostic factors in OCCC All variables significant on univariate Cox regression analysis ( P T mutation were the independent prognostic factors for OS in OCCC. Multivariate analyses confirmed the negative effect of FIGO stage and the positive effect of -124 C > T mutation on prognosis, with HRs for death of 14.968 (95% CI: 5.729–39.107; P < 0.001) and 0.216 (95% CI: 0.050–0.934; P = 0.040), respectively (Fig. 1 A). In addition, with an HR for disease progression of 8.466 (95% CI: 4.074–17.594; P T mutation showed significantly better OS ( P = 0.023) and PFS ( P = 0.035) compared with − 124C > T wild-type (Fig. 2 A, 2 B). After adjusting the stage in the multivariate analysis, patients with the − 124 C > T mutation had longer OS in advanced-stage, whereas OS was not statistically different between − 124 C > T TERT p-mutated and TERT p-wildtype patients in early-stage(Supplementary Fig. 1F,1G). In addition, the patients with early stage, unilateral tumour, no ascites, a normal preoperative CA125 level and p53 normal staining had a better OS and PFS compared to patients with advanced-stage, bilateral tumour, ascites, a higher preoperative CA125 level and p53 abnormal staining (Supplementary Fig. 1A-E, Supplementary Fig. 2A-E). To determine the possible influence of different TERT p mutations on prognosis, we examined the association between TERT p status and OS and PFS. The OS and PFS of OCCC with the − 124 C > T TERT p mutation were significantly longer than that of the wild type ( P = 0.026, P = 0.036, respectively) (Fig. 2 C, 2 D). Compared to patients with the − 146 C > T mutation, patients with the − 124 C > T mutation had a significantly longer OS ( P = 0.036) (Fig. 2 C). Although there was no statistical difference, patients carrying the − 146 C > T mutation tended to have worse OS (Fig. 1 C). 3.3 Correlation between − 124C > T mutations and other clinicopathological factors in OCCC Statistical analysis was performed using χ2 and Fisher exact tests to identify the correlations between the − 124 C > T mutation and other clinicopathological factors. Patients with the − 124 C > T mutation were more likely to have a normal preoperative serum CA125 level ( P = 0.017, Table 2 ), a higher prevalence of SNP ( P = 0.014, Table 2 ) and a less likely to relapse ( P = 0.025, Table 2 ) than the wild-type patients. However, TERT p mutation was not significantly associated with age, maximum diameter, stage, lateral, endometriosis, ascites, expression of ARID1A , HDAC6, Cyclin E1 and mutations of PIK3CA gene or the − 146 C > T mutation of TERT p. Table 2 Correlation between − 124C > T mutations and other clinicopathological factors in OCCC level Wild-type Mutated p Test N 68 19 CA125 (%) Normal 8 (14) 8 (44) 0.017 exact High 50 (86) 10 (56) SNP (%) Noncarrier 30 (44) 1 (8) 0.014 exact Carrier 38 (56) 12 (92) Recurrence (%) No 34 (50) 15 (79) 0.025 χ2 test Yes 34 (50) 4 (21) 4. Discussion In the present study, we investigated the prognostic significance of clinicopathological factors in patients with OCCC treated at our institution over a period of 23 years. We observed that the rates of ARID1A loss expression and somatic driver mutations of PIK3CA and TERT p to be 54% (70/129), 56% (61/109) and 26% (23/87), respectively. A large-scale sequencing of putative somatic driver mutations in 401 OCCC tumors showed that the mutation of the PIK3CA and TERT p genes were 49% and 20%, which were slightly lower than ours.(Bolton et al., 2022 ) In general, TERT p mutations correlate with increased TERT mRNA levels and increased telomerase activity.(Roake & Artandi, 2020 ) The primary TERT promoter ( TERT p) mutations occur at positions 1,295,228 (-124 C > T) and 1,295,250 (-146 C > T).(Hafezi & Perez Bercoff, 2020 ) Consistent with previous studies, the − 124 C > T mutation predominated among TERT p mutations with a mutation rate of 21.8%. (Boscolo-Rizzo, Tirelli et al., 2023 , Giunco, Boscolo-Rizzo et al., 2021 , Giunco, Padovan et al., 2023 , Huang et al., 2015 , Liu, Bishop et al., 2013 , Nishikimi, Nakagawa et al., 2018 , Spiegl-Kreinecker, Lotsch et al., 2015 ) The − 124 C > T mutation and stage were independent prognostic factor for OS in our cohort. Patients with the − 124 C > T mutation showed significantly longer PFS and OS than wild-type patients, and more likely to have a normal preoperative serum CA125 level, had a higher prevalence of SNP and less likely to relapse. Compared to other histological types of ovarian cancer, clear cell carcinomas have longer mean relative telomere lengths, and longer telomeres are associated with increased mortality.(Kuhn, Meeker et al., 2011 ) Ovarian clear cell carcinoma cell lines with the − 124C > T mutation in the TERT promoter ( TERT p) demonstrated elevated TERT mRNA expression compared to cell lines without the TERT p mutation. (Wu, Ayhan et al., 2014 ) Another study reported that the TERT p hotspot mutations (-124C > T and − 146C > T) had a higher promoter activity than the wild-type, and the promoter activity of the uncommon site mutations was the lowest. (Kobayashi, Nishikimi et al., 2023 ) Furthermore, TERT expression increased with tumor grade and stage. (Maraei, Hatta et al., 2012 ) However, the impact of TERT p mutations on patient outcomes in OCCC remains unclear. Huang et al found that TERT p mutation was an independent prognostic factor that correlated with shorter disease-free survival (DFS) and overall survival in early-stage patients.(Huang et al., 2015 ) Recently, Yoo et al demonstrated that TERT p mutations had significant prognostic value in predicting tumor recurrence, platinum resistance, and DFS in patients with OCCC.(Yoo H, 2023) A similar conclusion from Irshaid et al reported that a TERT p mutation could be further stratified as high-risk OCCC in the no specific molecular profile subgroup.(Irshaid, Costigan et al., 2023 ) In contrast to the above research, Kobayashi et al reported that the progression-free survival rate of the “enhancer-type” group including the hotspot mutations of TERT p was significantly longer than that of the wild-type and “suppressor-type” (with uncommon mutations) mutation groups.(Kobayashi et al., 2023 ) While no significant difference in disease-specific overall survival was observed between patients with and without TERT p hotspot mutations in the cohorts of Nishikimi et al and Wu et al.(Nishikimi et al., 2018 , Wu et al., 2014 ) In our study, patients with the − 124C > T mutation had longer PFS and OS than those with wild-type. We further analyzed the correlation between the two different hotspot mutations and prognosis. In addition, we have a longer observation period. This favorable prognosis associated with TERT p has also been demonstrated in some subgroups of medulloblastoma, glioma and melanoma. (Blateau, Coyaud et al., 2020 , Remke, Ramaswamy et al., 2013 , Yang, Cai et al., 2016 ) The prognostic and predictive role of TERT p mutations is complex, and may be related to tumor heterogeneity and diverse molecular backgrounds. The effect of the TERT p mutations on survival might be modified by a SNP at the mutation sites. The variant allele of the rs2853669 polymorphism decreased promoter activity in the presence of TERT p mutations, especially in the cases with − 124 C > T mutation, ultimately improving patients’ prognosis.(Rachakonda, Hosen et al., 2013 ) In our study, the − 124 C > T mutation was mainly accompanied by SNP. TERT p mutations might increase tumor immunogenicity. Analysis of pan-cancer cell lines revealed an expression signature of TERT p mutation dominated by epithelial-to-mesenchymal transition (EMT) and MAPK signaling.(Stern, Hibshman et al., 2020 ) In lung cancer, high EMT scores were associated with the increased expression of immune checkpoints.(Mak, Tong et al., 2016 ) Patients harboring TERT p mutations tended to show increased PD-L1 expression in glioma.(Holzl, Hutarew et al., 2021 ) Additional confounding factors such as MGMT promoter methylation, may influence patient survival in association with TERT p mutation status. Methylation of MGMT promoter significantly increased the PFS and OS of the patients with TERT p mutations in glioblastoma.(Arita, Yamasaki et al., 2016 ) Furthermore, the different prognosis between the − 124 C > T and − 146 C > T mutation may be attributed to different functions.(Li, Zhou et al., 2015 ) Further research is needed to be done to understand how TERT p mutations affect patient prognosis. ARID1A encodes an accessory subunit of the SWI/SNF chromatin remodeling complex, which exhibited a high frequency of mutations in OCCC.(Fukumoto, Magno et al., 2018 ) In a comprehensive study involving 1,432 patients with endometrium-related gynecological cancers, loss of ARID1A expression predicted shorter progression free survival.(Katagiri et al., 2012 , Liu, Xu et al., 2017 ) Studies have demonstrated that ARID1A directly represses HDAC6 gene transcription, and mutations in ARID1A and TP53 are mutually exclusive.(Bitler, Wu et al., 2017 , Guan, Wang et al., 2011 ) Additionally, high HDAC6 expression had an adverse effect on the PFS in patients with ARID1A loss.(Yano et al., 2019 ) Futhermore, PIK3CA mutations were significantly associated with a favorable overall survival in a cohort of 56 Japanese patients with OCCC.(Rahman et al., 2012 ) Huang et al reported a significant correlation between loss of ARID1A expression and PI3K-Akt signaling pathway activation.(Huang, Lin et al., 2014 ) In previous studies, TERT p mutations with loss of ARID1A expression or PIK3CA mutations in OCCC were mutually exclusive.(Huang et al., 2015 , Wu et al., 2014 ) Cyclin E1 is a highly conserved cell cycle regulation protein, and its overexpression is closely correlated with TERT p mutations and poor outcomes in stage I patients.(Ayhan et al., 2017 ) However, these associations were not found in our study with larger samples. In conclusion, we assessed the prognostic value of common gene mutations and clinicopathological factors in OCCC and found that the − 124 C > T mutation of TERT p represented a favorable prognostic factor for OS in OCCC. However, further studies are required to elucidate the molecular mechanisms by which TERT p mutation affect the prognosis of patients with OCCC. Declarations Funding This work was supported by grants from the National Natural Foundation Science of China (NSFC 81802597). Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Xiaonan Zhou, Yifei Liu and Rui Bi. JH, JZ, RM,JG and XC contributed to the methodology. The first draft of the manuscript was written by Xiaonan Zhou and Rui Bi. All authors commented on previous versions of the manuscript. 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Proc Natl Acad Sci U S A 110: 17426-31 Rahman M, Nakayama K, Rahman MT, Nakayama N, Ishikawa M, Katagiri A, Iida K, Nakayama S, Otsuki Y, Shih Ie M, Miyazaki K (2012) Clinicopathologic and biological analysis of PIK3CA mutation in ovarian clear cell carcinoma. Hum Pathol 43: 2197-206 Remke M, Ramaswamy V, Peacock J, Shih DJ, Koelsche C, Northcott PA, Hill N, Cavalli FM, Kool M, Wang X, Mack SC, Barszczyk M, Morrissy AS, Wu X, Agnihotri S, Luu B, Jones DT, Garzia L, Dubuc AM, Zhukova N et al. (2013) TERT promoter mutations are highly recurrent in SHH subgroup medulloblastoma. Acta Neuropathol 126: 917-29 Roake CM, Artandi SE (2020) Regulation of human telomerase in homeostasis and disease. Nat Rev Mol Cell Biol 21: 384-397 Siegel RL, Miller KD, Wagle NS, Jemal A (2023) Cancer statistics, 2023. CA Cancer J Clin 73: 17-48 Spiegl-Kreinecker S, Lotsch D, Ghanim B, Pirker C, Mohr T, Laaber M, Weis S, Olschowski A, Webersinke G, Pichler J, Berger W (2015) Prognostic quality of activating TERT promoter mutations in glioblastoma: interaction with the rs2853669 polymorphism and patient age at diagnosis. Neuro Oncol 17: 1231-40 Stern JL, Hibshman G, Hu K, Ferrara SE, Costello JC, Kim W, Tamayo P, Cech TR, Huang FW (2020) Mesenchymal and MAPK Expression Signatures Associate with Telomerase Promoter Mutations in Multiple Cancers. Mol Cancer Res 18: 1050-1062 Tan TZ, Ye J, Yee CV, Lim D, Ngoi NYL, Tan DSP, Huang RY (2019) Analysis of gene expression signatures identifies prognostic and functionally distinct ovarian clear cell carcinoma subtypes. EBioMedicine 50: 203-210 Wu RC, Ayhan A, Maeda D, Kim KR, Clarke BA, Shaw P, Chui MH, Rosen B, Shih Ie M, Wang TL (2014) Frequent somatic mutations of the telomerase reverse transcriptase promoter in ovarian clear cell carcinoma but not in other major types of gynaecological malignancy. J Pathol 232: 473-81 Yang P, Cai J, Yan W, Zhang W, Wang Y, Chen B, Li G, Li S, Wu C, Yao K, Li W, Peng X, You Y, Chen L, Jiang C, Qiu X, Jiang T, project C (2016) Classification based on mutations of TERT promoter and IDH characterizes subtypes in grade II/III gliomas. Neuro Oncol 18: 1099-108 Yano M, Katoh T, Miyazawa M, Miyazawa M, Ogane N, Miwa M, Hasegawa K, Narahara H, Yasuda M (2019) Clinicopathological correlation of ARID1A status with HDAC6 and its related factors in ovarian clear cell carcinoma. Sci Rep 9: 2397 Yoo H KH (2023) Clinicopathological and Prognostic Values of Telomerase Reverse Transcriptase (TERT) Promoter Mutations in Ovarian Clear Cell Carcinoma for Predicting Tumor Recurrence, Platinum Resistance and Survival. . Cancer Genomics Proteomics 20: 626-636 Zhu C, Xu Z, Zhang T, Qian L, Xiao W, Wei H, Jin T, Zhou Y (2021) Updates of Pathogenesis, Diagnostic and Therapeutic Perspectives for Ovarian Clear Cell Carcinoma. J Cancer 12: 2295-2316 Additional Declarations No competing interests reported. Supplementary Files SupplementaryFigure1.pdf Figure S1: Kaplan-Meier survival curves for OS of ovarian clear cell carcinoma (OCCC) patients. SupplementaryFigure2.pdf Figure S2: Kaplan-Meier survival curves for PFS of ovarian clear cell carcinoma (OCCC) patients. SupplementaryTables.xlsx Table S1. List of antibodies were used in this study; Table S2. List of primers were used in this study; Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3909705","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":270390777,"identity":"d0a16549-f4da-4529-8f0c-95c2cc4ee6cb","order_by":0,"name":"Xiaonan Zhou","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center, Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Xiaonan","middleName":"","lastName":"Zhou","suffix":""},{"id":270390778,"identity":"1c386398-8561-4b24-8c75-384a375ba92e","order_by":1,"name":"Yifei Liu","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center, Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Yifei","middleName":"","lastName":"Liu","suffix":""},{"id":270390779,"identity":"6c3aaae8-9b44-46e3-b2e0-fac74edf485a","order_by":2,"name":"Jue Hu","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center, Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Jue","middleName":"","lastName":"Hu","suffix":""},{"id":270390780,"identity":"ee58a85e-63ff-42a2-b4ff-546b17630c34","order_by":3,"name":"Jing Zhang","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center, Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Zhang","suffix":""},{"id":270390781,"identity":"e34e9e84-e7d7-422f-867d-1be2840f0067","order_by":4,"name":"Min Ren","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center, Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Ren","suffix":""},{"id":270390782,"identity":"ae5da363-dc25-4427-8584-977f437c5c48","order_by":5,"name":"Gang Ji","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center, Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Gang","middleName":"","lastName":"Ji","suffix":""},{"id":270390783,"identity":"47b6b2b8-fc40-4578-9d4e-cca1c8b9aeff","order_by":6,"name":"Xu Cai","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center, Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Cai","suffix":""},{"id":270390784,"identity":"62b2148a-cd8a-4124-af4f-61096572d96b","order_by":7,"name":"Rui Bi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAqklEQVRIiWNgGAWjYBACAyD+wMPAIMfG3n6AaC2MM4BajPl4ziSQpiVxnoSDAXFazKUPMDa8qbFLb5NgSGD4UbGNsBbLvgTGxjnHknPbpBsPMPacuU2Ew84wsD/mbTiQ2yZzIIGZsY04LYzNQC3pbBIJBqRpSSBei2UPA9gvhm3AQD5IlF/MeRjAISYv395+8MGPCiK0MDDwf4AzDxCjfhSMglEwCkYBEQAABas4nPIWc/UAAAAASUVORK5CYII=","orcid":"","institution":"Fudan University Shanghai Cancer Center, Fudan University","correspondingAuthor":true,"prefix":"","firstName":"Rui","middleName":"","lastName":"Bi","suffix":""}],"badges":[],"createdAt":"2024-01-30 06:29:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3909705/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3909705/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50576318,"identity":"d920b901-1ab9-4d1a-9602-0ae5e1141610","added_by":"auto","created_at":"2024-02-02 17:41:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":423543,"visible":true,"origin":"","legend":"\u003cp\u003eUnivariate analysis and multivariate cox regression analysis of clinicopathological factors in OCCC. (Attached with forest plots). A. Univariate and multivariate cox regression analysis for OS. B. Univariate and multivariate cox regression analysis for PFS. Abbreviations: Cl, confidence interval; HR, hazard ratio.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3909705/v1/3653c216c00e705f18f42c26.png"},{"id":50576319,"identity":"4fb38a7e-c01d-43a4-ad0f-652e149e0765","added_by":"auto","created_at":"2024-02-02 17:41:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":481621,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier survival curves for OS and PFS of ovarian clear cell carcinoma (OCCC) patients. A. Kaplan-Meier analysis of the -124C\u0026gt;T mutation for OS. B. Kaplan-Meier analysis of the -124C\u0026gt;T mutation for PFS. C. Kaplan -Meier analysis among wild -type, -124C\u0026gt;T mutation and -146C\u0026gt;T mutation for OS. D. Kaplan-Meier analysis among wildtype, -124C\u0026gt;T mutation and-146C\u0026gt;T mutation for OS. *: p\u0026lt;0.05. The significance of the prognostic value was tested by a log-rank test.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3909705/v1/119180a48ba396e92b3b86f6.png"},{"id":51812155,"identity":"d052db8e-e565-4950-932f-60146691bbeb","added_by":"auto","created_at":"2024-02-29 13:07:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":868649,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3909705/v1/38ad3778-35af-4c1d-8d35-a74a078e9a1e.pdf"},{"id":50576321,"identity":"e8a4385e-c2e2-428f-9f3c-abc7c0a6e9bb","added_by":"auto","created_at":"2024-02-02 17:41:16","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":675766,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure S1\u003c/strong\u003e: Kaplan-Meier survival curves for OS of ovarian clear cell carcinoma (OCCC) patients.\u003c/p\u003e","description":"","filename":"SupplementaryFigure1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3909705/v1/23f4ffc7b7c878b671dd3ad5.pdf"},{"id":50576322,"identity":"b2bf63b4-84f5-4fc0-8957-4762d475436d","added_by":"auto","created_at":"2024-02-02 17:41:16","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":614263,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure S2\u003c/strong\u003e: Kaplan-Meier survival curves for PFS of ovarian clear cell carcinoma (OCCC) patients.\u003c/p\u003e","description":"","filename":"SupplementaryFigure2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3909705/v1/08ef3ac75fa3c3b077adfb8f.pdf"},{"id":50576320,"identity":"4f6063b0-bfc2-4c0d-98ff-f0725b67937c","added_by":"auto","created_at":"2024-02-02 17:41:16","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":10318,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable S1\u003c/strong\u003e. List of antibodies were used in this study; \u003cstrong\u003eTable S2\u003c/strong\u003e. List of primers were used in this study;\u003c/p\u003e","description":"","filename":"SupplementaryTables.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-3909705/v1/9644e46256984900312633bf.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The -124C\u003eT mutation of TERT promoter indicated a favorable prognosis in OCCC: a monoinstitutional study in China","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eOvarian cancer is the leading cause of death from gynecologic cancers and the fifth leading cause of cancer death in women.(Siegel, Miller et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) Ovarian clear cell carcinoma (OCCC) is the second most common epithelial ovarian cancer and has increased significantly in the Southeast Asian population in recent years, with an incidence of 30% in Japan.. (Machida, Matsuo et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e, Tan, Ye et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) OCCC presents unique clinicopathological features and molecular alterations with frequent \u003cem\u003eARID1A\u003c/em\u003e, \u003cem\u003ePIK3CA\u003c/em\u003e and \u003cem\u003eTERT\u003c/em\u003e promoter (\u003cem\u003eTERT\u003c/em\u003ep) somatic alterations and usually coexist with endometriosis.(Bolton, Chen et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e, Zhu, Xu et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) Consistent with the standard treatment for high-grade serous ovarian cancer, staging surgery or optimal cytoreduction combined with chemotherapy is a major therapeutic approach for treating OCCC.(Armstrong, Alvarez et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) Despite favorable clinical outcomes in early-stage cases, patients with advanced or recurrent OCCC were resistant to chemotherapy and had a poor prognoses.(Iida, Okamoto et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHowever, specific prognostic markers for OCCC are currently lacking. The prognostic significance of high-frequency mutations remains controversial.(Huang, Chiang et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2015\u003c/span\u003e, Katagiri, Nakayama et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2012\u003c/span\u003e, Rahman, Nakayama et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) Previous studies have suggested adverse effects on patient outcomes associated with abnormal expression of HDAC6, Cyclin E1, and p53.(Ayhan, Kuhn et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e, Parra-Herran, Bassiouny et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2019\u003c/span\u003e, Yano, Katoh et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) However, these findings require further research. To search for prognostic markers, we conducted a relatively comprehensive study of commonly mutated genes and clinicopathological factors in OCCC to evaluate their clinical significance and prognostic value.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cp\u003e \u003cb\u003ePatients and Tissue Samples\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study included 176 patients of ovarian clear cell carcinoma who received treatment at Fudan University Shanghai Cancer Center (FUSCC) between 2000 and 2015. Finally, 169 patients were analyzed after the follow-up until May 2023.\u003c/p\u003e \u003cp\u003eThe following clinical information were extracted from the medical history and examination records: age, tumor size, lateral, ascites, preoperative serum CA125 level and Federation of Gynecology and Obstetrics (FIGO) stage. All international FIGO stages were reclassified according to the 2014 FIGO guidelines.(Mutch \u0026amp; Prat, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) We also examined the all slides of each case, and defined that the association of endometriosis was the endometriosis presented in any specimen not limited in the ovary.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTissue microarray (TMA) construction\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe TMA was prepared using 1mm triplicate core samples from 169 OCCCs to achieve a high level of standardization for immunohistochemical analysis as we have constructed and reported.(Ge, Xiao et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eImmunohistochemistry\u003c/b\u003e \u003c/p\u003e \u003cp\u003eImmunohistochemical staining was performed using a TMA with protocols as previously described.(Ge et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) We performed the immunohistochemical staining for ARID1A, p53, HDAC6 (histone deacetylase6) and Cyclin E1. The details of the antibody were summarized in Supplementary Table\u0026nbsp;1. All staining results were reviewed by Dr Rui Bi. Expression of the stained markers was scored using a histologic score (H score) as previously described. (McCarty, Szabo et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e1986\u003c/span\u003e) In briefly, the deficient ARID1A was interpreted as loss of expression that no tumor cells were stained.(Katagiri et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) HDAC6 was scored as 0 (0%), 1+ (1\u0026ndash;50%), 2+ (51\u0026ndash;80%), 3+ (81\u0026ndash;100%).(Yano et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) Cyclin E1 overexpression defined diffuse and intense immunoreactivity in \u0026gt;\u0026thinsp;80% of tumor cells.(Ayhan et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) Abnormal p53 expression refers to overexpression (strong nuclear expression involving\u0026thinsp;\u0026gt;\u0026thinsp;80% of tumor cell nuclei), complete absence of expression in tumor cell nuclei with retained internal control, or unequivocal cytoplasmic expression.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDNA Extraction and Mutation Analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe also extracted DNA from 3-um sections by QIAGEN DNA FFPE Tissue Kit (Qiagen, Shanghai, CA) according to the protocol of the manufacturer. The annealing temperature for all pairs of primers was 56\u0026deg;C. Sanger DNA sequencing was performed by Shenggong Bioengineering Co. Ltd (Shanghai, China) and sequencing data was analyzed using SnapGene version 6.0.2 software. All mutations detected were confirmed by re-sequencing. The primers of \u003cem\u003ePIK3CA\u003c/em\u003e exon 9 and 20, and \u003cem\u003eTERT\u003c/em\u003ep were summarized in Supplementary Table\u0026nbsp;2.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical Analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAge and diameter were summarized as medians and interquartile ranges (IQRs), and other factors were summarized as numbers and percentages using the R package tableone. Comparisons between groups were made using the chi-squared test or Fisher's exact test (categorical data) and the Mann-Whitney test or Kruskal-Wallis test (continuous data). To identify independent prognostic factors, all significant variables in univariate Cox regression analysis (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05) were subjected to multivariate Cox regression analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. Progression-free survival (PFS) and overall survival (OS) rates were calculated using the Kaplan-Meier method, followed by the log-rank test to determine significance. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant for all tests. All statistical analyses were performed with SPSS v25 and R v4.2.2.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Patient characteristics and clinicopathological factors\u003c/h2\u003e \u003cp\u003eThe clinicopathological features of the 169 OCCCs from FUSCC were summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Overall, the median age of our cohort was 53 years (range, 26 to 83 years) and the median maximal diameter was 11 cm (range, 2 to 35cm). Most tumors were FIGO stage I/II (67%) and unilateral (79%). One third (37%) of the patients had a history of endometriosis and half of the patients (50%) had ascites. Preoperative serum CA125 concentration was higher than normal in almost 80% (116/169) of patients.\u003c/p\u003e \u003cp\u003eARID1A deficiency was present in 54% (70/129) of cases. Abnormal expression of p53 occurred in 15% (25/165) of cases. HDAC6 expression was scored as 0, 1+, 2\u0026thinsp;+\u0026thinsp;and 3\u0026thinsp;+\u0026thinsp;and distributed in 36% (59/166), 22% (37/166), 24% (40/166) and 18% (30/166), respectively. Cyclin E1 overexpressed in 23% (38/167) OCCC. The rate of \u003cem\u003ePIK3CA\u003c/em\u003e mutations was 56% (61/109), in which the exon9 and exon20 mutation rates were 48% (51/107) and 18% (20/109), respectively. We examined the \u0026minus;\u0026thinsp;124, -138, -146 hot mutation sites in the \u003cem\u003eTERT\u003c/em\u003ep with mutation rates of 22% (19/87), 1% (1/87) and 5% (4/87), respectively. The single nucleotide polymorphism (SNP) (rs2853669) at -245 bp of the \u003cem\u003eTERT\u003c/em\u003ep region was also genotyped in 81 patients of our cohort, in which 62% (50/81) of patients carried the allelic variant.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe clinicopathological characteristics of 169 OCCCs.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 [48, 58]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiameter (median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 [7, 15]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFIGO Stage (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI/II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e113 (67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIII/IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e134 (79)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometriosis (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eabsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107 (63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscites (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eabsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCA125 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eabnormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116 (80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eARID1A (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep53 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140 (85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHDAC6(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCyclin E1 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129 (77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePIK3CA\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWild-type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMutated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExon9 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWild-type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMutated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExon20 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWild-type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMutated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTERT\u003c/em\u003e p(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWild-type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMutated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-124C\u0026thinsp;\u0026gt;\u0026thinsp;T (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWild-type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMutated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-138C\u0026thinsp;\u0026gt;\u0026thinsp;T (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWild-type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (99)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMutated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-146C\u0026thinsp;\u0026gt;\u0026thinsp;T (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWild-type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMutated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ers2853669 SNP (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNoncarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Prognostic factors in OCCC\u003c/h2\u003e \u003cp\u003eAll variables significant on univariate Cox regression analysis (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were subjected to multivariate Cox regression analysis. FIGO Stage and \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation were the independent prognostic factors for OS in OCCC. Multivariate analyses confirmed the negative effect of FIGO stage and the positive effect of -124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation on prognosis, with HRs for death of 14.968 (95% CI: 5.729\u0026ndash;39.107; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and 0.216 (95% CI: 0.050\u0026ndash;0.934; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.040), respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). In addition, with an HR for disease progression of 8.466 (95% CI: 4.074\u0026ndash;17.594; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), FIGO stage was the independent prognostic factor for PFS in OCCC (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Kaplan-Meier survival analysis revealed that presence of the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation showed significantly better OS (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.023) and PFS (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.035) compared with \u0026minus;\u0026thinsp;124C\u0026thinsp;\u0026gt;\u0026thinsp;T wild-type (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). After adjusting the stage in the multivariate analysis, patients with the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation had longer OS in advanced-stage, whereas OS was not statistically different between \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T \u003cem\u003eTERT\u003c/em\u003ep-mutated and \u003cem\u003eTERT\u003c/em\u003ep-wildtype patients in early-stage(Supplementary Fig.\u0026nbsp;1F,1G). In addition, the patients with early stage, unilateral tumour, no ascites, a normal preoperative CA125 level and p53 normal staining had a better OS and PFS compared to patients with advanced-stage, bilateral tumour, ascites, a higher preoperative CA125 level and p53 abnormal staining (Supplementary Fig.\u0026nbsp;1A-E, Supplementary Fig.\u0026nbsp;2A-E).\u003c/p\u003e \u003cp\u003eTo determine the possible influence of different \u003cem\u003eTERT\u003c/em\u003ep mutations on prognosis, we examined the association between \u003cem\u003eTERT\u003c/em\u003ep status and OS and PFS. The OS and PFS of OCCC with the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T \u003cem\u003eTERT\u003c/em\u003ep mutation were significantly longer than that of the wild type (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036, respectively) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). Compared to patients with the \u0026minus;\u0026thinsp;146 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation, patients with the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation had a significantly longer OS (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). Although there was no statistical difference, patients carrying the \u0026minus;\u0026thinsp;146 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation tended to have worse OS (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Correlation between \u0026minus;\u0026thinsp;124C\u0026thinsp;\u0026gt;\u0026thinsp;T mutations and other clinicopathological factors in OCCC\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using χ2 and Fisher exact tests to identify the correlations between the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation and other clinicopathological factors. Patients with the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation were more likely to have a normal preoperative serum CA125 level (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), a higher prevalence of SNP (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and a less likely to relapse (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) than the wild-type patients. However, \u003cem\u003eTERT\u003c/em\u003ep mutation was not significantly associated with age, maximum diameter, stage, lateral, endometriosis, ascites, expression of \u003cem\u003eARID1A\u003c/em\u003e, HDAC6, Cyclin E1 and mutations of \u003cem\u003ePIK3CA\u003c/em\u003e gene or the \u0026minus;\u0026thinsp;146 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation of \u003cem\u003eTERT\u003c/em\u003ep.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation between \u0026minus;\u0026thinsp;124C\u0026thinsp;\u0026gt;\u0026thinsp;T mutations and other clinicopathological factors in OCCC\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003elevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWild-type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMutated\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTest\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCA125\u003c/b\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eexact\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSNP\u003c/b\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNoncarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eexact\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecurrence\u003c/b\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eχ2 test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn the present study, we investigated the prognostic significance of clinicopathological factors in patients with OCCC treated at our institution over a period of 23 years. We observed that the rates of \u003cem\u003eARID1A\u003c/em\u003e loss expression and somatic driver mutations of \u003cem\u003ePIK3CA\u003c/em\u003e and \u003cem\u003eTERT\u003c/em\u003ep to be 54% (70/129), 56% (61/109) and 26% (23/87), respectively. A large-scale sequencing of putative somatic driver mutations in 401 OCCC tumors showed that the mutation of the \u003cem\u003ePIK3CA\u003c/em\u003e and \u003cem\u003eTERT\u003c/em\u003ep genes were 49% and 20%, which were slightly lower than ours.(Bolton et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) In general, \u003cem\u003eTERT\u003c/em\u003ep mutations correlate with increased \u003cem\u003eTERT\u003c/em\u003e mRNA levels and increased telomerase activity.(Roake \u0026amp; Artandi, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) The primary \u003cem\u003eTERT\u003c/em\u003e promoter (\u003cem\u003eTERT\u003c/em\u003ep) mutations occur at positions 1,295,228 (-124 C\u0026thinsp;\u0026gt;\u0026thinsp;T) and 1,295,250 (-146 C\u0026thinsp;\u0026gt;\u0026thinsp;T).(Hafezi \u0026amp; Perez Bercoff, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) Consistent with previous studies, the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation predominated among \u003cem\u003eTERT\u003c/em\u003ep mutations with a mutation rate of 21.8%. (Boscolo-Rizzo, Tirelli et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e, Giunco, Boscolo-Rizzo et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e, Giunco, Padovan et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e, Huang et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2015\u003c/span\u003e, Liu, Bishop et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2013\u003c/span\u003e, Nishikimi, Nakagawa et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2018\u003c/span\u003e, Spiegl-Kreinecker, Lotsch et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) The \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation and stage were independent prognostic factor for OS in our cohort. Patients with the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation showed significantly longer PFS and OS than wild-type patients, and more likely to have a normal preoperative serum CA125 level, had a higher prevalence of SNP and less likely to relapse.\u003c/p\u003e \u003cp\u003eCompared to other histological types of ovarian cancer, clear cell carcinomas have longer mean relative telomere lengths, and longer telomeres are associated with increased mortality.(Kuhn, Meeker et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) Ovarian clear cell carcinoma cell lines with the \u0026minus;\u0026thinsp;124C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation in the \u003cem\u003eTERT\u003c/em\u003e promoter (\u003cem\u003eTERT\u003c/em\u003ep) demonstrated elevated \u003cem\u003eTERT\u003c/em\u003e mRNA expression compared to cell lines without the \u003cem\u003eTERT\u003c/em\u003ep mutation. (Wu, Ayhan et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) Another study reported that the \u003cem\u003eTERT\u003c/em\u003ep hotspot mutations (-124C\u0026thinsp;\u0026gt;\u0026thinsp;T and \u0026minus;\u0026thinsp;146C\u0026thinsp;\u0026gt;\u0026thinsp;T) had a higher promoter activity than the wild-type, and the promoter activity of the uncommon site mutations was the lowest. (Kobayashi, Nishikimi et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) Furthermore, \u003cem\u003eTERT\u003c/em\u003e expression increased with tumor grade and stage. (Maraei, Hatta et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) However, the impact of \u003cem\u003eTERT\u003c/em\u003ep mutations on patient outcomes in OCCC remains unclear. Huang et al found that \u003cem\u003eTERT\u003c/em\u003ep mutation was an independent prognostic factor that correlated with shorter disease-free survival (DFS) and overall survival in early-stage patients.(Huang et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) Recently, Yoo et al demonstrated that \u003cem\u003eTERT\u003c/em\u003ep mutations had significant prognostic value in predicting tumor recurrence, platinum resistance, and DFS in patients with OCCC.(Yoo H, 2023) A similar conclusion from Irshaid et al reported that a \u003cem\u003eTERT\u003c/em\u003ep mutation could be further stratified as high-risk OCCC in the no specific molecular profile subgroup.(Irshaid, Costigan et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) In contrast to the above research, Kobayashi et al reported that the progression-free survival rate of the \u0026ldquo;enhancer-type\u0026rdquo; group including the hotspot mutations of \u003cem\u003eTERT\u003c/em\u003ep was significantly longer than that of the wild-type and \u0026ldquo;suppressor-type\u0026rdquo; (with uncommon mutations) mutation groups.(Kobayashi et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) While no significant difference in disease-specific overall survival was observed between patients with and without \u003cem\u003eTERT\u003c/em\u003ep hotspot mutations in the cohorts of Nishikimi et al and Wu et al.(Nishikimi et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2018\u003c/span\u003e, Wu et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) In our study, patients with the \u0026minus;\u0026thinsp;124C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation had longer PFS and OS than those with wild-type. We further analyzed the correlation between the two different hotspot mutations and prognosis. In addition, we have a longer observation period. This favorable prognosis associated with \u003cem\u003eTERT\u003c/em\u003ep has also been demonstrated in some subgroups of medulloblastoma, glioma and melanoma. (Blateau, Coyaud et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e, Remke, Ramaswamy et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e, Yang, Cai et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe prognostic and predictive role of \u003cem\u003eTERT\u003c/em\u003ep mutations is complex, and may be related to tumor heterogeneity and diverse molecular backgrounds. The effect of the \u003cem\u003eTERT\u003c/em\u003ep mutations on survival might be modified by a SNP at the mutation sites. The variant allele of the rs2853669 polymorphism decreased promoter activity in the presence of \u003cem\u003eTERT\u003c/em\u003ep mutations, especially in the cases with \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation, ultimately improving patients\u0026rsquo; prognosis.(Rachakonda, Hosen et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) In our study, the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation was mainly accompanied by SNP. \u003cem\u003eTERT\u003c/em\u003ep mutations might increase tumor immunogenicity. Analysis of pan-cancer cell lines revealed an expression signature of \u003cem\u003eTERT\u003c/em\u003ep mutation dominated by epithelial-to-mesenchymal transition (EMT) and MAPK signaling.(Stern, Hibshman et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) In lung cancer, high EMT scores were associated with the increased expression of immune checkpoints.(Mak, Tong et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) Patients harboring \u003cem\u003eTERT\u003c/em\u003ep mutations tended to show increased PD-L1 expression in glioma.(Holzl, Hutarew et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) Additional confounding factors such as \u003cem\u003eMGMT\u003c/em\u003e promoter methylation, may influence patient survival in association with \u003cem\u003eTERT\u003c/em\u003ep mutation status. Methylation of \u003cem\u003eMGMT\u003c/em\u003e promoter significantly increased the PFS and OS of the patients with \u003cem\u003eTERT\u003c/em\u003ep mutations in glioblastoma.(Arita, Yamasaki et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) Furthermore, the different prognosis between the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T and \u0026minus;\u0026thinsp;146 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation may be attributed to different functions.(Li, Zhou et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) Further research is needed to be done to understand how \u003cem\u003eTERT\u003c/em\u003ep mutations affect patient prognosis.\u003c/p\u003e \u003cp\u003e \u003cem\u003eARID1A\u003c/em\u003e encodes an accessory subunit of the SWI/SNF chromatin remodeling complex, which exhibited a high frequency of mutations in OCCC.(Fukumoto, Magno et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) In a comprehensive study involving 1,432 patients with endometrium-related gynecological cancers, loss of ARID1A expression predicted shorter progression free survival.(Katagiri et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2012\u003c/span\u003e, Liu, Xu et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) Studies have demonstrated that ARID1A directly represses HDAC6 gene transcription, and mutations in ARID1A and TP53 are mutually exclusive.(Bitler, Wu et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2017\u003c/span\u003e, Guan, Wang et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) Additionally, high HDAC6 expression had an adverse effect on the PFS in patients with ARID1A loss.(Yano et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) Futhermore, \u003cem\u003ePIK3CA\u003c/em\u003e mutations were significantly associated with a favorable overall survival in a cohort of 56 Japanese patients with OCCC.(Rahman et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) Huang et al reported a significant correlation between loss of ARID1A expression and PI3K-Akt signaling pathway activation.(Huang, Lin et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) In previous studies, \u003cem\u003eTERT\u003c/em\u003ep mutations with loss of ARID1A expression or \u003cem\u003ePIK3CA\u003c/em\u003e mutations in OCCC were mutually exclusive.(Huang et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2015\u003c/span\u003e, Wu et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) Cyclin E1 is a highly conserved cell cycle regulation protein, and its overexpression is closely correlated with \u003cem\u003eTERT\u003c/em\u003ep mutations and poor outcomes in stage I patients.(Ayhan et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) However, these associations were not found in our study with larger samples.\u003c/p\u003e \u003cp\u003eIn conclusion, we assessed the prognostic value of common gene mutations and clinicopathological factors in OCCC and found that the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation of \u003cem\u003eTERT\u003c/em\u003ep represented a favorable prognostic factor for OS in OCCC. However, further studies are required to elucidate the molecular mechanisms by which \u003cem\u003eTERT\u003c/em\u003ep mutation affect the prognosis of patients with OCCC.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from the National Natural Foundation Science of China (NSFC 81802597).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Xiaonan Zhou, Yifei Liu and Rui Bi. JH, JZ, RM,JG and XC contributed to the methodology. The first draft of the manuscript was written by Xiaonan Zhou and Rui Bi. All authors commented on previous versions of the manuscript. All authors contributed to final manuscript revision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data presented in this study are available on request from the corresponding authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study complies with all relevant ethical regulations and was approved by the Ethics Committee of Fudan University Shanghai Cancer Center (No. 050432-4-121B, 13 December 2012).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eArita H, Yamasaki K, Matsushita Y, Nakamura T, Shimokawa A, Takami H, Tanaka S, Mukasa A, Shirahata M, Shimizu S, Suzuki K, Saito K, Kobayashi K, Higuchi F, Uzuka T, Otani R, Tamura K, Sumita K, Ohno M, Miyakita Y et al. 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Patients with advanced or recurrent OCCC were resistant to chemotherapy and had poor prognosis. The purpose of this study was to identify specific prognostic markers in ovarian clear cell carcinoma.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A cohort of 169 patients with OCCC were enrolled, and their clinicopathological features were reviewed. Mutations in the \u003cem\u003eTERT\u003c/em\u003e promoter and \u003cem\u003ePIK3CA\u003c/em\u003e gene were detected by Sanger sequencing in 87 and 109 cases, respectively. Immunohistochemical markers for ARID1A, HDAC6, Cyclin E1, and p53 were stained on the tissue microarrays. Kaplan-Meier curves and Cox regression analysis were used to assess the correlation between these parameters and prognosis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe overall survival (OS) and progression-free survival (PFS) of patients with the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation in the \u003cem\u003eTERT\u003c/em\u003e promoter were significantly longer than those of wild-type patients. The \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation was an independent factor associated with a favorable OS. Patients with the \u0026minus;\u0026thinsp;124 C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation were more likely to have a normal preoperative serum CA125 level (P\u0026thinsp;=\u0026thinsp;0.017), a higher prevalence of single nucleotide polymorphism (SNP) (P\u0026thinsp;=\u0026thinsp;0.014), and a lower probability of relapse (P\u0026thinsp;=\u0026thinsp;0.025) than wild-type patients. No correlation between other factors and prognosis was observed in this cohort.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur results suggest that the \u0026minus;\u0026thinsp;124C\u0026thinsp;\u0026gt;\u0026thinsp;T mutation in the TERT promoter may serve as a favorable prognostic factor for overall survival in patients with OCCC.\u003c/p\u003e","manuscriptTitle":"The -124C\u0026gt;T mutation of TERT promoter indicated a favorable prognosis in OCCC: a monoinstitutional study in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-02 17:41:11","doi":"10.21203/rs.3.rs-3909705/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"33ac7bc5-99ef-44a4-8684-646f6a90664b","owner":[],"postedDate":"February 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-29T12:59:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-02 17:41:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3909705","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3909705","identity":"rs-3909705","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}