A 3D Bioprinted Hormone-producing Model for BRCA Mutated Patients After Risk Reducing Surgery: the DISC-OVARY Trial
Phase: NA
Conditions: BRCA Mutation, Estrogen Deficiency, Surgical Menopause, Menopause Related Conditions, Menopause, Premature, Ovarian Cancer
Sponsor: Fondazione Policlinico Universitario Agostino Gemelli IRCCS

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Protocol Title 
 
A 3D bioprinted hormone-producing model for BRCA mutated patients 
after Risk Reducing Surgery:  the DISC-OVARY trial 
 
(Version 2 –10/01/2024) 
PI:  
Dott.ssa C. Marchetti 
 
Co-PI:  
Dott.ssa A. Battaglia 
Dott.ssa R. Ergasti 
Prof.ssa A. Fagotti 
Prof. M. Papi 
Dott.ssa C.M. Sassu 
Prof. G. Scambia 
 

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1. SYNOPSIS 
 
Title 
A 3D bioprinted hormone-producing model for BRCA mutated patients after Risk Reducing 
Surgery:  the DISC-OVARY trial 
Version 
2.0 (10.01.2024) 
PI 
Dott.ssa Claudia Marchetti 
Co-PI 
Dott.ssa A. Battaglia; Dott.ssa R. Ergasti; Prof.ssa A. Fagotti; Prof. M. Papi; Dott.ssa C.M. Sassu; 
Prof. G. Scambia. 
Promoter, 
coordinator center 
Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 
Rome, Italy; Department Woman and Child Health Sciences, Universita' Cattolica del Sacro 
Cuore, Rome, Italy 
Collaborator 
centers 
none 
Background 
Women carrying germline BReast CAncer gene (BRCA) 1/2 mutations have an increased 
lifetime risk of breast and ovarian cancers [1,2]. Risk-reducing salpingo-oophorectomy 
(RRSO) by the age of 40 (postponable to age of 45 for BRCA2mut)[3] is the standard of 
care in ovarian cancer risk reduction (about 80%)[4]. Although potentially lifesaving, 
RRSO may negatively affect quality of life and impair long-term health.   
 
To overcome these side effects, hormone replacement therapy (HRT) is crucial but 
remains a major concern, especially due to its negative effects (potential breast cancer 
risk[9], thromboembolic events[10]) and, overall, due to the long-term safety lack of 
data. Preliminary data from the literature revealed that only 70% of gynecologists 
recommend HRT after RRSO due to oncological safety concerns and low women’s 
requests (more than 70% of cases were oral prescriptions, while only 24% preferred 
local administration) [5].  
 
In conclusion, for some women, the concern of menopause risks act as a deterrent for 
a lifesaving procedure (RRSO). In this scenario, it is fundamental to provide a new 
strategy for BRCA mutated patients, in order to reduce menopausal drawbacks without 
exposing them to a higher breast cancer risk, reproducing the physiological hormonal 
rhythm without compliance issue.  

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Rationale 
Selecting theca and granulosa cells from removed ovaries of BRCA1/2mut patients 
undergoing RRSO and developing a 3D bioprinted hormone-producing bioprosthetic 
model. If efficacy and tolerability are confirmed in vivo, this bioprosthetic model might 
be used to replace hormones’ production in BRCA mutated patients undergoing 
prophylactic surgery.  
Type of the study 
Feasibility single-institution study 
Primary endpoint 
Develop a 3D bioprinted model able to produce estrogens and progesterone and 
confirm in vitro functionality. 
Sample size 
No study has previously investigated the feasibility of 3D bioprinted hormone-
producing model, hence this configures as a pilot study which, as such, does not need 
any formal sample size calculation.  
Inclusion criteria 
- Women between 18-40 y.o; 
- BRCA1/2 germline mutations; 
- Completed childbearing; 
- Willing to undergo RRSO; 
- Negative final histological examination; 
- No previous breast cancer. 
Exclusion criteria 
- Other malignancies; 
- final histological examination reporting malignant disease (any); 
- desire of fertility sparing. 
Bibliography 
1. Antoniou et al., Am J Hum Genet 2003 
2. Gabaldó Barrios et al., Fam Cancer 2017 
3. Dwyer et al., NCCN Guidelines ®  2023 
4. Marchetti et al., BMC Womens Health 2014 
5. Palaia et al., Int J Gynecol Can 2022 
6. Taneja et al., Front Immunol 2018 
 
 
 
 

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Background and Rationale  
 
Women carrying germline BReast CAncer gene (BRCA) 1/2 mutations have an increased lifetime risk 
of breast and ovarian cancers (72% and 44% for BRCA1 and 69% and 17% for BRCA2, respectively) 
[1,2]. Risk-reducing salpingo-oophorectomy (RRSO) by the age of 40 (postponable to age of 45 for 
BRCA2mut)[3] is the standard of care in ovarian cancer risk reduction (about 80%)[4].  Although 
potentially lifesaving, RRSO may negatively affect quality of life and impair long-term health[5,6] 
(cardiovascular disease, osteoporosis[7] and impairment of immune response[8]).  
 
To overcome these side effects, hormone replacement therapy (HRT) is crucial but remains a major 
concern, especially due to its negative effects (potential breast cancer risk[9], thromboembolic 
events[10]) and, overall, due to the long-term safety lack of data. Synthetic and animal-derived 
hormones seem to be associated with breast cancer risk[11].  Although breast cancer risk is lower for 
bioidentical hormones (i.e. estriol)[12], data continue to be discordant. Several evidence still sustain 
estriol’s impact on breast cancer (especially for lobular histotype; OR 2.0, 95% CI 1.3–3.2)[13] and 
endometrial disease (endometrial cancer: OR 3.0, 95% CI 2.0-4.4 and endometrial atypical 
hyperplasia: OR 8.3, 95% CI 4.0-17.4, respectively)[14]. Furthermore, estriol’s efficacy on 
cardiovascular disease and osteoporosis is still unclear when compared to other estrogen 
compounds[15]. Side effects of estriol therapy may include breast tenderness, nausea, bloating, 
mood changes, headache, and vaginal bleeding or spotting[16]. Moreover, all the HRT’s 
administration routes (oral, transdermal, and vaginal) need daily/frequent assumption, thus 
compliance of the patients is essential and adherence to long-term therapy in developed countries is 
reported around 50% with a high risk of forgetfulness or discontinuation[17–19]. Each route also has 
specific disadvantages (i.e. the risk of thromboembolism in the oral one[20]). Finally, HRT may 
influence other hormones’ production: it increases T4 dosage requirements of women being treated 
for primary hypothyroidism as well as alter the pituitary-thyroid axis in euthyroid women[21]. While 
for cortisol level findings are still inconsistent[22], hormone exogenous intake does not permit to 
follow the daily hormonal fluctuation. Aging and hypoestrogenism, in postmenopausal women, 
determine immune system changes which may play a crucial role in the development of 
postmenopausal diseases (diabetes or atherosclerosis) and may be negatively influenced by HRT [23]. 
Preliminary data of a recent MITO group survey revealed that only 70% of gynecologists recommend 
HRT after RRSO due to oncological safety concerns and low women’s requests (more than 70% of 
cases were oral prescriptions, while only 24% preferred local administration) [24].  
 
In conclusion, for some women, the concern of menopause risks act as a deterrent for a lifesaving 
procedure (RRSO). In this scenario, it is fundamental to provide a new strategy for BRCA mutated 
patients, in order to reduce menopausal drawbacks without exposing them to a higher breast cancer 
risk, reproducing the physiological hormonal rhythm without compliance issue. Our 3D bioprinted 
hormone-producing model from patients' own autologous cells could meet this need. 
 
HYPOTHESIS 
 
We hypothesize to select theca and granulosa cells from removed ovaries of BRCA1/2mut patients 
undergoing RRSO, avoiding the epithelial ones at risk of developing cancer, and use those cells to 

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develop a 3D bioprinted hormone-producing bioprosthetic model in order to replace patients' own 
production.  
 
AIMS 
 
Primary endpoint: Develop a 3D bioprinted model able to produce estrogens and progesterone and 
confirm in vitro functionality. 
 
 
EXPERIMENTAL DESIGN 
 
No study has previously investigated the feasibility of 3D bioprinted hormone-producing model, 
hence this configures as a pilot study which, as such, does not need any formal sample size 
calculation.  
The proposed research project aims to select theca and granulosa cells from patients’ removed 
ovaries, combine them with different ratios of extracted mesenchymal cells; print them onto the 
prosthetic model scaffolds and assess its hormone production.  
   
 
The Project Team will include young, dedicated and selected members from:  
- 
Department of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli 
IRCCS: the “Genetic/Familial high-risk patients’ clinic” (where Dr. Marchetti is already currently 
involved) and Operating Rooms (for blood and tissue samples’ collection)  
- 
3D Bioprinting Facility, to enable the fabrication of three-dimensional structures using living cells 
and biomaterials.  
- 
Operational Unit of Gynecologic Pathology and Breast Pathology 
 
IMPACT ON CANCER 
 
The results of this pilot project will provide a 3D bioprinted model able to produce estrogens and 
progesterone in vitro. If functionality is confirmed in vivo, our model might be used in BRCA mutated 
patients allowing them to avoid surgery induced menopause’s side effects. Specifically, a 3D 
bioprinted hormone-producing bioprosthetic model would provide patients with a viable alternative 
to surgery-induced menopause and traditional HRT.