Clear cell carcinoma is a clinically and pathologically distinct entity among surface epithelial ovarian neoplasms, recognized for its resistance to standard platinum-based chemotherapy at advanced stage disease and poor prognosis. Despite advances in our understanding of the biology of other surface epithelial ovarian neoplasms, very little is known about the molecular genetic mechanisms that are involved in clear cell tumorigenesis. Early mitotic inhibitor-1 (Emi1) protein is a key cell cycle regulator, that promotes S-phase and mitotic entry by inhibiting the anaphase promoting complex. In cell culture systems, overexpression of Emi1 leads to tetraploidy and genomic instability, especially in the absence of normal p53 function. We investigated Emi1 protein expression in ovarian neoplasms using a tissue microarray constructed from 339 primary ovarian surface epithelial (serous, endometrioid, clear cell, and mucinous) and peritoneal (serous) neoplasms, stromal and mesenchymal tumors, germ cell tumors, and normal ovarian tissue. Significant overexpression of Emi1 protein was present in 82% (27/33) clear cell carcinoma, including one borderline tumor in a diffuse, granular cytoplasmic and perinuclear staining pattern, independent of patient age, presence of ovarian and/or pelvic endometriosis, and FIGO stage. In contrast, only 10% (17/177) primary ovarian and primary peritoneal serous carcinomas, 0% (0/10) mucinous carcinomas, and 19% (6/32) endometrioid carcinomas exhibited significant Emi1 protein overexpression. Accumulation of Emi1 protein was not linked to Ki-67 labeling index, but was directly correlated with cyclin E and inversely correlated with ER in clear cell carcinoma (Po0.001). Compared to the serous surface epithelial subtype, which comprises the majority of ovarian carcinomas, clear cell carcinoma is less common (less than 15%) and is frequently associated with ovarian and/or pelvic endometriosis, paraneoplastic hypercalcemia, and thromboembolic complications. Unlike its serous counterpart, clear cell carcinoma frequently presents at low FIGO stage and exhibits a comparatively poor response to conventional platinum-based chemotherapy at high-stage disease. The pathologic features of clear cell carcinoma are distinctive. Clear cell carcinoma, originally thought to be of mesonephric origin by Schiller (hence the old term 'mesonephroma'), is noted for its characteristic hobnail cells, clear cytoplasm, and mixed glandular, solid and tubulocystic architecture. In recent years, a dualistic model for the development and progression of ovarian cancer has been proposed, based in part on the presence or absence of recognizable precursor lesions.2 The evidence