**6. GCT-derived cell lines**

The human KGN and COV434 cell lines, have been thought to be derived from GCT, and are extensively used in studies of GCT as well as to model normal GC function. Both cell lines exhibit some features that are reminiscent of normal proliferating GC, including a functional FSH receptor and aromatase activity. Jamieson *et al.* analyzed the FOXL2 status of both cell lines [70], concluding the COV434 cells lack FOXL2 expression and indeed the C134W mutation, lending to the assumption that they are derived from a jGCT [70]. In contrast, the KGN cell line (established from a metastatic aGCT), expresses FOXL2 and is heterozygous for the FOXL2 mutation, which is consistent with it being derived from an aGCT [70]. Both cell lines were established from patients with advanced aggressive disease.

Both KGN and COV434 cell lines are notable for constitutive activity of the NFκB and Braf/ERK signaling pathways [91, 95, 103]. A molecular study using a transcriptomic approach conducted by Rosario *et al.* was used to identify potential targets of FOXL2 in KGN and COV434 cells [104]. They observed that many of the genes regulated by wild-type FOXL2 were also regulated by the mutant FOXL2, notably genes involved in the transforming growth factor-beta (TGF-β) signaling pathway. Their analysis also highlighted the significant differences between the COV434 and the KGN gene-expression profiles [104]. In our transcriptomic analysis of aGCT [83], we observed over 3000 entities that differed greater than twofold (p value of *<*0.05) when 12 aGCT were compared with the KGN cells. This was in stark contrast to only 24 differentially expressed genes observed when comparing the stages 1 and 3 aGCT. Thus, although the two cell lines are valuable tools in the analysis of signaling pathways in the context of both GCT and indeed GC, they do not assist in the genomic and/or genetic analysis of aGCT.

The classification of COV434 as a GCT-derived cell line has been questioned. Recent studies show that this cell line was likely derived from a small-cell carcinoma of the ovary hypercalcemic-type (SCCOHT) [105–107]. The cell of origin of these tumors is unknown, with reports postulating they are likely derived from the germ cells [108]. Recent advances in molecular genetics have indicated that SCCOHT can be regarded as an ovarian malignant teratoid/rhabdoid tumor (MRT) [109]. SCCOHT are characterized by the loss of both SMARCA2 and SMARCA4, which are also not expressed in COV434 cells [105, 107]. Moreover, the lack of expression of RUNX2 and high expression of RUNX3 in COV434 suggests that these cells do not represent primary jGCT [106]. Noticeably, the study of Karnezis *et al.* indicates that COV434 cell line has all morphological, immunohistochemical, genetic and clinical

**75**

for tumor progression [121–123].

**8. Treatment strategies for SCST**

limited studies performed to date.

*Genetics and Mutational Landscape of Ovarian Sex Cord-Stromal Tumors*

mice increases when transplanting with COV434 [107].

characteristics of SCCOHT [107]. They also noted that the level of serum calcium in

A number of mouse models in which GCT arise have been reported, however none truly recapitulate the human disease [2, 110]. Liu *et al.* have described the development of GCT in mice with conditional inactivation of FOXO1/3 in GC [110]. The development of these tumors was accelerated with perturbation of the multi-functional tumor suppressor gene PTEN. An examination of PTEN and FOXO1/3 expression in five primary human aGCT samples found low expression for each [110], leading them to conclude that this mouse model, in contrast to others, shares some characteristics with aGCT. Arguably however, involvement of PTEN in the model, is more consistent with activation of PI3K/AKT which is more of a feature of jGCT. It should be noted that neither mutation, over-expression of PIK3CA or PIK3R1, nor loss of expression of PTEN, has been reported in aGCT [111]. Work from Lague *et al.* has provided evidence in mouse models for a synergistic effect of the Wnt/β-catenin and PI3K/AKT pathways in the formation of GCT, which is of interest given the potential role for AKT1 mutations in jGCT [112]. Wnt/β-catenin signaling pathway has well established roles in ovarian development and in GC function [2]. Although dysregulation of Wnt/β-catenin signaling has been identified in many human cancers, there is no evidence for activation of this pathway in human GCT [113, 114], which contrasts to equine GCT where there is clear evidence of Wnt/β-catenin signaling activation [113]. Increased ovarian R-spondin1 signaling, which modulates Wnt signaling is associated with GC-like tumors [115]. Gao *et al.* targeted expression of a constitutively activated TGF-β receptor to GC and found GCT that were associated with elevated inhibin and estrogen levels [116] as is seen in human GCT which perhaps more closely recapitulates the clinical situation than earlier models in which inhibin gene deletion resulted in GCT (see below) [117]. One of the downstream consequences of this activation is again, increased AKT signaling. The knockout of the inhibin α subunit (shared by both inhibin A and B) causes the development of SCST in mice of both sexes as early as four weeks [117–119]. In these inhibin α null mice, FSH levels has increased by two to three fold which correspond to inhibin's physiological function to suppress FSH [118]. However, a double knockout of inhibin α and FSH unexpectedly showed development of gonadal tumors in the mice; the tumors developed after 12 weeks of age [117–121]. The inhibin α knockout led to increasing levels of activin which induce the activation of SMAD2/3 signaling pathway in GC [117, 121]. The study of Madh3 (SMAD3-null) and inhibin α double knockout mice demonstrated slow progression of tumor growth; SMAD 3 is thus important

The uncommon nature of SCST limits the ability to develop targeted therapies and evaluate them in well-powered clinical trials. A recent search of clinicaltrials. gov showed only 11 trials that are either active of recruiting involving SCSTs, with only five completed results described. The application of new sequencing technologies may lead to the discovery of novel driver genes that lead to these rare ovarian cancers. However, as discussed above, these have so far been elusive from the

*DOI: http://dx.doi.org/10.5772/intechopen.97540*

**7. Animal models of ovarian SCST**

characteristics of SCCOHT [107]. They also noted that the level of serum calcium in mice increases when transplanting with COV434 [107].
