Evaluation of liquid from the Papanicolaou test and other liquid biopsies for the detection of endometrial and ovarian cancers

Endometrial and ovarian cancers can be detected through the analysis of DNA from Pap test fluids, intrauterine samples, and plasma. Brushing up on early cancer detection Despite the many recent advances in cancer diagnosis and treatment, ovarian cancer remains one of the most lethal malignancies, in part because there are no accurate screening methods for this disease and it is often diagnosed at a late stage. To develop a screening tool for ovarian and endometrial cancers, Wang et al. combined genetic analysis of fluids obtained through routine Papanicolau testing, normally done for cervical cancer, with analysis of tumor DNA circulating in the blood. The authors also used intrauterine sampling with Tao brushes to further increase the sensitivity of detection for the less accessible tumors. We report the detection of endometrial and ovarian cancers based on genetic analyses of DNA recovered from the fluids obtained during a routine Papanicolaou (Pap) test. The new test, called PapSEEK, incorporates assays for mutations in 18 genes as well as an assay for aneuploidy. In Pap brush samples from 382 endometrial cancer patients, 81% [95% confidence interval (CI), 77 to 85%] were positive, including 78% of patients with early-stage disease. The sensitivity in 245 ovarian cancer patients was 33% (95% CI, 27 to 39%), including 34% of patients with early-stage disease. In contrast, only 1.4% of 714 women without cancer had positive Pap brush samples (specificity, ~99%). Next, we showed that intrauterine sampling with a Tao brush increased the detection of malignancy over endocervical sampling with a Pap brush: 93% of 123 (95% CI, 87 to 97%) patients with endometrial cancer and 45% of 51 (95% CI, 31 to 60%) patients with ovarian cancer were positive, whereas none of the samples from 125 women without cancer were positive (specificity, 100%). Finally, in 83 ovarian cancer patients in whom plasma was available, circulating tumor DNA was found in 43% of patients (95% CI, 33 to 55%). When plasma and Pap brush samples were both tested, the sensitivity for ovarian cancer increased to 63% (95% CI, 51 to 73%). These results demonstrate the potential of mutation-based diagnostics to detect gynecologic cancers at a stage when they are more likely to be curable.

[1]  Susan J. Curry,et al.  Screening for Ovarian Cancer: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement , 2012, Annals of Internal Medicine.

[2]  A. Mariani,et al.  Incidence and factors associated with synchronous ovarian and endometrial cancer: a population-based case-control study. , 2012, Gynecologic oncology.

[3]  M. Hendrickson,et al.  Uterine papillary serous and clear cell carcinomas predict for poorer survival compared to grade 3 endometrioid corpus cancers , 2006, British Journal of Cancer.

[4]  T. Kitanaka,et al.  A randomized study of screening for ovarian cancer: a multicenter study in Japan , 2007, International Journal of Gynecologic Cancer.

[5]  M. Ladanyi,et al.  Therapy-Related Clonal Hematopoiesis in Patients with Non-hematologic Cancers Is Common and Associated with Adverse Clinical Outcomes. , 2017, Cell stem cell.

[6]  I. Shih,et al.  Molecular pathogenesis and extraovarian origin of epithelial ovarian cancer--shifting the paradigm. , 2011, Human pathology.

[7]  H. Meden,et al.  CA 125 in Benign Gynecological Conditions , 1998, The International journal of biological markers.

[8]  Ludmila V. Danilova,et al.  Detection and localization of surgically resectable cancers with a multi-analyte blood test , 2018, Science.

[9]  K. Kinzler,et al.  Serial assessment of human tumor burdens in mice by the analysis of circulating DNA. , 2007, Cancer research.

[10]  D. Oram,et al.  Risk of epithelial ovarian cancer in asymptomatic women with ultrasound‐detected ovarian masses: a prospective cohort study within the UK collaborative trial of ovarian cancer screening (UKCTOCS) , 2012, Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology.

[11]  Benjamin J. Raphael,et al.  Integrated Genomic Analyses of Ovarian Carcinoma , 2011, Nature.

[12]  K. Kinzler,et al.  Evaluation of DNA from the Papanicolaou Test to Detect Ovarian and Endometrial Cancers , 2013, Science Translational Medicine.

[13]  G. Mills,et al.  High frequency of PIK3R1 and PIK3R2 mutations in endometrial cancer elucidates a novel mechanism for regulation of PTEN protein stability. , 2011, Cancer discovery.

[14]  B. Reva,et al.  Genomic Analysis of Uterine Lavage Fluid Detects Early Endometrial Cancers and Reveals a Prevalent Landscape of Driver Mutations in Women without Histopathologic Evidence of Cancer: A Prospective Cross-Sectional Study , 2016, PLoS medicine.

[15]  E. Lengyel,et al.  Genomics of Ovarian Cancer Progression Reveals Diverse Metastatic Trajectories Including Intraepithelial Metastasis to the Fallopian Tube. , 2016, Cancer discovery.

[16]  L. Geldenhuys,et al.  Sensitivity and Specificity of the Pap Smear for Glandular Lesions of the Cervix and Endometrium , 2007, Acta Cytologica.

[17]  B. Ebert,et al.  Clonal hematopoiesis of indeterminate potential and its distinction from myelodysplastic syndromes. , 2015, Blood.

[18]  Ie-Ming Shih,et al.  The Origin and Pathogenesis of Epithelial Ovarian Cancer: A Proposed Unifying Theory , 2010, The American journal of surgical pathology.

[19]  K. Kinzler,et al.  Detection of aneuploidy in patients with cancer through amplification of long interspersed nucleotide elements (LINEs) , 2018, Proceedings of the National Academy of Sciences.

[20]  Thorsten Verch,et al.  The use of multiple novel tumor biomarkers for the detection of ovarian carcinoma in patients with a pelvic mass. , 2008, Gynecologic oncology.

[21]  K. Kinzler,et al.  Detection and quantification of rare mutations with massively parallel sequencing , 2011, Proceedings of the National Academy of Sciences.

[22]  M. Choti,et al.  Detection of Circulating Tumor DNA in Early- and Late-Stage Human Malignancies , 2014, Science Translational Medicine.

[23]  A. Bardelli,et al.  Integrating liquid biopsies into the management of cancer , 2017, Nature Reviews Clinical Oncology.

[24]  L. Wood,et al.  Cancer‐Associated Mutations in Endometriosis without Cancer , 2017, The New England journal of medicine.

[25]  J. Gohagan,et al.  Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. , 2011, JAMA.

[26]  R. Drapkin,et al.  Modeling high-grade serous ovarian carcinogenesis from the fallopian tube , 2011, Proceedings of the National Academy of Sciences.

[27]  Kathleen R. Cho,et al.  ‘High‐grade serous carcinomas arise in the mouse oviduct via defects linked to the human disease’ , 2017, The Journal of pathology.

[28]  Gretchen A. Stevens,et al.  Global burden of cancer attributable to high body-mass index in 2012: a population-based study. , 2015, The Lancet. Oncology.

[29]  K. Kinzler,et al.  Cancer Genome Landscapes , 2013, Science.

[30]  Yeon Jeong Kim,et al.  Intron retention is a widespread mechanism of tumor-suppressor inactivation , 2015, Nature Genetics.

[31]  K. Kinzler,et al.  Diagnostic potential of tumor DNA from ovarian cyst fluid , 2016, eLife.

[32]  Matthew Burnell,et al.  Sensitivity of transvaginal ultrasound screening for endometrial cancer in postmenopausal women: a case-control study within the UKCTOCS cohort. , 2011, The Lancet. Oncology.

[33]  K. Kinzler,et al.  Detection of Somatic TP53 Mutations in Tampons of Patients With High-Grade Serous Ovarian Cancer , 2014, Obstetrics and gynecology.

[34]  J. Reagan,et al.  Significance of endometrial cells in the detection of endometrial carcinoma and its precursors. , 1974, Acta cytologica.

[35]  L. Tao.  Direct intrauterine sampling: The IUMC endometrial sampler , 1997, Diagnostic cytopathology.

[36]  David A. Fishman,et al.  The role of ultrasound evaluation in the detection of early-stage epithelial ovarian cancer. , 2005, American journal of obstetrics and gynecology.

[37]  T. Elsheikh,et al.  Endometrial brush biopsy (Tao brush). Histologic diagnosis of 200 cases with complementary cytology: an accurate sampling technique for the detection of endometrial abnormalities. , 2000, American journal of clinical pathology.

[38]  D. Oram,et al.  Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial , 2016, The Lancet.

[39]  I. Shih,et al.  The Dualistic Model of Ovarian Carcinogenesis: Revisited, Revised, and Expanded. , 2016, The American journal of pathology.

[40]  P. A. Futreal,et al.  Intratumor heterogeneity and branched evolution revealed by multiregion sequencing. , 2012, The New England journal of medicine.

[41]  D. Bae,et al.  Prognostic Factors in Women With Synchronous Endometrial and Ovarian Cancers , 2014, International Journal of Gynecologic Cancer.

[42]  J. Sorosky,et al.  Clinical Significance of Atypical Glandular Cells on Cervical Cytology , 2006, Obstetrics and gynecology.

[43]  K. Kinzler,et al.  Detection of somatic mutations and HPV in the saliva and plasma of patients with head and neck squamous cell carcinomas , 2015, Science Translational Medicine.

[44]  Bert Vogelstein,et al.  DETECTION OF CIRCULATING TUMOR DNA IN EARLY AND LATE STAGE HUMAN MALIGNANCIES , 2014 .

[45]  K. Kinzler,et al.  FAST-SeqS: A Simple and Efficient Method for the Detection of Aneuploidy by Massively Parallel Sequencing , 2012, PloS one.

[46]  J. Sampalis,et al.  Assessment of symptomatic women for early diagnosis of ovarian cancer: results from the prospective DOvE pilot project. , 2012, The Lancet. Oncology.

[47]  Matthew Burnell,et al.  Risk Algorithm Using Serial Biomarker Measurements Doubles the Number of Screen-Detected Cancers Compared With a Single-Threshold Rule in the United Kingdom Collaborative Trial of Ovarian Cancer Screening , 2015, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[48]  A. Nickles Fader,et al.  Uterine Papillary Serous Carcinoma , 2011, Clinical obstetrics and gynecology.

[49]  Benjamin D. Smith,et al.  Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. , 2014, Cancer research.

[50]  Mingming Jia,et al.  COSMIC: somatic cancer genetics at high-resolution , 2016, Nucleic Acids Res..

[51]  T. Druley,et al.  Clonal haematopoiesis harbouring AML-associated mutations is ubiquitous in healthy adults , 2016, Nature Communications.

[52]  R. Burger,et al.  Simultaneously detected endometrial and ovarian carcinomas--a prospective clinicopathologic study of 74 cases: a gynecologic oncology group study. , 2001, Gynecologic oncology.

[53]  V. Moyer,et al.  Screening for Ovarian Cancer: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement , 2012, Annals of Internal Medicine.

[54]  C. Holschneider,et al.  Coexisting Ovarian Malignancy in Young Women With Endometrial Cancer , 2005, Obstetrics and gynecology.

[55]  Scott R. Kennedy,et al.  Ultra-deep sequencing detects ovarian cancer cells in peritoneal fluid and reveals somatic TP53 mutations in noncancerous tissues , 2016, Proceedings of the National Academy of Sciences.

[56]  John B. Shoven,et al.  I , Edinburgh Medical and Surgical Journal.

[57]  J. Garber,et al.  A candidate precursor to serous carcinoma that originates in the distal fallopian tube (J Pathol 2007; 211: 26–35) , 2007, The Journal of pathology.

[58]  Chengquan Zhao,et al.  Histologic follow-up results in 662 patients with Pap test findings of atypical glandular cells: results from a large academic womens hospital laboratory employing sensitive screening methods. , 2009, Gynecologic oncology.

[59]  Steven J. M. Jones,et al.  Integrated genomic characterization of endometrial carcinoma , 2013, Nature.