Notes: Abstract Background: Conflicting data have been reported about the associationbetween glutathione S-transferase (GST), a family of proteins implicated indetoxification of cytotoxic drugs in human ovarian in vitro models, andresponse to chemotherapy and prognosis in ovarian cancer patients. The aim ofthis study was to analyze the possible clinical role of GST activity in alarge series of primary ovarian cancer patients. Patients and methods: The study included a large series of primaryuntreated ovarian cancer patients who underwent cytoreductive surgery andchemotherapy and who were followed up in a single institution. GST activitylevels were assessed in tumor extracts by using a biochemical assay. A cut-offof 250 units of enzymatic activity was chosen according to the receiveroperating characteristics (ROC) curve. Results: GST activity levels were distributed in an asymmetrical manner(median: 266 units; range: 4–918 units) and did not seem to beassociated with stage, histopathological grading, ascites, or residual tumorafter surgery. Higher GST activity levels were found in patients who respondedto chemotherapy (median: 298 units, range: 50–691) than in those whoresponded only partially (median: 227 units, range: 19–747) or not atall to chemotherapy (median: 246 units, range: 4–811) (H = 7.02, P =0.029). Moreover, the percentage of cases with 〉250 units was significantlyhigher among complete responders (66%) than partial responders(37%) or non-responders (48%) (χ2 = 7.32;P = 0.025). When multivariate analysis, including clinico-pathologicalparameters and GST activity status as predictors of response to chemotherapy,was carried out, residual tumor, stage and GST status retained independentpredictive value. Patients with high GST activity had more favourableprognosis than those with low GST activity. The median PFS was 42 months forpatients with high GST activity compared to 17 months for those with low GSTactivity (P = 0.037). The median overall survival was 72 months forhigh-GST-activity and42 months for low-GST-activity patients (P = 0.043). Substantially similarresults were obtained in the subgroup of stage II–III–IV ovariancancer patients. Multivariate analysis including the clinico-pathologicalparameters and GST activity status was performed in stage III–IV ovariancancer patients: Stage IV disease, residual tumor 〉2 cm, the presence ofascites and low GST activity status retained independent negative prognosticroles. Conclusion: A direct association between high GST activity and a betterclinical outcome in terms of response to chemotherapy and survival has beenobserved in a large series of primary untreated ovarian cancer patients. Theseresults, which are contrary to the expectations raised by in vitro studies,emphasize the need for caution when translating in vitro-generated hypothesesto the clinical setting.