High-grade serous ovarian carcinoma (HGSC) is associated with late-stage disease presentation and poor prognosis, with a limited understanding of early transformation events. Our study analyzes HGSC tumor progression and organ-specific metastatic dissemination to identify hypoxia-associated molecular, cellular, and histological alterations. Clinical characteristics of the HGSC were replicated in orthotopic xenografts, which involve metastatic dissemination and the prevalence of group B tumors (volume: >0.0625 ≤ 0.5 cm3). Enhanced hyaluronic acid (HA) deposition, expanded tumor vasculature, and increased necrosis contributed to the remodeling of tumor tissue architecture. The proliferative potential of tumor cells and the ability to form glands were also altered during tumor growth. Flow cytometry and label chase-based molecular profiling across the tumor regenerative hierarchy identified the hypoxia-vasculogenic niche and the hybrid epithelial-mesenchymal tumor-cell state as determinants of self-renewal capabilities of progenitors and cancer stem cells. A regulatory network and mathematical model based on tumor histology and molecular signatures predicted hypoxia-inducible factor 1-alpha (HIF1A) as a central node connecting HA synthesis, epithelial-mesenchymal transition, metabolic, vasculogenic, inflammatory, and necrotic pathways in HGSC tumors. Thus, our findings provide a temporal resolution of hypoxia-associated events that sculpt HGSC tumor growth; an in-depth understanding of it may aid in the early detection and treatment of HGSC.

1.
Al Habyan
S
,
Kalos
C
,
Szymborski
J
,
McCaffrey
L
.
Multicellular detachment generates metastatic spheroids during intra-abdominal dissemination in epithelial ovarian cancer
.
Oncogene
.
2018
;
37
(
37
):
5127
35
.
2.
Anttila
MA
,
Tammi
RH
,
Tammi
MI
,
Syrjänen
KJ
,
Saarikoski
SV
,
Kosma
VM
.
High levels of stromal hyaluronan predict poor disease outcome in epithelial ovarian cancer
.
Cancer Res
.
2000
;
60
(
1
):
150
5
.
3.
Balamurugan
K
.
HIF-1 at the crossroads of hypoxia, inflammation, and cancer: hypoxia, inflammation, and cancer
.
Int J Cancer
.
2016
;
138
(
5
):
1058
66
.
4.
Balzer
EM
,
Konstantopoulos
K
.
Intercellular adhesion: mechanisms for growth and metastasis of epithelial cancers
.
Wiley Interdiscip Rev Syst Biol Med
.
2012
;
4
(
2
):
171
81
.
5.
Bapat
SA
,
Krishnan
A
,
Ghanate
AD
,
Kusumbe
AP
,
Kalra
RS
.
Gene expression: protein interaction systems network modeling identifies transformation-associated molecules and pathways in ovarian cancer
.
Cancer Res
.
2010
;
70
(
12
):
4809
19
.
6.
Bapat
SA
,
Mali
AM
,
Koppikar
CB
,
Kurrey
NK
.
Stem and progenitor-like cells contribute to the aggressive behavior of human epithelial ovarian cancer
.
Cancer Res
.
2005
;
65
(
8
):
3025
9
.
7.
Benita
Y
,
Kikuchi
H
,
Smith
AD
,
Zhang
MQ
,
Chung
DC
,
Xavier
RJ
.
An integrative genomics approach identifies Hypoxia Inducible Factor-1 (HIF-1)-target genes that form the core response to hypoxia
.
Nucleic Acids Res
.
2009
;
37
(
14
):
4587
602
.
8.
Berger
AC
,
Korkut
A
,
Kanchi
RS
,
Hegde
AM
,
Lenoir
W
,
Liu
W
, et al
.
A comprehensive pan-cancer molecular study of gynecologic and breast cancers
.
Cancer Cell
.
2018
;
33
(
4
):
690
705.e9
.
9.
Bourguignon
LYW
,
Shiina
M
,
Li
J-J
.
Hyaluronan-CD44 interaction promotes oncogenic signaling, microRNA functions, chemoresistance, and radiation resistance in cancer stem cells leading to tumor progression
.
Adv Cancer Res
.
2014
;
123
:
255
75
.
10.
Bryant
CS
,
Munkarah
AR
,
Kumar
S
,
Batchu
RB
,
Shah
JP
,
Berman
J
, et al
.
Reduction of hypoxia-induced angiogenesis in ovarian cancer cells by inhibition of HIF-1 alpha gene expression
.
Arch Gynecol Obstet
.
2010
;
282
(
6
):
677
83
.
11.
Byers
LA
,
Diao
L
,
Wang
J
,
Saintigny
P
,
Girard
L
,
Peyton
M
, et al
.
An epithelial-mesenchymal transition gene signature predicts resistance to EGFR and PI3K inhibitors and identifies Axl as a therapeutic target for overcoming EGFR inhibitor resistance
.
Clin Cancer Res
.
2013
;
19
(
1
):
279
90
.
12.
Chanmee
T
,
Ontong
P
,
Izumikawa
T
,
Higashide
M
,
Mochizuki
N
,
Chokchaitaweesuk
C
, et al
.
Hyaluronan production regulates metabolic and cancer stem-like properties of breast cancer cells via hexosamine biosynthetic pathway-coupled HIF-1 signaling
.
J Biol Chem
.
2016
;
291
(
46
):
24105
20
.
13.
Chen
B
,
Khodadoust
MS
,
Liu
CL
,
Newman
AM
,
Alizadeh
AA
.
Profiling tumor infiltrating immune cells with CIBERSORT
.
Methods Mol Biol
.
2018
;
1711
:
243
59
.
14.
Cormio
G
,
Rossi
C
,
Cazzolla
A
,
Resta
L
,
Loverro
G
,
Greco
P
, et al
.
Distant metastases in ovarian carcinoma
.
Int J Gynecol Cancer
.
2003
;
13
(
2
):
125
9
.
15.
Cybulska
P
,
Stewart
JM
,
Sayad
A
,
Virtanen
C
,
Shaw
PA
,
Clarke
B
, et al
.
A genomically characterized collection of high-grade serous ovarian cancer xenografts for preclinical testing
.
Am J Pathol
.
2018
;
188
(
5
):
1120
31
.
16.
D’Ignazio
L
,
Bandarra
D
,
Rocha
S
.
NF-κB and HIF crosstalk in immune responses
.
FEBS J
.
2016
;
283
(
3
):
413
24
.
17.
Davidson
B
,
Trope
CG
,
Reich
R
.
The role of the tumor stroma in ovarian cancer
.
Front Oncol
.
2014
;
4
:
1
11
.
18.
De Nola
R
,
Menga
A
,
Castegna
A
,
Loizzi
V
,
Ranieri
G
,
Cicinelli
E
, et al
.
The crowded crosstalk between cancer cells and stromal microenvironment in gynecological malignancies: biological pathways and therapeutic implication
.
Int J Mol Sci
.
2019
;
20
(
10
):
E2401
29
.
19.
Deng
K
,
Yang
C
,
Tan
Q
,
Song
W
,
Lu
M
,
Zhao
W
, et al
.
Sites of distant metastases and overall survival in ovarian cancer: a study of 1481 patients
.
Gynecol Oncol
.
2018
;
150
(
3
):
460
5
.
20.
Domcke
S
,
Sinha
R
,
Levine
DA
,
Sander
C
,
Schultz
N
.
Evaluating cell lines as tumour models by comparison of genomic profiles
.
Nat Commun
.
2013
;
4
:
2126
10
.
21.
Du
R
,
Sun
W
,
Xia
L
,
Zhao
A
,
Yu
Y
,
Zhao
L
, et al
.
Hypoxia-induced down-regulation of microRNA-34a promotes EMT by targeting the Notch signaling pathway in tubular epithelial cells
.
PLoS One
.
2012
;
7
(
2
):
e30771
.
22.
Eales
KL
,
Hollinshead
KER
,
Tennant
DA
.
Hypoxia and metabolic adaptation of cancer cells
.
Oncogenesis
.
2016
;
5
(
1
):
e190
.
23.
Faustino-Rocha
A
,
Oliveira
PA
,
Pinho-Oliveira
J
,
Teixeira-Guedes
C
,
Soares-Maia
R
,
da Costa
RG
, et al
.
Estimation of rat mammary tumor volume using caliper and ultrasonography measurements
.
Lab Anim
.
2013
;
42
(
6
):
217
24
.
24.
Gaikwad
SM
,
Gunjal
L
,
Junutula
AR
,
Astanehe
A
,
Gambhir
SS
,
Ray
P
.
Non-invasive imaging of phosphoinositide-3-kinase-catalytic-subunit-alpha (PIK3CA) promoter modulation in small animal models
.
PLoS One
.
2013
;
8
(
2
):
e55971
.
25.
Gardi
NL
,
Deshpande
TU
,
Kamble
SC
,
Budhe
SR
,
Bapat
SA
.
Discrete molecular classes of ovarian cancer suggestive of unique mechanisms of transformation and metastases
.
Clin Cancer Res
.
2014
;
20
(
1
):
87
99
.
26.
George
JT
,
Jolly
MK
,
Xu
S
,
Somarelli
JA
,
Levine
H
.
Survival outcomes in cancer patients predicted by a partial EMT gene expression scoring metric
.
Cancer Res
.
2017
;
77
(
22
):
6415
28
.
27.
Gilkes
DM
,
Semenza
GL
,
Wirtz
D
.
Hypoxia and the extracellular matrix: drivers of tumour metastasis
.
Nat Rev Cancer
.
2014
;
14
(
6
):
430
9
.
28.
Gomez-Roman
N
,
Sahasrabudhe
NM
,
McGregor
F
,
Chalmers
AJ
,
Cassidy
J
,
Plumb
J
.
Hypoxia-inducible factor 1 alpha is required for the tumourigenic and aggressive phenotype associated with Rab25 expression in ovarian cancer
.
Oncotarget
.
2016
;
7
(
16
):
22650
64
.
29.
Han
J
,
Xi
Q
,
Meng
Q
,
Liu
J
,
Zhang
Y
,
Han
Y
, et al
.
Interleukin-6 promotes tumor progression in colitis-associated colorectal cancer through HIF-1α regulation
.
Oncol Lett
.
2016
;
12
(
6
):
4665
70
.
30.
Hanahan
D
,
Weinberg
RA
.
Hallmarks of cancer: the next generation
.
Cell
.
2011
;
144
(
5
):
646
74
.
31.
Hanahan
D
,
Weinberg
RA
.
The hallmarks of cancer
.
Cell
.
2000
;
100
(
1
):
57
70
.
32.
Harris
AL
.
Hypoxia: a key regulatory factor in tumour growth
.
Nat Rev Cancer
.
2002
;
2
(
1
):
38
47
.
33.
Harris
FR
,
Zhang
P
,
Yang
L
,
Hou
X
,
Leventakos
K
,
Weroha
SJ
, et al
.
Targeting HER2 in patient-derived xenograft ovarian cancer models sensitizes tumors to chemotherapy
.
Mol Oncol
.
2019
;
13
(
2
):
132
52
.
34.
Hemmerlein
B
,
Kugler
A
,
Özisik
R
,
Ringert
RH
,
Radzun
HJ
,
Thelen
P
.
Vascular endothelial growth factor expression, angiogenesis, and necrosis in renal cell carcinomas
.
Virchows Arch
.
2001
;
439
(
5
):
645
52
.
35.
Hjerpe
E
,
Egyhazi Brage
S
,
Carlson
J
,
Frostvik Stolt
M
,
Schedvins
K
,
Johansson
H
, et al
.
Metabolic markers GAPDH, PKM2, ATP5B and BEC-index in advanced serous ovarian cancer
.
BMC Clin Pathol
.
2013
;
13
(
1
):
30
.
36.
Horvath
LE
,
Werner
T
,
Boucher
K
,
Jones
K
.
The relationship between tumor size and stage in early versus advanced ovarian cancer
.
Med Hypotheses
.
2013
;
80
(
5
):
684
7
.
37.
Huang
B
,
Lu
M
,
Jia
D
,
Ben-Jacob
E
,
Levine
H
,
Onuchic
JN
.
Interrogating the topological robustness of gene regulatory circuits by randomization
.
PLoS Comput Biol
.
2017
;
13
(
3
):
e1005456
.
38.
Hubbi
ME
,
Semenza
GL
.
Regulation of cell proliferation by hypoxia-inducible factors
.
Am J Physiol Cell Physiol
.
2015
;
309
(
12
):
C775
82
.
39.
Imai
T
,
Horiuchi
A
,
Wang
C
,
Oka
K
,
Ohira
S
,
Nikaido
T
, et al
.
Hypoxia attenuates the expression of E-cadherin via up-regulation of SNAIL in ovarian carcinoma cells
.
Am J Pathol
.
2003
;
163
(
4
):
1437
47
.
40.
Jolly
MK
,
Boareto
M
,
Huang
B
,
Jia
D
,
Lu
M
,
Onuchic
JN
, et al
.
Implications of the hybrid epithelial/mesenchymal phenotype in metastasis
.
Front Oncol
.
2015
;
5
:
1
19
.
41.
Jolly
MK
,
Preca
B-T
,
Tripathi
SC
,
Jia
D
,
George
JT
,
Hanash
SM
, et al
.
Interconnected feedback loops among ESRP1, HAS2, and CD44 regulate epithelial-mesenchymal plasticity in cancer
.
APL Bioeng
.
2018
;
2
(
3
):
031908
.
42.
Kalra
RS
,
Bapat
SA
.
Expression proteomics predicts loss of RXR-γ during progression of epithelial ovarian cancer
.
PLoS One
.
2013
;
8
(
8
):
e70398
.
43.
Kamble
SC
,
Sen
A
,
Dhake
RD
,
Joshi
AN
,
Midha
D
,
Bapat
SA
.
Clinical stratification of high-grade ovarian serous carcinoma using a panel of six biomarkers
.
J Clin Med
.
2019
;
8
(
3
):
330
.
44.
Krock
BL
,
Skuli
N
,
Simon
MC
.
Hypoxia-induced angiogenesis: good and evil
.
Genes Cancer
.
2011
;
2
(
12
):
1117
33
.
45.
Kusumbe
AP
,
Bapat
SA
.
Cancer stem cells and aneuploid populations within developing tumors are the major determinants of tumor dormancy
.
Cancer Res
.
2009
;
69
(
24
):
9245
53
.
46.
Kusumbe
AP
,
Mali
AM
,
Bapat
SA
.
CD133-expressing stem cells associated with ovarian metastases establish an endothelial hierarchy and contribute to tumor vasculature
.
Stem Cells
.
2009
;
27
(
3
):
498
508
.
47.
Lee
SY
,
Ju
MK
,
Jeon
HM
,
Jeong
EK
,
Lee
YJ
,
Kim
CH
, et al
.
Regulation of tumor progression by programmed necrosis
.
Oxid Med Cell Longev
.
2018
;
2018
:
3537471
.
48.
Lengyel
E
.
Ovarian cancer development and metastasis
.
Am J Pathol
.
2010
;
177
(
3
):
1053
64
.
49.
Liu
W
,
Ye
H
,
Liu
YF
,
Xu
CQ
,
Zhong
YX
,
Tian
T
, et al
.
Transcriptome-derived stromal and immune scores infer clinical outcomes of patients with cancer
.
Oncol Lett
.
2018
;
15
(
4
):
4351
7
.
50.
Lu
M
,
Jolly
MK
,
Levine
H
,
Onuchic
JN
,
Ben-Jacob
E
.
MicroRNA-based regulation of epithelial-hybrid-mesenchymal fate determination
.
Proc Natl Acad Sci U S A
.
2013
;
110
(
45
):
18144
9
.
51.
Mukoyama
N
,
Suzuki
H
,
Hanai
N
,
Sone
M
,
Hasegawa
Y
.
Pathological tumor volume predicts survival outcomes in oral squamous cell carcinoma
.
Oncol Lett
.
2018
;
16
(
2
):
2471
7
.
52.
Muz
B
,
de la Puente
P
,
Azab
F
,
Azab
AK
.
The role of hypoxia in cancer progression, angiogenesis, metastasis, and resistance to therapy
.
Hypoxia
.
2015
;
3
92
.
53.
Naik
RR
,
Gardi
NL
,
Bapat
SA
.
Elucidation of molecular and functional heterogeneity through differential expression network analyses of discrete tumor subsets
.
Sci Rep
.
2016a
;
6
:
25261
.
54.
Naik
RR
,
Luo
T
,
Kohandel
M
,
Bapat
SA
.
Tumor deconstruction as a tool for advanced drug screening and repositioning
.
Pharmacol Res
.
2016b
;
111
:
815
9
.
55.
Naik
RR
,
Singh
AK
,
Mali
AM
,
Khirade
MF
,
Bapat
SA
.
A tumor deconstruction platform identifies definitive end points in the evaluation of drug responses
.
Oncogene
.
2016c
;
35
(
6
):
727
37
.
56.
Nakazawa
MS
,
Keith
B
,
Simon
MC
.
Oxygen availability and metabolic adaptations
.
Nat Rev Cancer
.
2016
;
16
(
10
):
663
73
.
57.
Newman
AM
,
Liu
CL
,
Green
MR
,
Gentles
AJ
,
Feng
W
,
Xu
Y
, et al
.
Robust enumeration of cell subsets from tissue expression profiles
.
Nat Methods
.
2015
;
12
(
5
):
453
7
.
58.
Petrova
V
,
Annicchiarico-Petruzzelli
M
,
Melino
G
,
Amelio
I
.
The hypoxic tumour microenvironment
.
Oncogenesis
.
2018 Jan 24
;
7
(
1
):
10
.
59.
Pfister
R
,
Schwarz
KA
,
Janczyk
M
,
Dale
R
,
Freeman
JB
.
Good things peak in pairs: a note on the bimodality coefficient
.
Front Psychol
.
2013
;
4
:
700
.
60.
Preca
BT
,
Bajdak
K
,
Mock
K
,
Lehmann
W
,
Sundararajan
V
,
Bronsert
P
, et al
.
A novel ZEB1/HAS2 positive feedback loop promotes EMT in breast cancer
.
Oncotarget
.
2017
;
8
(
7
):
11530
43
.
61.
Quail
DF
,
Joyce
JA
.
Microenvironmental regulation of tumor progression and metastasis
.
Nat Med
.
2013
;
19
(
11
):
1423
37
.
62.
Rose
PG
,
Piver
MS
,
Tsukada
Y
,
Lau
TS
.
Metastatic patterns in histologic variants of ovarian cancer. An autopsy study
.
Cancer
.
1989
;
64
(
7
):
1508
13
.
63.
Schaefer
E
,
Wu
W
,
Mark
C
,
Yang
A
,
DiGiacomo
E
,
Carlton-Smith
C
, et al
.
Intermittent hypoxia is a proinflammatory stimulus resulting in IL-6 expression and M1 macrophage polarization
.
Hepatol Commun
.
2017
;
1
(
4
):
326
37
.
64.
Seeber
LMS
,
Horrée
N
,
van der Groep
P
,
van der Wall
E
,
Verheijen
RHM
,
van Diest
PJ
.
Necrosis related HIF-1α expression predicts prognosis in patients with endometrioid endometrial carcinoma
.
BMC Cancer
.
2010
;
10
:
307
11
.
65.
Shaw
TJ
,
Senterman
MK
,
Dawson
K
,
Crane
CA
,
Vanderhyden
BC
.
Characterization of intraperitoneal, orthotopic, and metastatic xenograft models of human ovarian cancer
.
Mol Ther
.
2004
;
10
(
6
):
1032
42
.
66.
Singh
AK
,
Chandra
N
,
Bapat
SA
.
Evaluation of epigenetic drug targeting of heterogenous tumor cell fractions using potential biomarkers of response in ovarian cancer
.
Clin Cancer Res
.
2015
;
21
(
22
):
5151
63
.
67.
Singh
M
,
Mukundan
S
,
Jaramillo
M
,
Oesterreich
S
,
Sant
S
.
Three-dimensional breast cancer models mimic hallmarks of size-induced tumor progression
.
Cancer Res
.
2016
;
76
(
13
):
3732
43
.
68.
Sowter
HM
,
Ratcliffe
PJ
,
Watson
P
,
Greenberg
AH
,
Harris
AL
.
HIF-1-dependent regulation of hypoxic induction of the cell death factors BNIP3 and NIX in human tumors
.
Cancer Res
.
2001
;
61
(
18
):
6669
73
.
69.
Tan
TZ
,
Miow
QH
,
Miki
Y
,
Noda
T
,
Mori
S
,
Huang
RYJ
, et al
.
Epithelial-mesenchymal transition spectrum quantification and its efficacy in deciphering survival and drug responses of cancer patients
.
EMBO Mol Med
.
2014
;
6
(
10
):
1279
93
.
70.
Tomayko
MM
,
Reynolds
CP
.
Determination of subcutaneous tumor size in athymic (nude) mice
.
Cancer Chemother Pharmacol
.
1989
;
24
(
3
):
148
54
.
71.
Toole
BP
,
Zoltan-Jones
A
,
Misra
S
,
Ghatak
S
.
Hyaluronan: a critical component of epithelial-mesenchymal and epithelial-carcinoma transitions
.
Cells Tissues Organs
.
2005
;
179
(
1–2
):
66
72
.
72.
Tudrej
P
,
Kujawa
KA
,
Cortez
AJ
,
Lisowska
KM
.
Characteristics of in vivo model systems for ovarian cancer studies
.
Diagnostics
.
2019
;
9
(
3
):
120
.
73.
Varankar
SS
,
More
M
,
Abraham
A
,
Pansare
K
,
Kumar
B
,
Narayanan
NJ
, et al
.
Functional balance between Tcf21-Slug defines cellular plasticity and migratory modalities in high grade serous ovarian cancer cell lines
.
Carcinogenesis
.
2020
;
41
(
4
):
515
26
.
74.
Wang
P
,
Wan
WW
,
Xiong
SL
,
Feng
H
,
Wu
N
.
Cancer stem-like cells can be induced through dedifferentiation under hypoxic conditions in glioma, hepatoma and lung cancer
.
Cell Death Discov
.
2017 Jan 23
;
3
:
16105
.
75.
Wani
AA
,
Sharma
N
,
Shouche
YS
,
Bapat
SA
.
Nuclear-mitochondrial genomic profiling reveals a pattern of evolution in epithelial ovarian tumor stem cells
.
Oncogene
.
2006
;
25
(
47
):
6336
44
.
76.
Ween
MP
,
Oehler
MK
,
Ricciardelli
C
.
Role of versican, hyaluronan and CD44 in ovarian cancer metastasis
.
Int J Mol Sci
.
2011
;
12
(
2
):
1009
29
.
77.
Xing
D
,
Orsulic
S
.
A genetically defined mouse ovarian carcinoma model for the molecular characterization of pathway-targeted therapy and tumor resistance
.
Proc Natl Acad Sci U S A
.
2005
;
102
(
19
):
6936
41
.
78.
Xu
X
,
Ayub
B
,
Liu
Z
,
Serna
VA
,
Qiang
W
,
Liu
Y
, et al
.
Anti-miR182 reduces ovarian cancer burden, invasion, and metastasis: an in vivo study in orthotopic xenografts of nude mice
.
Mol Cancer Ther
.
2014
;
13
(
7
):
1729
39
.
79.
Yousefi
M
,
Dehghani
S
,
Nosrati
R
,
Ghanei
M
,
Salmaninejad
A
,
Rajaie
S
, et al
.
Current insights into the metastasis of epithelial ovarian cancer: hopes and hurdles
.
Cell Oncol
.
2020
;
43
(
4
):
515
38
.
80.
Zhang
J
,
Gold
KA
,
Lin
HY
,
Swisher
SG
,
Xing
Y
,
Lee
JJ
, et al
.
Relationship between tumor size and survival in non-small-cell lung cancer (NSCLC): an analysis of the surveillance, epidemiology, and end results (SEER) registry
.
J Thorac Oncol
.
2015
;
10
(
4
):
682
90
.
You do not currently have access to this content.