Abstract
Ovarian high-grade serous carcinoma (HGSC) is characterized by extensive intra-peritoneal dissemination and tumor heterogeneity. In the metastatic cascade, tumors utilize several transcriptional programs to translocate and survive in distant tissues. Here, we analyzed multi-modal, real-world data from 350 tumor samples across 160 patients with HGSC to identify transcriptional programs that drive intra-peritoneal metastasis and heterogeneity. We identified nine transcriptional programs, including those regulating epithelial-mesenchymal transition and immune modulation and cytoskeletal reorganization, which shape distinct metastatic trajectories to solid and ascitic environments and are associated to treatment response. Our results reveal pronounced intra-patient transcriptional heterogeneity, which in some cases surpassed inter-patient heterogeneity, highlighting the importance of multi-site sampling for accurate prognostication and combinatorial treatments in HGSC. Our extensive characterization offers novel insights into intra-peritoneal metastasis with significant prognostic implications, reveals histomorphological biomarkers for patient stratification and paves the way for innovative therapeutic strategies aimed at impairing cancer cell adaptability and limiting metastasis.