Adult-type granulosa cell tumor (aGCT) is a rare malignant ovarian sex cord-stromal tumor, harboring recurrent FOXL2 c.C402G/p.C134W hotspot mutations in 97% of cases. These tumors are considered to have a favorable prognosis, however aGCTs have a tendency for local spread and late recurrences, which are associated with poor survival rates. We sought to determine the genetic alterations associated with aGCT disease progression. We subjected primary non-recurrent aGCTs (n = 7), primary aGCTs that subsequently recurred (n = 9) and their matched recurrences (n = 9), and aGCT recurrences without matched primary tumors (n = 10) to targeted massively parallel sequencing of ≥410 cancer-related genes. In addition, three primary non-recurrent aGCTs and nine aGCT recurrences were subjected to FOXL2 and TERT promoter Sanger sequencing analysis. All aGCTs harbored the FOXL2 C134W hotspot mutation. TERT promoter mutations were found to be significantly more frequent in recurrent (18/28, 64%) than primary aGCTs (5/19, 26%, p = 0.017). In addition, mutations affecting TP53, MED12, and TET2 were restricted to aGCT recurrences. Pathway annotation of altered genes demonstrated that aGCT recurrences displayed an enrichment for genetic alterations affecting cell cycle pathway-related genes. Analysis of paired primary and recurrent aGCTs revealed that TERT promoter mutations were either present in both primary tumors and matched recurrences or were restricted to the recurrence and absent in the respective primary aGCT. Clonal composition analysis of these paired samples further revealed that aGCTs display intra-tumor genetic heterogeneity and harbor multiple clones at diagnosis and relapse. We observed that in a subset of cases, recurrences acquired additional genetic alterations not present in primary aGCTs, including TERT, MED12, and TP53 mutations and CDKN2A/B homozygous deletions. Albeit harboring relatively simple genomes, our data provide evidence to suggest that aGCTs are genetically heterogeneous tumors and that TERT promoter mutations and/or genetic alterations affecting other cell cycle-related genes may be associated with disease progression and recurrences.

成人型颗粒细胞瘤 (aGCT) 是一种罕见的恶性卵巢性索间质肿瘤，97% 的病例中存在复发性FOXL2 c.C402G/p.C134W 热点突变。这些肿瘤被认为具有良好的预后，但 aGCT 具有局部扩散和晚期复发的倾向，这与较差的生存率相关。我们试图确定与 aGCT 疾病进展相关的遗传改变。我们对原发性非复发性 aGCT ( n  = 7)、随后复发的原发性 aGCT ( n = 9) 及其匹配的复发 ( n  = 9) 以及无匹配原发性肿瘤的 aGCT 复发 ( n  = 10) 进行了靶向大规模并行测序≥410 个癌症相关基因。此外，对 3 个原发性非复发 aGCT 和 9 个 aGCT 复发进行了FOXL2和TERT启动子 Sanger 测序分析。所有 aGCT 均含有FOXL2 C134W 热点突变。发现复发性 aGCT 中TERT启动子突变 (18/28, 64%) 的频率明显高于原发性 aGCT (5/19, 26%, p  = 0.017)。此外，影响TP53、MED12和TET2的突变仅限于 aGCT 复发。改变基因的通路注释表明，aGCT 复发显示出影响细胞周期通路相关基因的遗传改变的富集。对配对原发性和复发性 aGCT 的分析表明，TERT启动子突变要么存在于原发性肿瘤和匹配的复发中，要么仅限于复发且在各自的原发性 aGCT 中不存在。这些配对样本的克隆组成分析进一步揭示，aGCT 显示肿瘤内遗传异质性，并在诊断和复发时存在多个克隆。我们观察到，在一部分病例中，复发获得了原发性 aGCT 中不存在的额外遗传改变，包括TERT、MED12和TP53突变以及CDKN2A/B纯合缺失。尽管基因组相对简单，但我们的数据提供的证据表明，aGCT 是遗传异质性肿瘤，TERT启动子突变和/或影响其他细胞周期相关基因的遗传改变可能与疾病进展和复发有关。