The lethality of ovarian cancer stems from its propensity to involve the peritoneal cavity. However, the mechanisms that enable ovarian cancer cells to readily adapt to the peritoneal environment are not well understood. Here, we describe our recent studies in which we identified the mechanisms by which the transcription factor encoded by the patterning gene HOXA9 promotes the aggressive behavior of ovarian cancer. Firstly, we identified that HOXA9 promotes ovarian tumor growth and angiogenesis

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... by activating the gene encoding transforming growth factor-2 (TGF-2), which in turn stimulates peritoneal fibroblasts and mesenchymal stem cells to acquire features of cancer-associated fibroblasts. Secondly, by inducing TGF-2 and chemokine (C-C motif) ligand 2, HOXA9 stimulates peritoneal macrophages to acquire an immunosuppressive phenotype. Thirdly, HOXA9 stimulates attachment of ovarian cancer cells to peritoneal mesothelial cells by inducing expression of P-cadherin. By inducing P-cadherin, HOXA9 also enables floating cancer cells in the peritoneal cavity to form aggregates and escape anoikis. Together, our studies demonstrate that HOXA9 enables ovarian cancer cells to adapt to the peritoneal environment and 'educates' different types of stromal cells to become permissive for tumor growth. Our studies provide new insights into the regulation of tumor-stroma interactions in ovarian cancer and implicate several key effector molecules as candidate therapeutic targets.