Ovarian cancer stands as one of the deadliest malignant tumors affecting the female reproductive system. Its asymptomatic early stages lead to most patients receiving diagnoses at advanced stages, which complicates treatment and worsens prognosis. Even though ovarian cancer treatment has seen successes through surgery and chemotherapy procedures, major clinical challenges still exist due to high recurrence rates and drug resistance. Antibody-drug conjugates (ADCs) have gained recognition as a promising targeted therapy in cancer research during recent years. It fuses monoclonal antibodies with cytotoxic medications to deliver targeted cancer treatment while protecting healthy tissues from damage. The article will analyze how ADCs are used to treat ovarian cancer along with their influence on patient outcomes and will examine potential future research paths.

What is Ovarian Cancer?

Ovarian cancer describes malignant growths that develop from ovarian tissue. Pathological classification divides ovarian cancer into numerous subtypes, which include most commonly serous ovarian cancer as well as mucinous ovarian cancer, endometrioid ovarian cancer, and clear cell ovarian cancer. Ovarian cancer develops through a complex process that includes several different factors. The pathogenesis and treatment response of ovarian cancer differ across its various subtypes while presenting distinct clinical manifestations. Research findings illustrate that ovarian cancer development depends on genetic factors along with hormone levels, lifestyle choices, and environmental conditions. For example, ovarian cancer risk in women increases significantly when they carry BRCA gene mutations because these mutations serve as major genetic risk factors for the disease. Additionally, ovarian cancer occurrence has shown associations with long-term oral contraceptive use and having fewer childbirths.

Fig. 1. Ovarian cancer.

Ovarian Cancer Treatment

Treatment protocols for ovarian cancer now involve surgery followed by chemotherapy and radiotherapy along with targeted therapy. Surgical procedures aim to excise the maximum tumor mass possible, and chemotherapy serves to destroy remaining cancerous cells. Platinum-based agents like cisplatin and carboplatin, together with paclitaxel, represent the main chemotherapy drugs used. Radiotherapy serves as an infrequent treatment method for ovarian cancer, and doctors typically reserve it for patients experiencing local recurrence or who require palliative care. Radiotherapy provides symptom relief but does not effectively control distant metastatic spread. In recent years targeted therapy has emerged as an essential advancement in the treatment of ovarian cancer. Targeted drugs work directly on molecular targets found in tumor cells, including vascular endothelial growth factor (VEGF) and poly(ADP-ribose) polymerase (PARP). Targeted therapy delivers higher precision and reduced toxicity when compared to conventional chemotherapy, which leads to better survival outcomes and enhanced quality of life for patients. However, targeted therapy also encounters challenges, including the development of drug resistance alongside negative side effects.

Antibody-Drug Conjugate

ADCs are complexes that combine monoclonal antibodies with potent cytotoxic drugs through chemical linkers, aiming to achieve precise tumor targeting. This innovative cancer therapy integrates the targeting ability of monoclonal antibodies with the powerful cytotoxic effects of chemotherapy drugs, thereby enhancing therapeutic efficacy while minimizing damage to normal cells.

• Antibody-Drug Conjugate Structure

The structure of ADCs consists of three main components: the antibody, the small-molecule drug, and the linker.

• Antibody Component: The antibody is a crucial part of ADCs, capable of specifically recognizing and binding to antigens on the surface of tumor cells. By selecting an appropriate antibody, ADCs can precisely target tumor cells for therapy. For example, trastuzumab (Herceptin) is a monoclonal antibody targeting HER2, widely used for treating HER2-positive breast cancer.
• Small-Molecule Drug: The small-molecule drug is another essential part of ADCs, possessing strong cytotoxic properties to kill tumor cells. These drugs are typically modified chemotherapeutic agents, such as microtubule inhibitors and DNA-damaging agents. For instance, monomethyl auristatin E (MMAE) is a commonly used cytotoxic drug with potent antitumor activity.
• Linker: The linker is a chemical bond connecting the antibody to the small-molecule drug. The stability of the linker is critical for the efficacy and safety of ADCs. An ideal linker should remain stable in the bloodstream while efficiently releasing the drug inside tumor cells. For example, cleavable linkers such as valine-citrulline linkers can be enzymatically degraded in the acidic tumor microenvironment, thereby releasing the drug.

• Antibody-Drug Conjugate Mechanism of Action

The fundamental principle of ADCs is to use the targeting function of antibodies to precisely deliver small-molecule drugs to tumor cells. Once ADCs bind to antigens on the tumor cell surface, they are internalized and subsequently release the small-molecule drug within lysosomes. These drugs then act directly on the tumor cell nucleus or cytoskeleton, leading to tumor cell death.

• Targeting Mechanism: ADCs achieve precise localization by binding specific antibodies to antigens on the surface of tumor cells. For instance, trastuzumab deruxtecan (DS-8201/T-DXd) targets HER2, allowing the direct delivery of cytotoxic drugs to tumor cells.
• Endocytosis: After binding to the tumor cell surface antigen, ADCs enter the cell through receptor-mediated endocytosis. Within the cell, the ADC-antigen complex is enclosed in early endosomes, which subsequently fuse with lysosomes.
• Drug Release: In the acidic environment of lysosomes, the linker is enzymatically degraded, releasing the small-molecule drug. The released drug then diffuses into the cytoplasm and acts on intracellular targets such as microtubules or DNA.
• Cytotoxic Effects: The released small-molecule drug directly acts on the nucleus or cytoskeleton of tumor cells, inducing apoptosis. For example, microtubule inhibitors prevent cell division, while DNA-damaging agents disrupt the genetic material of the cells.

ADC for Ovarian Cancer

Ovarian Cancer and Antibody-Drug Conjugates

ADC holds great promise in the treatment of ovarian cancer, particularly in platinum-resistant ovarian cancer (PROC), where it has demonstrated significant potential. Currently, multiple ADCs are undergoing clinical trials in the field of ovarian cancer, with those targeting folate receptor alpha (FRα), HER2, and NaPi2b attracting the most attention. These drugs show great promise in overcoming chemotherapy resistance, prolonging progression-free survival (PFS), and improving patients' quality of life. Furthermore, with continuous advancements in antibody engineering, linker optimization, and highly potent cytotoxic payloads, the application prospects of ADCs in ovarian cancer treatment are becoming increasingly broad. In the future, by combining ADCs with immunotherapy, PARP inhibitors, or other targeted therapies, their efficacy is expected to be further enhanced, providing ovarian cancer patients with more precise and effective treatment options. The following are some approved or clinically investigated ADC drugs and their applications in ovarian cancer treatment.

• Mirvetuximab Soravtansine (MIRV)

• Mechanism of Action: MIRV is an ADC targeting folate receptor alpha (FRα). Since FRα is overexpressed in many ovarian cancer cells, MIRV binds to FRα and delivers cytotoxic drugs to cancer cells.
• Clinical Research Progress: In the SORAYA study, MIRV demonstrated significant efficacy in platinum-resistant ovarian cancer patients, particularly in those with high FRα expression. The FORWARD I study further confirmed the efficacy and safety of MIRV in platinum-resistant ovarian cancer patients. Additionally, the MIRASOL study indicated that MIRV has significant antitumor activity in patients with late-stage, high-grade epithelial ovarian cancer resistant to platinum-based therapy.
• Application Prospects: MIRV has been approved for the treatment of platinum-resistant ovarian cancer patients with FRα overexpression, providing a new treatment option for ovarian cancer.

• Upitifamab Rilsodotin (UpRi)

• Mechanism of Action: UpRi is an ADC targeting sodium-dependent phosphate transporter 2b (NaPi2b). Since NaPi2b is highly expressed in many ovarian cancer cells, UpRi binds to NaPi2b and delivers cytotoxic drugs to cancer cells.
• Clinical Research Progress: The UP-NEXT study is evaluating the efficacy and safety of UpRi in platinum-sensitive recurrent ovarian cancer patients. However, in 2023, the FDA suspended UpRi's clinical trials for platinum-sensitive ovarian cancer due to safety and efficacy concerns.
• Application Prospects: Although UpRi's application in platinum-sensitive ovarian cancer is currently restricted, its potential in platinum-resistant ovarian cancer still requires further investigation.

• Sacituzumab Govitecan (SG)

• Mechanism of Action: SG is an ADC targeting trophoblast cell surface antigen 2 (Trop-2). Since Trop-2 is highly expressed in many ovarian cancer cells, SG binds to Trop-2 and delivers cytotoxic drugs to cancer cells.
• Clinical Research Progress: SG has demonstrated promising antitumor activity in clinical trials for ovarian cancer, particularly in patients who have failed other treatments.
• Application Prospects: SG has been approved by the FDA for the treatment of triple-negative breast cancer, and its potential applications in ovarian cancer remain promising.

• Other ADCs

• IMGN853: IMGN853 is an ADC targeting folate receptor alpha (FRα), currently undergoing clinical trials for platinum-resistant ovarian cancer.
• SHR-A1921: SHR-A1921 is an ADC targeting Trop-2, and its clinical trials in ovarian cancer patients are also ongoing.

Advantages of Antibody-Drug Conjugates

• High Selectivity and Targeting Ability: The greatest advantage of ADC drugs is their high selectivity and targeting ability. Guided by specific antibodies, ADCs can precisely locate tumor cells, reducing damage to normal cells. This targeted therapy approach not only improves treatment efficacy but also significantly lowers side effects.
• Reduced Damage to Normal Cells: Compared with traditional chemotherapy drugs, ADCs release cytotoxic drugs more precisely. Cytotoxic drugs are only released when ADCs bind to tumor cells and undergo endocytosis. This mechanism minimizes damage to normal cells during treatment, improving patient tolerance.
• Enhanced Treatment Efficacy and Patient Survival Rates: Clinical trial data indicate that ADCs can significantly improve treatment outcomes and survival rates for ovarian cancer patients. For example, in some refractory ovarian cancer patients, ADC therapy has achieved partial or even complete remission, offering new hope for patients.

Limitations of Antibody-Drug Conjugates

• Toxicity and Side Effects: Although ADCs have high specificity, they still exhibit certain toxicities. For instance, some ADCs may cause bone marrow suppression, liver function abnormalities, and other side effects. These adverse reactions require close monitoring and management during treatment.
• Resistance Issues: Similar to traditional chemotherapy drugs, ADCs also face resistance problems. Tumor cells may evade ADC attacks through various mechanisms, leading to treatment failure. Overcoming resistance remains a significant challenge in the application of ADCs for ovarian cancer treatment.
• Manufacturing and Cost Challenges: The production of ADCs is complex, requiring precise control over the conjugation ratio of antibodies and small-molecule drugs. Additionally, the high cost of ADC research, development, and manufacturing limits their widespread clinical application.

Future Prospects of ADCs in Ovarian Cancer Treatment

• Exploration of New Targets: With advancements in molecular research on ovarian cancer, new therapeutic targets are continuously being discovered. Future ADC drug development will focus on designing agents targeting these novel biomarkers to enhance treatment efficacy and reduce resistance.
• Development of Novel Linkers: Creating more stable and efficient linkers is a key direction in ADC research. Novel linkers should remain stable in circulation while efficiently releasing cytotoxic payloads within tumor cells, thereby improving ADC efficacy and safety.
• Combination with Chemotherapy: Clinical studies have shown that combining ADCs with chemotherapy agents can significantly improve treatment outcomes. For example, in certain refractory ovarian cancer cases, combining ADCs with platinum-based drugs has achieved higher response rates and prolonged survival.
• Combination with Targeted Therapies: The combination of ADCs with targeted therapies is another important research area. For instance, the combination of ADCs with PARP inhibitors can exert synergistic effects, enhancing cytotoxicity against ovarian cancer cells.
• Genetic Testing and Precision Medicine: With advancements in genetic testing technologies, personalized medicine is playing an increasingly important role in ovarian cancer treatment. By analyzing a patient's genetic mutations, physicians can select the most suitable ADC therapy, enabling precision treatment.
• Development of Biomarkers: Identifying biomarkers that predict ADC efficacy is a crucial research focus. By detecting these biomarkers, clinicians can predict patient responses to ADCs before treatment, optimizing therapeutic strategies.

In Conclusion

As an innovative targeted therapy, ADCs have demonstrated immense potential in the treatment of ovarian cancer. Their high specificity allows for precise targeting of tumor cells, significantly improving therapeutic efficacy while minimizing damage to normal tissues. However, challenges such as toxicity, resistance, and production costs remain. In the future, with advancements in ADC drug development, combination therapies, and personalized medicine, ADCs are expected to play an increasingly vital role in ovarian cancer treatment. We look forward to ADCs bringing new hope and better prognoses for ovarian cancer patients.

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