YGYNO-976984; No. of pages: 5; 4C: Gynecologic Oncology xxx (2017) xxx–xxx Contents lists available at ScienceDirect Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno Clinical characteristics and outcomes of patients with BRCA1 or RAD51C methylated versus mutated ovarian carcinoma Sarah S. Bernards a, Kathryn P. Pennington a, Maria I. Harrell a, Kathy J. Agnew a, Rochelle L. Garcia b, Barbara M. Norquist a, Elizabeth M. Swisher a,⁎ a b Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195, USA Department of Pathology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195, USA H I G H L I G H T S • Methylation and mutation of RAD51C or BRCA1 were mutually exclusive. • Methylation of BRCA1 was associated with younger age at diagnosis. • Germline BRCA1 mutations and BRCA1 methylation were associated with HGS histology. a r t i c l e i n f o Article history: Received 22 July 2017 Received in revised form 28 November 2017 Accepted 4 December 2017 Available online xxxx Keywords: Ovarian carcinoma Methylation Homologous recombination Mutation a b s t r a c t Objective. In ovarian carcinoma, mutations in homologous recombination DNA repair (HRR) genes, including BRCA1 and RAD51C, are associated with increased survival and specific clinical features. Promoter hypermethylation is another mechanism of reducing gene expression. We assessed whether BRCA1 and RAD51C promoter hypermethylation is associated with similar survival and clinical characteristics. Methods. Promoter methylation of BRCA1 and RAD51C was evaluated using methylation-sensitive PCR in 332 primary ovarian carcinomas. Damaging germline and somatic mutations in 16 HRR genes were identified using BROCA sequencing. Results. BRCA1 methylation was detected in 22 carcinomas (6.6%) and RAD51C methylation in 9 carcinomas (2.7%). These small numbers limited the power to detect differences in survival and platinum sensitivity. Mutations in one or more HRR genes were found in 95 carcinomas (29%). Methylation of BRCA1 or RAD51C was mutually exclusive with mutations in these genes (P = 0.001). Patients whose carcinomas had BRCA1 methylation (57.7 years ± 2.5) or BRCA1 mutations (54.1 years ± 1.4) were younger than those without (63.3 years ± 0.8; P = 0.029, P b 0.0001). BRCA1 methylation and germline BRCA1 mutation were associated with high grade serous (HGS) histology (P = 0.045, P = 0.001). BRCA1 mutations were associated with increased sensitivity to platinum chemotherapy while BRCA1 methylation was not (P = 0.034, P = 0.803). Unlike HRR mutations, methylation was not associated with improved overall survival compared to cases without methylation or mutation. Conclusions. Patients with BRCA1-methylated carcinomas share clinical characteristics with patients with BRCA1-mutated carcinomas including younger age and predominantly HGS histology. However, unlike mutation, RAD51C and BRCA1 methylation were not associated with improved survival or greater sensitivity to platinum chemotherapy. © 2017 Published by Elsevier Inc. 1. Introduction ⁎ Corresponding author at: University of Washington Medical Center, Department of Obstetrics and Gynecology, Box 356460, Seattle, WA 98195-6460, USA. E-mail addresses: [email protected] (S.S. Bernards), [email protected] (K.P. Pennington), [email protected] (M.I. Harrell), [email protected] (K.J. Agnew), [email protected] (R.L. Garcia), [email protected] (B.M. Norquist), [email protected] (E.M. Swisher). Ovarian, fallopian tube and primary peritoneal (collectively called ovarian) carcinomas commonly have deleterious mutations in the homologous recombination DNA repair pathway (HRR) genes BRCA1 and BRCA2 (BRCA1/2), with germline mutations in approximately 15% of patients and somatic mutations in another 6% of carcinomas [1–4]. Germline mutations in these genes are the most common cause of inherited ovarian carcinoma and are associated with increased https://doi.org/10.1016/j.ygyno.2017.12.004 0090-8258/© 2017 Published by Elsevier Inc. Please cite this article as: S.S. Bernards, et al., Clinical characteristics and outcomes of patients with BRCA1 or RAD51C methylated versus mutated ovarian carcinoma, Gynecol Oncol (2017), https://doi.org/10.1016/j.ygyno.2017.12.004 2 S.S. Bernards et al. / Gynecologic Oncology xxx (2017) xxx–xxx sensitivity to platinum chemotherapy, better five-year survival, high grade serous (HGS) histology, and somatic TP53 mutations [5–8]. Our group and others have recently shown that somatic mutations in BRCA1/2 and some non-BRCA1/2 HRR genes including RAD51C are also associated with platinum sensitivity, improved survival, and sensitivity to poly (ADP-ribose) polymerase (PARP) inhibitors [2,9–11]. Promoter hypermethylation (methylation) is another biologic mechanism of reducing gene expression and occurs frequently in cancer [12]. BRCA1 promoter methylation is common in ovarian carcinoma with rates from 8 to 15% and is associated with both reduced RNA and protein expression [12–19]. In HGS ovarian carcinomas, The Cancer Genome Atlas (TCGA) identified BRCA1 and RAD51C as the only HRR genes in which promoter methylation correlated with reduced RNA expression [1]. RAD51C methylation has been described in 1–3% of ovarian carcinomas [1,15]. Given the improved outcomes seen with BRCA1 mutation and the functional impact of BRCA1 promoter methylation (decreased RNA and protein expression), we hypothesized that BRCA1 and RAD51C methylation would also be associated with improved outcomes and similar clinicopathological characteristics. However, there are conflicting reports of the prognostic value of BRCA1 methylation in regards to sensitivity to platinum chemotherapy and survival [1,14,15,20,21]. No previous study except TCGA, which was limited only to ovarian carcinomas of HGS histology, has considered both methylation and mutation in many HRR genes in comparing outcomes [1,14,15,20,21]. We sought to evaluate BRCA1 methylation and RAD51C methylation in ovarian carcinomas of varying histologies and compare outcomes and characteristics of methylated versus mutated cases. 2. Methods Patients with ovarian, fallopian tube, or peritoneal carcinoma provided IRB-approved informed consent to enroll in the University of Washington gynecologic oncology tissue bank at the time of their primary debulking surgery. Patients diagnosed with carcinoma at the time of planned prophylactic bilateral salpingo-oophorectomy were excluded. Germline and neoplastic DNA was sequenced using BROCA, a targeted capture and massively parallel sequencing platform previously described [2,22,23]. Carcinomas with a damaging germline or somatic mutation in ATM, ATR, BARD1, BLM, BRCA1, BRCA2, BRIP1, CDK12, CHEK2, MRE11A, NBN, PALB2, RAD51C, RAD51D, RBBP8, SLX4, or XRCC2 were classed as having HRR deficiency. Methylation of RAD51C and BRCA1 in neoplastic DNA was assessed by bisulfite conversion using the Zymo Research EZ DNA MethylationDirect kit followed by methylation-specific PCR as previously described [9,17]. Methylation was evaluated in primary carcinomas and, if available, in corresponding recurrent carcinomas. Patients were considered to have a “strong family history” of cancer if they had a relative with OC, a relative with breast cancer before age 50, or two relatives with breast cancer at any age. All statistical analyses were pre-planned based on our hypotheses. The Fisher's exact test was used to test the significance of contingency tables (Tables 1 and 2). Progression-free survival (PFS) was defined as the time between study enrollment and disease progression or death. Patients who did not receive chemotherapy and those for whom chemotherapy information was not available were excluded from the PFS analysis. Overall survival (OS) was defined as the time between study enrollment and last follow up visit or death. Patients with stage I disease were excluded from survival analyses. Kaplan Meier curves were generated for OS and PFS and evaluated by the Log Rank test. The study sample size was not large enough to correct for confounders with multivariate analysis. 3. Results Primary carcinomas from a total of 332 patients were evaluated. Table 1 provides demographic information for all subjects. For 12 patients, paired recurrent neoplasms were also analyzed for methylation. Tables 1 and 2 summarize the methylation and germline mutation status of the primary carcinomas. Mutation information for all but three patients was previously published [2]. Sixty-nine (20.8%) carcinomas had a germline mutation in one or more of the HRR genes assayed (1 ATM, 2 BARD1, 38 BRCA1, 13 BRCA2, 4 BRIP1, 3 CHEK2, 1 NBN, 1 PALB2, 3 RAD51C, and 4 RAD51D). Twenty-eight (8.4%) carcinomas had a somatic mutation in one or more HRR genes (2 ATM, 16 BRCA1, 5 BRCA2, 1 BRIP1, 4 CHEK2, 1 MRE11A, 1 RAD51C, 1 SLX4). Among these mutated cases, six (1.8%) had mutations in more than one gene. These cases were a germline BRCA1 mutation with a somatic CHEK2 mutation, a germline BRCA1 mutation with a somatic ATM mutation, a germline BRCA1 mutation with a germline BARD1 mutation, a germline CHEK2 mutation with a somatic BRCA2 mutation, a somatic CHEK2 mutation with a somatic SLX4 mutation, and a case with somatic mutations in BRCA1, BRIP1, and MRE11A. A total of 31 primary carcinomas were found to have methylation of either BRCA1 (22, 6.6%) or RAD51C (9, 2.7%). Two hundred seven (62.3%) carcinomas had neither methylation nor mutation. No carcinoma had both a germline mutation in a HRR gene and methylation of either BRCA1 or RAD51C (P = 0.0008). One carcinoma with a somatic mutation in BRIP1 had methylation of BRCA1. When available, paired recurrent carcinomas were also evaluated for somatic mutations and methylation. All paired carcinomas had concordant methylation status: eleven of the recurrent carcinomas were unmethylated as were their corresponding primary neoplasms, and one recurrent carcinoma was BRCA1 methylated, as was the primary neoplasm associated with it. Table 1 describes the clinical features of the study population by methylation and mutation status. At time of diagnosis, patients with BRCA1 methylation of their carcinoma were on average 5.6 years younger (mean 57.7 years ± 2.5) than patients without germline or somatic mutations and without methylation (mean 63.3 years ± 0.79) (P = 0.029). Patients with germline or somatic BRCA1 mutations were younger at diagnosis than patients without mutations and without methylation by 9.3 years ± 1.7 (mean 54.1 years ± 1.4) (P b 0.0001). The difference in age at diagnosis was more pronounced when the analysis was restricted to patients with germline BRCA1 mutations, who were on average 10.9 years younger (mean 52.4 years ± 1.4) than patients without mutations and without methylation (P b 0.0001). Patients with germline or somatic mutations in HRR genes other than BRCA1 or RAD51C were also younger at diagnosis than patients without mutations and without methylation by 5.83 ± 2.04 years (mean 57.5 ± 1.9 years) (P = 0.005). Germline BRCA1 mutations and BRCA1 methylation were both associated with HGS histology when compared to carcinomas without mutation or methylation (95% vs 71%, P = 0.001; 91% vs 71%, P = 0.045), but this was not true for BRCA1 somatic mutations. Of the 16 somatically mutated BRCA1 carcinomas, eight were HGS, four were undifferentiated, two were endometrioid, one was clear cell, and one was a carcinosarcoma. A strong family history of breast or ovarian carcinoma was more common in patients with germline HRR mutations including mutations in BRCA1 and RAD51C (55% vs 17% of patients whose carcinomas were neither mutated nor methylated, P b 0.0001). Patients with germline HRR gene mutations had a significantly higher incidence of a personal history of breast cancer (21.7% vs 3.4% of those with neither mutation nor methylation, P b 0.0001). Advanced stage disease (stage III or IV), utilization of neoadjuvant chemotherapy, and achievement of optimal primary surgical debulking was similar in carcinomas with or without mutation or methylation. As previously published, germline or somatic BRCA1 mutations were associated with increased platinum sensitivity compared to carcinomas without mutation or methylation (80% vs Please cite this article as: S.S. Bernards, et al., Clinical characteristics and outcomes of patients with BRCA1 or RAD51C methylated versus mutated ovarian carcinoma, Gynecol Oncol (2017), https://doi.org/10.1016/j.ygyno.2017.12.004 S.S. Bernards et al. / Gynecologic Oncology xxx (2017) xxx–xxx 3 Table 1 Clinicopathologic characteristics of study patients by mutation and methylation status. N Median age at dx (range)b Strong family historyc Personal hx of br ca Neoadjuvant chemo Somatic TP53 mutation Optimally debulked (b1 cm) Yes No Not available Platinum sensitivityd Sensitive Resistant Refractory Not available Histology HG serous Undifferentiated LG serous Endometrioid Clear cell Carcinosarcoma Transitional Neuroendocrine FIGO stage Stage I Stage II Stage III Stage IV Unstaged Germline or somatic BRCA1 mutation BRCA1 methylation Germline or somatic RAD51C mutation RAD51C methylation Germline or somatic mutations in another HRR genea No mutation or methylation All patients 54 (16.3%) 53 (29–76) 27 (50%) 10 (18.5%) 3 (5.6%) 48 (88.9%) 22 (6.6%) 55 (37–85) 7 (31.8%) 3 (13.6%) 2 (9.1%) 18 (81.8%) 4 (1.2%) 57.5 (47–70) 2 (50%) 0 0 2 (50%) 9 (2.7%) 59 (39–67) 3 (33.3%) 0 2 (22.2%) 4 (44.4%) 37 (11.1%)e 56 (34–83) 18 (50%) 6 (16.7%) 4 (11.1%) 24 (64.9%) 207 (62.3%) 63 (34–90) 36 (17.4%) 7 (3.4%) 19 (9.2%) 138 (66.7%) 332 60 (29–90) 93 (28%) 26 (7.8%) 30 (9%) 234 (70.5%) 35 (64.8%) 18 (33.3%) 1 (1.9%) 16 (72.7%) 6 (27.3%) 0 4 (100%) 0 0 5 (55.6%) 4 (44.4%) 0 29 (80.6%) 7 (19.4%) 0 141 (68.1%) 64 (30.9%) 2 (1%) 230 (69.3%) 99 (29.8%) 3 (0.9%) 36 (66.7%) 6 (11.1%) 3 (5.5%) 9 (16.7%) 13 (59.1%) 4 (18.2%) 2 (9.1%) 3 (13.6%) 2 (50%) 1 (25%) 1 (25%) 0 3 (33.3%) 1 (11.1%) 4 (44.5%) 1 (11.1%) 28 (77.8%) 2 (5.6%) 3 (8.3%) 3 (8.3%) 109 (52.7%) 31 (15%) 35 (16.9%) 32 (15.4%) 191 (57.5%) 45 (13.5%) 48 (14.5%) 48 (14.5%) 44 (81.5%) 5 (9.2%) 0 3 (5.5%) 1 (1.9%) 1 (1.9%) 0 0 20 (91%) 1 (4.5%) 0 1 (4.5%) 0 0 0 0 2 (50%) 1 (25%) 0 0 0 1 (25%) 0 0 5 (55.6%) 3 (33.3%) 0 0 1 (11.1%) 0 0 0 24 (66.7%) 4 (11.1%) 1 (2.8%) 3 (8.3%) 4 (11.1%) 0 0 0 146 (70.5%) 14 (6.8%) 8 (3.9%) 16 (7.7%) 10 (4.8%) 11 (5.3%) 1 (0.5%) 1 (0.5%) 241 (72.6%) 28 (8.5%) 9 (2.7%) 23 (6.9%) 16 (4.8%) 13 (3.9%) 1 (0.3%) 1 (0.3%) 2 (3.7%) 1 (1.9%) 42 (77.7%) 8 (14.8%) 1 (1.9%) 1 (4.5%) 1 (4.5%) 15 (68.2%) 3 (13.7%) 2 (9.1%) 0 1 (25%) 1 (25%) 2 (50%) 0 0 1 (11.1%) 7 (77.8%) 1 (11.1%) 0 5 (13.9%) 2 (5.6%) 26 (72.2%) 3 (8.3%) 0 14 (6.8%) 13 (6.3%) 151 (72.9%) 29 (14%) 0 22 (6.6%) 19 (5.7%) 242 (72.9%) 46 (13.9%) 3 (0.9%) a Mutation in: ATM, ATR, BARD1, BLM, BRCA2, BRIP1, CDK12, CHEK2, MRE11A, NBN, PALB2, RAD51D, RBBP8, SLX4, or XRCC2. All cases of somatic mutations in multiple HRR genes were counted in the “Germline or Somatic mutations in another HRR gene” category with two exceptions. If one of the genes was BRCA1, the patient was added to the “Germline or Somatic BRCA1 Mutation” category instead. If the patient had a somatic mutation in multiple HRR genes including RAD51C but excluding BRCA1, the patient was counted in the “Germline or Somatic RAD51C Mutation” group. b There is a statistically significant difference in age at diagnosis between cases with “BRCA1 methylation” (5.6 ± 2.5 years younger) and cases with “No mutations or methylation” (P = 0.029), between cases with “Germline or Somatic BRCA1 mutation” (9.3 ± 1.7 years younger) and cases with “No mutations or methylation” (P ≤ 0.0001), and between cases with “Germline or somatic mutations in another HRR gene” (5.83 ± 2.04 years younger) and cases with “No mutations or methylation” (P = 0.005). c Strong family history = a relative with OC, a relative with breast cancer b 50 years of age, or two relatives with breast cancer at any age. Two “Germline or Somatic BRCA1 mutation” patients, one “RAD51C methylation” patient, one “Germline or somatic mutations in another HRR gene” patient, and five “No mutation or methylation” patients have unknown family history due to being adopted. d “Germline or Somatic BRCA1 mutation” was associated with platinum sensitivity when compared to cases with “No mutation or methylation” (P = 0.034). Cases with “Germline or somatic mutations in another HRR gene” were also associated with platinum sensitivity (P = 0.015). “BRCA1 methylation” was not associated with platinum sensitivity (P = 0.803). e One carcinoma with a somatic BRIP1 mutation was also BRCA1 methylated and is counted in both categories in the “N” row (“BRCA1 methylated” and “Germline or somatic mutations in another HRR gene”). It is counted only in the “BRCA1 methylated” category for the remaining rows. 62%, P = 0.034) [2]. Germline or somatic mutations in HRR genes other than BRCA1 or RAD51C were also associated with increased sensitivity to platinum chemotherapy (85% vs 62%, P = 0.015). Conversely, BRCA1 methylation was not associated with increased platinum sensitivity (68% vs 62%, P = 0.803). Taking into account the existing platinum sensitivity rate of 75% and the number of cases with missing platinum sensitivity data, we had an 80% power to detect a 30% change in the fraction of cases that are platinum sensitive comparing the methylated cases to the non-methylated, non-mutated cases. Germline or somatic BRCA1 mutations were associated with TP53 mutations when compared to carcinomas without methylation or mutations (89% vs 67% P = 0.0012). Table 2 Methylation of BRCA1 or RAD51C and mutation in HRR genes in study patients. + for methylation – for methylation Total + for HHR muta – for HRR muta Total 1b 94 95 30 207 237 31 301 332 BRCA1 methylation was not associated with TP53 mutations (82% vs 67%, P = 0.23). Fig. 1 provides survival analyses of this patient cohort divided into carcinomas with BRCA1 or RAD51C methylation, carcinomas with germline or somatic mutations in HRR genes, and carcinomas without methylation or mutations. There was no significant difference in progression-free survival between these three groups, though PFS assessment was limited by missing data for many patients. Patients whose carcinomas had HRR mutations had a statistically significant increase in overall survival compared to those with methylated or with unmethylated, non-mutated carcinomas. The small total number of methylated cases (31/332, 9.3%) meant we were underpowered to detect a difference in survival between methylated cases and unmethylated, non-mutated cases. Median survival was 41 months in methylated cases (HR 0.79, 95% CI 0.51–1.26), 43 months in neither mutated nor methylated cases, and 66 months in mutated cases (HR 0.70, 95% CI 0.53–0.94). 4. Discussion a HRR = Homologous Recombination Repair; mutation in: ATM, ATR, BARD1, BLM, BRCA1, BRCA2, BRIP1, CKD12, CHEK2, MRE11A, NBN, PALB2, RAD51C, RAD51D, RBBP8, SLX4, or XRCC2. b BRCA1 methylation, somatic BRIP1 mutation. BRCA1 methylation was present in 6.6% (22/332) of ovarian carcinomas in our series. Compared to studies also unrestricted by histology, our rate was similar to the rate reported by Cunningham et al. (9%, Please cite this article as: S.S. Bernards, et al., Clinical characteristics and outcomes of patients with BRCA1 or RAD51C methylated versus mutated ovarian carcinoma, Gynecol Oncol (2017), https://doi.org/10.1016/j.ygyno.2017.12.004 S.S. Bernards et al. / Gynecologic Oncology xxx (2017) xxx–xxx Percent survival 4 Mutation Category Hazard Ratio (95% CI) P-value RAD51C and BRCA1 Methylation 0.79 (0.51-1.26) 0.3 Mutation in any HR gene 0.70 (0.53-0.94) 0.02 Median Months PFS Percent survival 100 Mutation in any HR gene (25) RAD51C and BRCA1 methylation (18) No mutation, no methylation (17) 50 0 0 50 100 150 200 250 Months Mutation Category Hazard Ratio (95% CI) P-value RAD51C and BRCA1 Methylation 0.80 (0.51-1.27) 0.36 Mutation in any HR gene 0.76 (0.56-1.02) 0.07 Fig. 1. Overall and progression-free survival by mutation and methylation status. 45/482, P = 0.19) but possibly lower than Baldwin et al. (12.2%, 12/98, P = 0.08) [15,16]. Two studies assessed BRCA1 methylation only in HGS ovarian carcinomas including TCGA (11.5%, 56/489) and Ruscito et al. (14.8%, 38/257) [1,14]. When we restricted our analyses to only our 241 HGS cases, BRCA1 methylation was present in 20 (8.3%) carcinomas, which was similar to TCGA's study (11.5%, P = 0.20) but lower than found by Ruscito et al. (14.8%, P = 0.03) [1,14]. We developed our own RAD51C methylation sensitive PCR assay [9] after finding inconsistent results from repetitive experiments using the assay previously reported [25]. Despite differences in RAD51C methylation assays, we found similar rates to that seen in TCGA (3%, P = 1) and Cunningham et al. (1%, P = 0.21) [1,15]. Promoter hypermethylation of RAD51C and BRCA1 did not occur in cases with damaging germline or somatic mutations in these genes (P = 0.001). This mutual exclusivity was also evident in two large studies of methylation in ovarian carcinoma [1,15]. These data support methylation as an alternate mechanism for HRR down regulation that provides a similar advantage in ovarian tumorigenesis as that for HRR mutation. In this study, we found similarities in the clinical presentation of BRCA1 methylated and mutated carcinomas, including younger patient age at diagnosis and HGS histology. Ruscito et al. also found that BRCA1 methylation was associated with younger patient age at diagnosis in 257 HGS ovarian carcinomas [14]. However, a larger study is needed to confirm these findings. Why somatic BRCA1 methylation is associated with younger age of diagnosis is not immediately clear, but deserves further investigation. Despite these similarities in clinical features, there were important differences between BRCA1 methylated and mutated ovarian carcinomas. BRCA1 methylation was not associated with longer overall survival. However, our power to detect a survival difference between BRCA1 methylated and unmethylated, non-mutated cases was limited by the small number of BRCA1 methylated cases in this series. In contrast, BRCA1 mutation was associated with longer survival and sensitivity to platinum chemotherapy, as previously shown [2,5–8,24]. Similarly, TCGA's study found that patients with BRCA1 or BRCA2 mutated carcinomas had longer overall survival than those with BRCA1 methylation or without alteration of BRCA1 or BRCA2 [1]. Some studies have shown that BRCA2 mutation carriers have improved 5-year survival compared to BRCA1 mutation carriers [3,8]. However, these studies were either very large [3] or studied a patient population with high BRCA1/2 mutation rates [8]. The current study was too small to separately compare survival in BRCA1 versus BRCA2 carriers. Similar to our findings for overall survival, we found no association between BRCA1 and RAD51C methylation and platinum sensitivity, but again, these analyses are limited by small numbers of methylated cancers. Ruscito et al. also found no significant difference in response to platinum chemotherapy between BRCA1 methylated and unmethylated cases, but did not account for mutation status [14]. The lack of an association with platinum sensitivity for cases with BRCA1 or RAD51C methylation is somewhat surprising as methylation of these genes in recurrent ovarian cancer has recently been associated with a high response to the PARP inhibitor rucaparib, suggesting that methylation confers a homologous recombination deficient phenotype [9]. BRCA1 and RAD51C promoter hypermethylation have also been recently associated with high genomic loss of heterozygosity (LOH), consistent with homologous recombination deficiency [9]. It is possible that some cases have only hemi-allelic BRCA1 promoter methylation without associated loss of heterozygosity, which would not be expected to impact therapeutic sensitivity. The lack of a survival advantage in patients with methylated ovarian carcinomas could also result from relatively rapid loss of methylation during treatment with platinum chemotherapy, as loss of methylation has been recently described in platinum and PARP inhibitor resistant ovarian carcinoma [25]. Alternatively, treatment with platinum chemotherapy could select for unmethylated carcinoma cells among an initially heterogeneous population. Unfortunately, we had few paired cases to test these hypotheses, and the only methylated primary carcinoma with a paired recurrent sample was also methylated in the recurrence. For that case, both the methylated primary carcinoma and the methylated paired recurrence responded well to platinum therapy. Baldwin et al. evaluated matched recurrent samples for two BRCA1 methylated primary cases, both of which were also methylated in the recurrence [16]. Patch et al. found one case in which the primary, platinum sensitive carcinoma was BRCA1 methylated while the platinum resistant recurrence was unmethylated [25]. In a larger series of 13 BRCA1 methylated primary ovarian carcinomas, 4 (31%) were unmethylated in a paired recurrent biopsy, though all were predicted to be platinum sensitive based on interval to recurrence [9]. Technical advances and declining costs have made sequencing patients' carcinomas more feasible. Genetic and genomic markers to direct anti-neoplastic therapies are becoming increasingly common; the poly ADP-ribose polymerase (PARP) inhibitor rucaparib was recently approved for treatment of recurrent ovarian cancer with germline and somatic mutations, making BRCA1 and BRCA2 mutations the first “actionable” somatic mutations in ovarian cancer associated with an approved, targeted therapy [26]. The role of promoter methylation (or loss of methylation) of specific genes and relationship to sensitivity or resistance to various therapies deserves additional study. Our data suggest that BRCA1 and RAD51C methylation are not associated with improved outcomes or with platinum sensitivity in patients with unselected primary ovarian carcinomas. Please cite this article as: S.S. Bernards, et al., Clinical characteristics and outcomes of patients with BRCA1 or RAD51C methylated versus mutated ovarian carcinoma, Gynecol Oncol (2017), https://doi.org/10.1016/j.ygyno.2017.12.004 S.S. Bernards et al. / Gynecologic Oncology xxx (2017) xxx–xxx Conflict of interest statement The authors have no conflicts of interest to declare. Funding University of Washington School of Medicine Medical Student Research Training Program (MSRTP) [SSB], Stand Up To Cancer – Ovarian Cancer Research Fund Alliance – National Ovarian Cancer Coalition Dream Team Translational Research Grant (Grant Number: SU2C-AACR-DT16-15) [EMS]. Stand Up to Cancer is a program of the Entertainment Industry Foundation; research grants are administered by the American Association for Cancer Research, a scientific partner of Stand Up To Cancer. V Foundation Translational Research Award [EMS]. References [1] D. Bell, et al., Integrated genomic analyses of ovarian carcinoma, Nature 474 (7353) (2011) 609–615. [2] K.P. Pennington, et al., Germline and somatic mutations in homologous recombination genes predict platinum response and survival in ovarian, fallopian tube, and peritoneal carcinomas, Clin. 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