Lavage of the Uterine Cavity for the Diagnosis of Ovarian and Tubal Carcinoma - Study of Sensitivity and Specificity
Condition: Ovarian Epithelial Cancer
MeSH terms: Carcinoma, Ovarian Epithelial
Study type: Interventional

Summary: 
      The ovarian surface, the Fallopian tubes, the uterine cavity and the peritoneal cavity all
      together form a communicating compartment. The physiologic function of the ciliated lining of
      the tubes is to transport the egg, after ovulation, into the uterine cavity. Thus, making it
      very likely that exfoliated cells from pathologic changes of the ovarian surface and
      Fallopian tube lining will be present in a lavage from the uterine cavity.

      The proof of concept that malignant cells from the upper genital tract get transported even
      into the lower genital tract was recently published by Kind I. et al. Liquid-based cervical
      cytology allows not only cytological evaluation but also collection of DNA. A panel of genes
      that are commonly mutated in endometrial and ovarian cancers was assembled with new
      whole-exome sequencing data from 22 endometrial cancers and previously published data on
      other tumour types, including mutations in the TP53 gene. This panel was used to search for
      mutations in 24 endometrial and 22 ovarian cancers and identified mutations in all 46
      samples. With a sensitive massively parallel sequencing method, it was possible to identify
      the same mutations in the DNA from liquid Pap smear specimens in 100% of endometrial cancers
      (24 of 24) and in 41% of ovarian cancers (9 of 22).

      In the current project the investigators will study the specificity and sensitivity of the
      lavage of uterine cavity and proximal tubes as a test to differentiate between malign and
      benign ovarian tumours. The investigators aim to detect cells from EOCs or genetic material
      from those cells in the lavage.
    

Detailed description: 
      Epithelial ovarian cancer (EOC) is the leading cause of death among gynaecologic malignancies
      in western civilized countries, with an estimated prevalence in Europe and the US of 752,600
      in 2007 and 59,828 deaths annually. Treatment and survival of the patients depend primarily
      on the stage of the disease. Of all EOC patients only 25% are diagnosed at an early stage
      while the tumour is confined to the pelvis. In these cases the five-year survival rate is 80%
      to 90% and the disease can often be cured by the combination of surgery and chemotherapy.
      Unfortunately, almost 75% of women affected have advanced stage disease with metastatic
      spread throughout the abdominal cavity or to retroperitoneal lymph nodes at the time of
      diagnosis; five-year survival rates drop to 10%-30% for advanced disease, despite maximum
      surgical effort and combination chemotherapy.

      Currently, state of the art differential diagnosis between malignant and benign ovarian
      pathologies suspicious for EOC relies predominantly on transvaginal ultrasonography and serum
      cancer antigen (CA-125) measurements. The specificity of these diagnostic tools however is
      low, and both tests are not effective enough to reliably differentiate between benign and
      malignant conditions. Even in highly specialised units, of all patients receiving surgery for
      suspected ovarian cancer only about 20% will have a malignant disease. These findings
      underline the need for new diagnostic tests, able to better differentiate between benign and
      malignant ovarian changes. This would possibly spear many patients from unnecessary surgery
      completely and improve the triage of patients with malignant ovarian tumours to highly
      specialised gynaecologic oncology units.

      A promising approach for improvement of differential diagnosis of suspicious ovarian changes
      has been established by Paul Speiser and Robert Zeillinger (Molecular Oncology Group,
      Department of General Gynaecology and Gynaecologic Oncology, Medical University of Vienna,
      Austria) (EK 1148/2011). This approach is called the ALPINE technique (Austrian Lavage
      Procedure for the Detection of tubal Intraepithelial Neoplasms) (manuscript under
      preparation). It includes a lavage of the uterine cavity and proximal fallopian tubes and
      subsequent analysis of this lavage fluid for the presence of pre-malignant and malignant
      cells.

      For the proof of principle that tumour cells are shed from ovarian cancer and can be found in
      the lavages of the uterine cavity, uterine lavages were collected before a surgical
      intervention for suspected ovarian malignancy at the investigators' institution and at the
      Catholic University Leuven, Department of Obstetrics and Gynaecology. After malignancy was
      confirmed, genetic changes in the TP53 and KRAS gene were determined in tumour tissue. In a
      set of 9 epithelial ovarian cancer patients (EOC) and 1 ovarian metastases of a signet ring
      carcinoma, the presence of these genetic changes was examined in lavage samples, using
      digital droplet PCR (ddPCR). Ten genetic changes were identified in tumour tissue of these
      patients and 9/10 (90%) of these changes were detected in the corresponding lavage specimen
      too. Mutation rates were in the range between 0.01% and 39.65% in EOC patients. Furthermore,
      a filter approach, followed by p53 immunofluorescence staining was established, confirming
      the presence of tumour cells in the lavage sample of one additional patient.

      In a next step, lavage samples of 22 ovarian carcinoma patients, and if applicable
      corresponding tumour tissue, were analysed through deep sequencing by the group of Bert
      Vogelstein (Johns Hopkins University, Baltimore, USA). The presence of genetic changes,
      indicative for ovarian cancer, could be confirmed in 16/22 (72.7%) lavage specimen. Of 18
      patients, corresponding tumor tissues were available, showing the same mutation.

      These results are proof that ovarian cancer cells are shed into the fallopian tubes and
      uterine cavity, and can be collected through our ALPINE technique. The fact that ovarian
      cancer cells were detected with high sensitivity in the lavage of the uterine cavity and
      proximal tubes shows that this approach has a great potential in differential diagnosis of
      ovarian masses.
    

Intervention name(s): Lavage of the Cavum uteri and proximal fallopian tubes
Intervention type(s): Procedure
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Neoplasms; Glandular and Epithelial; Ovarian Neoplasms; Ovarian cancer