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.

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.
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.
Balamurugan K. HIF-1 at the crossroads of hypoxia, inflammation, and cancer: hypoxia, inflammation, and cancer. Int J Cancer. 2016;138(5):1058–66.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Chen B, Khodadoust MS, Liu CL, Newman AM, Alizadeh AA. Profiling tumor infiltrating immune cells with CIBERSORT. Methods Mol Biol. 2018;1711:243–59.
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.
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.
D’Ignazio L, Bandarra D, Rocha S. NF-κB and HIF crosstalk in immune responses. FEBS J. 2016;283(3):413–24.
Davidson B, Trope CG, Reich R. The role of the tumor stroma in ovarian cancer. Front Oncol. 2014;4:1–11.
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.
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.
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.
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.
Eales KL, Hollinshead KER, Tennant DA. Hypoxia and metabolic adaptation of cancer cells. Oncogenesis. 2016;5(1):e190.
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.
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.
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.
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.
Gilkes DM, Semenza GL, Wirtz D. Hypoxia and the extracellular matrix: drivers of tumour metastasis. Nat Rev Cancer. 2014;14(6):430–9.
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.
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.
Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. Cell. 2011;144(5):646–74.
Hanahan D, Weinberg RA. The hallmarks of cancer. Cell. 2000;100(1):57–70.
Harris AL. Hypoxia: a key regulatory factor in tumour growth. Nat Rev Cancer. 2002;2(1):38–47.
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.
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.
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.
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.
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.
Hubbi ME, Semenza GL. Regulation of cell proliferation by hypoxia-inducible factors. Am J Physiol Cell Physiol. 2015;309(12):C775–82.
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.
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.
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.
Kalra RS, Bapat SA. Expression proteomics predicts loss of RXR-γ during progression of epithelial ovarian cancer. PLoS One. 2013;8(8):e70398.
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.
Krock BL, Skuli N, Simon MC. Hypoxia-induced angiogenesis: good and evil. Genes Cancer. 2011;2(12):1117–33.
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.
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.
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.
Lengyel E. Ovarian cancer development and metastasis. Am J Pathol. 2010;177(3):1053–64.
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.
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.
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.
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.
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.
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.
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.
Nakazawa MS, Keith B, Simon MC. Oxygen availability and metabolic adaptations. Nat Rev Cancer. 2016;16(10):663–73.
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.
Petrova V, Annicchiarico-Petruzzelli M, Melino G, Amelio I. The hypoxic tumour microenvironment. Oncogenesis. 2018 Jan 24;7(1):10.
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.
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.
Quail DF, Joyce JA. Microenvironmental regulation of tumor progression and metastasis. Nat Med. 2013;19(11):1423–37.
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.
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.
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.
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.
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.
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.
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.
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.
Tomayko MM, Reynolds CP. Determination of subcutaneous tumor size in athymic (nude) mice. Cancer Chemother Pharmacol. 1989;24(3):148–54.
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.
Tudrej P, Kujawa KA, Cortez AJ, Lisowska KM. Characteristics of in vivo model systems for ovarian cancer studies. Diagnostics. 2019;9(3):120.
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.
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.
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.
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.
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.
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.
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.
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.