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Gotoh O, Sugiyama Y, Tonooka A, Kosugi M, Kitaura S, Minegishi R, Sano M, Amino S, Furuya R, Tanaka N, Kaneyasu T, Kumegawa K, Abe A, Nomura H, Takazawa Y, Kanao H, Maruyama R, Noda T, Mori S. Genetic and epigenetic alterations in precursor lesions of endometrial endometrioid carcinoma. J Pathol 2024; 263:275-287. [PMID: 38734880 DOI: 10.1002/path.6278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/09/2024] [Accepted: 02/27/2024] [Indexed: 05/13/2024]
Abstract
The hyperplasia-carcinoma sequence is a stepwise tumourigenic programme towards endometrial cancer in which normal endometrial epithelium becomes neoplastic through non-atypical endometrial hyperplasia (NAEH) and atypical endometrial hyperplasia (AEH), under the influence of unopposed oestrogen. NAEH and AEH are known to exhibit polyclonal and monoclonal cell growth, respectively; yet, aside from focal PTEN protein loss, the genetic and epigenetic alterations that occur during the cellular transition remain largely unknown. We sought to explore the potential molecular mechanisms that promote the NAEH-AEH transition and identify molecular markers that could help to differentiate between these two states. We conducted target-panel sequencing on the coding exons of 596 genes, including 96 endometrial cancer driver genes, and DNA methylome microarrays for 48 NAEH and 44 AEH lesions that were separately collected via macro- or micro-dissection from the endometrial tissues of 30 cases. Sequencing analyses revealed acquisition of the PTEN mutation and the clonal expansion of tumour cells in AEH samples. Further, across the transition, alterations to the DNA methylome were characterised by hypermethylation of promoter/enhancer regions and CpG islands, as well as hypo- and hyper-methylation of DNA-binding regions for transcription factors relevant to endometrial cell differentiation and/or tumourigenesis, including FOXA2, SOX17, and HAND2. The identified DNA methylation signature distinguishing NAEH and AEH lesions was reproducible in a validation cohort with modest discriminative capability. These findings not only support the concept that the transition from NAEH to AEH is an essential step within neoplastic cell transformation of endometrial epithelium but also provide deep insight into the molecular mechanism of the tumourigenic programme. © 2024 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Osamu Gotoh
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Yuko Sugiyama
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
- Division of Gynecology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Akiko Tonooka
- Division of Pathology, Cancer Institute, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Mayuko Kosugi
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Sunao Kitaura
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Ryu Minegishi
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Masatoshi Sano
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Sayuri Amino
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Rie Furuya
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Norio Tanaka
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Tomoko Kaneyasu
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Kohei Kumegawa
- Project for Cancer Epigenomics, Cancer Institute, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Akiko Abe
- Division of Gynecology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Hidetaka Nomura
- Division of Gynecology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Yutaka Takazawa
- Department of Pathology, Toranomon Hospital, Minato-ku, Japan
| | - Hiroyuki Kanao
- Division of Gynecology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Reo Maruyama
- Project for Cancer Epigenomics, Cancer Institute, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Tetsuo Noda
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
| | - Seiichi Mori
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Koto-ku, Japan
- Department of Genetic Diagnosis, Cancer Institute Hospital, JFCR, Koto-ku, Japan
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2
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Wever BMM, Schaafsma M, Bleeker MCG, van den Burgt Y, van den Helder R, Lok CAR, Dijk F, van der Pol Y, Mouliere F, Moldovan N, van Trommel NE, Steenbergen RDM. Molecular analysis for ovarian cancer detection in patient-friendly samples. COMMUNICATIONS MEDICINE 2024; 4:88. [PMID: 38755429 PMCID: PMC11099128 DOI: 10.1038/s43856-024-00517-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 05/03/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND High ovarian cancer mortality rates motivate the development of effective and patient-friendly diagnostics. Here, we explored the potential of molecular testing in patient-friendly samples for ovarian cancer detection. METHODS Home-collected urine, cervicovaginal self-samples, and clinician-taken cervical scrapes were prospectively collected from 54 patients diagnosed with a highly suspicious ovarian mass (benign n = 25, malignant n = 29). All samples were tested for nine methylation markers, using quantitative methylation-specific PCRs that were verified on ovarian tissue samples, and compared to non-paired patient-friendly samples of 110 age-matched healthy controls. Copy number analysis was performed on a subset of urine samples of ovarian cancer patients by shallow whole-genome sequencing. RESULTS Three methylation markers are significantly elevated in full void urine of ovarian cancer patients as compared to healthy controls (C2CD4D, P = 0.008; CDO1, P = 0.022; MAL, P = 0.008), of which two are also discriminatory in cervical scrapes (C2CD4D, P = 0.001; CDO1, P = 0.004). When comparing benign and malignant ovarian masses, GHSR shows significantly elevated methylation levels in the urine sediment of ovarian cancer patients (P = 0.024). Other methylation markers demonstrate comparably high methylation levels in benign and malignant ovarian masses. Cervicovaginal self-samples show no elevated methylation levels in patients with ovarian masses as compared to healthy controls. Copy number changes are identified in 4 out of 23 urine samples of ovarian cancer patients. CONCLUSIONS Our study reveals increased methylation levels of ovarian cancer-associated genes and copy number aberrations in the urine of ovarian cancer patients. Our findings support continued research into urine biomarkers for ovarian cancer detection and highlight the importance of including benign ovarian masses in future studies to develop a clinically useful test.
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Affiliation(s)
- Birgit M M Wever
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pathology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Mirte Schaafsma
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pathology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Antoni van Leeuwenhoek/Netherlands Cancer Institute, Department of Gynecologic Oncology, Center of Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - Maaike C G Bleeker
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pathology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Yara van den Burgt
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pathology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Rianne van den Helder
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pathology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Antoni van Leeuwenhoek/Netherlands Cancer Institute, Department of Gynecologic Oncology, Center of Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - Christianne A R Lok
- Antoni van Leeuwenhoek/Netherlands Cancer Institute, Department of Gynecologic Oncology, Center of Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - Frederike Dijk
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Pathology, Amsterdam, The Netherlands
| | - Ymke van der Pol
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pathology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Florent Mouliere
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pathology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Norbert Moldovan
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pathology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Nienke E van Trommel
- Antoni van Leeuwenhoek/Netherlands Cancer Institute, Department of Gynecologic Oncology, Center of Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - Renske D M Steenbergen
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pathology, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.
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3
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Illah O, Scott M, Redl E, Barrett JE, Schreiberhuber L, Herzog C, Vavourakis CD, Jones A, Evans I, Reisel D, Chandrasekaran D, Doufekas K, Graham R, Kotsopoulos IC, MacDonald N, Arora R, Olaitan A, Rosenthal A, Widschwendter M. High performance of the DNA methylation-based WID-qEC test for detecting uterine cancers independent of sampling modalities. Int J Cancer 2024. [PMID: 38739012 DOI: 10.1002/ijc.35000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024]
Abstract
Endometrial cancer (EC) is the most prevalent gynaecological cancer in high-income countries and its incidence is continuing to rise sharply. Simple and objective tools to reliably detect women with EC are urgently needed. We recently developed and validated the DNA methylation (DNAme)-based women's cancer risk identification-quantitative polymerase chain reaction test for endometrial cancer (WID-qEC) test that could address this need. Here, we demonstrate that the stability of the WID-qEC test remains consistent regardless of: (i) the cervicovaginal collection device and sample media used (Cervex brush and PreservCyt or FLOQSwab and eNAT), (ii) the collector of the specimen (gynaecologist- or patient-based), and (iii) the precise sampling site (cervical, cervicovaginal and vaginal). Furthermore, we demonstrate sample stability in eNAT medium for 7 days at room temperature, greatly facilitating the implementation of the test into diagnostic laboratory workflows. When applying FLOQSwabs (Copan) in combination with the eNAT (Copan) sample collection media, the sensitivity and specificity of the WID-qEC test to detect uterine (i.e., endometrial and cervical) cancers in gynaecologist-taken samples was 92.9% (95% confidence interval [CI] = 75.0%-98.8%) and 98.6% (95% CI = 91.7%-99.9%), respectively, whilst the sensitivity and specificity in patient collected self-samples was 75.0% (95% CI = 47.4%-91.7%) and 100.0% (95% CI = 93.9%-100.0%), respectively. Taken together these data confirm the robustness and clinical potential of the WID-qEC test.
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Affiliation(s)
- Ojone Illah
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Malcolm Scott
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Elisa Redl
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Hall in Tirol, Austria
| | - James E Barrett
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Hall in Tirol, Austria
| | - Lena Schreiberhuber
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Hall in Tirol, Austria
| | - Chiara Herzog
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Hall in Tirol, Austria
| | - Charlotte D Vavourakis
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Hall in Tirol, Austria
| | - Allison Jones
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Iona Evans
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Dan Reisel
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Dhivya Chandrasekaran
- Department of Gynaecological Oncology, University College London Hospital, London, UK
| | - Kostas Doufekas
- Department of Gynaecological Oncology, University College London Hospital, London, UK
| | - Radha Graham
- Department of Gynaecological Oncology, University College London Hospital, London, UK
| | - Ioannis C Kotsopoulos
- Department of Gynaecological Oncology, University College London Hospital, London, UK
| | - Nicola MacDonald
- Department of Gynaecological Oncology, University College London Hospital, London, UK
| | - Rupali Arora
- Department of Pathology, University College London Hospital, London, UK
| | - Adeola Olaitan
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Adam Rosenthal
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
- Department of Gynaecological Oncology, University College London Hospital, London, UK
| | - Martin Widschwendter
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Hall in Tirol, Austria
- Department of Gynecology and Obstetrics, General Hospital Hall, Tirol Kliniken, Hall in Tirol, Austria
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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4
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Cai B, Du J, Wang Y, Liu Z, Wang Y, Li L, Liu P, Wang L, Liu Q, Meng Z. The endometrial cancer detection using non-invasive hypermethylation of CDO1 and CELF4 genes in women with postmenopausal bleeding in Northwest China. Cytojournal 2024; 21:15. [PMID: 38841418 PMCID: PMC11152555 DOI: 10.25259/cytojournal_78_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/28/2023] [Indexed: 06/07/2024] Open
Abstract
Objective The objective of this study was to verify the clinical predictive performance of methylated cysteine dioxygenase type 1 (CDO1m) and CUGBP Elav-like family member 4 (CELF4m) in endometrial cancer (EC) women with postmenopausal bleeding (PMB). Material and Methods A single-center, prospective, and case-control study was conducted in the Gansu Provincial Maternity and Child-care Hospital with 138 female postmenopausal patients enrolled in 2022. All patients underwent body mass index (BMI) detection, transvaginal ultrasonography (TVUS) detection, carbohydrate antigen 125 detection, and the cervical exfoliated cell CDO1/CELF4 gene methylation detection to analyze the sensitivity, specificity, and accuracy of different screening tests statistically with the biopsy and/or dilation and curettage (D&C) pathological diagnosis under hysteroscopy as the gold standard. Results There was no significant difference in age between the EC group and the non-EC group, P = 0.492. Using quantitative polymerase chain reaction (qPCR) technology, we validated the CDO1 and CELF4 methylation detection with 87.5% sensitivity and 95.9% specificity as a useful strategy for the triage of women with PMB for the detection of EC. In addition, 100% of type II EC (n = 6) were positively detected by the CDO1 or CELF4 methylation test. Conclusion The CDO1 and CELF4 methylation test with high specificity as an auxiliary diagnostic tool or alternative method provides physicians with a reference to distinguish between benign and malignant tumors in women with postmenopausal bleeding, to justify the necessity of using invasive methods to confirm diagnosis.
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Affiliation(s)
- Bingxin Cai
- Department of Obstetrics and Gynecology, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China
| | - Jun Du
- Department of Obstetrics and Gynecology, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China
| | - Yishan Wang
- Department of Medical Laboratory, Beijing Origin-Poly Bio-Tec Co., Ltd., Beijing, China
| | - Zhijie Liu
- Department of Obstetrics and Gynecology, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China
| | - Yan Wang
- Department of Obstetrics and Gynecology, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China
| | - Liuyu Li
- Department of Obstetrics and Gynecology, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China
| | - Pei Liu
- Department of Medical Laboratory, Beijing Origin-Poly Bio-Tec Co., Ltd., Beijing, China
| | - Linhai Wang
- Department of Medical Laboratory, Beijing Origin-Poly Bio-Tec Co., Ltd., Beijing, China
| | - Qing Liu
- Department of Obstetrics and Gynecology, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China
| | - Zhaoyan Meng
- Department of Obstetrics and Gynecology, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China
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Njoku K, Pierce A, Chiasserini D, Geary B, Campbell AE, Kelsall J, Reed R, Geifman N, Whetton AD, Crosbie EJ. Detection of endometrial cancer in cervico-vaginal fluid and blood plasma: leveraging proteomics and machine learning for biomarker discovery. EBioMedicine 2024; 102:105064. [PMID: 38513301 PMCID: PMC10960138 DOI: 10.1016/j.ebiom.2024.105064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/16/2024] [Accepted: 03/04/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The anatomical continuity between the uterine cavity and the lower genital tract allows for the exploitation of uterine-derived biomaterial in cervico-vaginal fluid for endometrial cancer detection based on non-invasive sampling methodologies. Plasma is an attractive biofluid for cancer detection due to its simplicity and ease of collection. In this biomarker discovery study, we aimed to identify proteomic signatures that accurately discriminate endometrial cancer from controls in cervico-vaginal fluid and blood plasma. METHODS Blood plasma and Delphi Screener-collected cervico-vaginal fluid samples were acquired from symptomatic post-menopausal women with (n = 53) and without (n = 65) endometrial cancer. Digitised proteomic maps were derived for each sample using sequential window acquisition of all theoretical mass spectra (SWATH-MS). Machine learning was employed to identify the most discriminatory proteins. The best diagnostic model was determined based on accuracy and model parsimony. FINDINGS A protein signature derived from cervico-vaginal fluid more accurately discriminated cancer from control samples than one derived from plasma. A 5-biomarker panel of cervico-vaginal fluid derived proteins (HPT, LG3BP, FGA, LY6D and IGHM) predicted endometrial cancer with an AUC of 0.95 (0.91-0.98), sensitivity of 91% (83%-98%), and specificity of 86% (78%-95%). By contrast, a 3-marker panel of plasma proteins (APOD, PSMA7 and HPT) predicted endometrial cancer with an AUC of 0.87 (0.81-0.93), sensitivity of 75% (64%-86%), and specificity of 84% (75%-93%). The parsimonious model AUC values for detection of stage I endometrial cancer in cervico-vaginal fluid and blood plasma were 0.92 (0.87-0.97) and 0.88 (0.82-0.95) respectively. INTERPRETATION Here, we leveraged the natural shed of endometrial tumours to potentially develop an innovative approach to endometrial cancer detection. We show proof of principle that endometrial cancers secrete unique protein signatures that can enable cancer detection via cervico-vaginal fluid assays. Confirmation in a larger independent cohort is warranted. FUNDING Cancer Research UK, Blood Cancer UK, National Institute for Health Research.
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Affiliation(s)
- Kelechi Njoku
- Division of Cancer Sciences, University of Manchester, School of Medical Sciences, Faculty of Biology, Medicine and Health, 5th Floor Research, St Mary's Hospital, Road, Manchester, M13 9WL, UK; Stoller Biomarker Discovery Centre, Institute of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Clinical Oncology, Christie NHS Foundation Trust, Manchester, UK.
| | - Andrew Pierce
- North Wales Medical School, Bangor University, Bangor, Gwynedd, LL57 2DG, UK
| | - Davide Chiasserini
- Department of Medicine and Surgery, Section of Physiology and Biochemistry, University of Perugia, 06132, Perugia, Italy
| | - Bethany Geary
- Medical Research Council Protein Phosphorylation and Ubiquitylation Unit, School of Life Sciences, University of Dundee, Dow Street, Dundee, DD1 5EH, UK
| | - Amy E Campbell
- Stoller Biomarker Discovery Centre, Institute of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Janet Kelsall
- Stoller Biomarker Discovery Centre, Institute of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Rachel Reed
- Stoller Biomarker Discovery Centre, Institute of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Nophar Geifman
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, GU2 7XH, UK
| | - Anthony D Whetton
- Veterinary Health Innovation Engine, School of Veterinary Medicine, Faculty of Health and Medical Sciences, University of Surrey, GU2 7XH, UK
| | - Emma J Crosbie
- Division of Cancer Sciences, University of Manchester, School of Medical Sciences, Faculty of Biology, Medicine and Health, 5th Floor Research, St Mary's Hospital, Road, Manchester, M13 9WL, UK.
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Evans I, Reisel D, Jones A, Bajrami A, Nijjar S, Solangon SA, Arora R, Redl E, Schreiberhuber L, Ishaq-Parveen I, Rothärmel J, Herzog C, Jurkovic D, Widschwendter M. Performance of the WID-qEC test versus sonography to detect uterine cancers in women with abnormal uterine bleeding (EPI-SURE): a prospective, consecutive observational cohort study in the UK. Lancet Oncol 2023; 24:1375-1386. [PMID: 37944542 DOI: 10.1016/s1470-2045(23)00466-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND To detect uterine cancer, simpler and more specific index tests are needed to triage women with abnormal uterine bleeding to a reference histology test. We aimed to compare the performance of conventional index imaging tests with the novel WID-qEC DNA methylation test in terms of detecting the presence or absence of uterine cancers in women with abnormal uterine bleeding. METHODS EPI-SURE was a prospective, observational study that invited all women aged 45 years and older with abnormal uterine bleeding attending a tertiary gynaecological diagnostic referral centre at University College London Hospital (London, UK) to participate. Women meeting these inclusion criteria who consented to participate were included. Pregnant women and those with previous hysterectomy were excluded. A cervicovaginal sample for the WID-qEC test was obtained before standard assessment using index imaging tests (ie, ultrasound) and, where applicable, reference histology (ie, biopsy, hysteroscopy, or both) was performed. Technicians performing the WID-qEC test were masked to the final clinical outcome. The result of the WID-qEC test is defined as the sum of the percentage of fully methylated reference (ΣPMR) of the ZSCAN12 and GYPC regions. Patients were followed until diagnostic resolution or until June 12, 2023. The primary outcome was to assess the real-world performance of the WID-qEC test in comparison with ultrasound with regard to the area under the receiver-operating-characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values. EPI-SURE is registered with ISRCTN (16815568). FINDINGS From June 1, 2022, to Nov 24, 2022, 474 women were deemed eligible to participate. 74 did not accept the invitation to participate, and one woman withdrew after providing consent. 399 women were included in the primary analysis cohort. Based on 603 index imaging tests, 186 (47%) women were recommended for a reference histology test (ie, biopsy, hysteroscopy, or both). 12 women were diagnosed with cancer, 375 were not diagnosed with cancer, and 12 had inconclusive clinical outcomes and were considered study dropouts. 198 reference histology test procedures detected nine cases of cancer and missed two; one further cancer was directly diagnosed at hysterectomy without a previous reference test. The AUC for detection of uterine cancer based on endometrial thickness in mm was 87·2% (95% CI 71·1-100·0) versus 94·3% (84·7-100·0) based on WID-qEC (p=0·48). Endometrial thickness assessment on ultrasound scan was possible in 379 (95%) of the 399 women and a prespecified cut-off of 4·5 mm or more showed a sensitivity of 90·9% (95% CI 62·3-98·4), a specificity of 79·1% (74·5-82·9), a positive predictive value of 11·8% (6·5-20·3), and a negative predictive value of 99·6% (98·0-99·9). The WID-qEC test was possible in 390 (98%) of the 399 patients with a sensitivity of 90·9% (95% CI 62·3-98·4), a specificity of 92·1% (88·9-94·4), a positive predictive value of 25·6% (14·6-41·1), and a negative predictive value of 99·7% (98·3-99·9), when the prespecified threshold of 0·03 ΣPMR or more was applied. When a higher threshold (≥0·3 ΣPMR) was applied the specificity increased to 97·3% (95% CI 95·1-98·5) without a change in sensitivity. INTERPRETATION The WID-qEC test delivers fast results and shows improved performance compared with a combination of imaging index tests. Triage of women with abnormal uterine bleeding using the WID-qEC test could reduce the number of women requiring histological assessments for identification of potential malignancy and specifically reduce the false positive rate. FUNDING The Eve Appeal, Land Tirol, and the European Research Council under the European Union's Horizon 2020 Research and Innovation Programme.
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Affiliation(s)
- Iona Evans
- Department of Women's Cancer, EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Daniel Reisel
- Department of Women's Cancer, EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Allison Jones
- Department of Women's Cancer, EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Alba Bajrami
- Department of Reproductive Health, EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Simrit Nijjar
- Department of Reproductive Health, EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Sarah Annie Solangon
- Department of Reproductive Health, EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Rupali Arora
- Department of Cellular Pathology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Elisa Redl
- European Translational Oncology Prevention and Screening Institute, University of Innsbruck, Tirol, Austria; Research Institute for Biomedical Aging Research, University of Innsbruck, Innsbruck, Austria
| | - Lena Schreiberhuber
- European Translational Oncology Prevention and Screening Institute, University of Innsbruck, Tirol, Austria; Research Institute for Biomedical Aging Research, University of Innsbruck, Innsbruck, Austria
| | - Isma Ishaq-Parveen
- European Translational Oncology Prevention and Screening Institute, University of Innsbruck, Tirol, Austria
| | - Julia Rothärmel
- European Translational Oncology Prevention and Screening Institute, University of Innsbruck, Tirol, Austria
| | - Chiara Herzog
- European Translational Oncology Prevention and Screening Institute, University of Innsbruck, Tirol, Austria; Research Institute for Biomedical Aging Research, University of Innsbruck, Innsbruck, Austria
| | - Davor Jurkovic
- Department of Reproductive Health, EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Martin Widschwendter
- Department of Women's Cancer, EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK; European Translational Oncology Prevention and Screening Institute, University of Innsbruck, Tirol, Austria; Research Institute for Biomedical Aging Research, University of Innsbruck, Innsbruck, Austria; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Gynaecology and Obstetrics, Tirol Kliniken, Tirol, Austria.
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7
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Qi B, Sun Y, Lv Y, Hu P, Ma Y, Gao W, Li S, Zhang X, Jin X, Liou Y, Liu P, Liu S. Hypermethylated CDO1 and CELF4 in cytological specimens as triage strategy biomarkers in endometrial malignant lesions. Front Oncol 2023; 13:1289366. [PMID: 38107069 PMCID: PMC10722236 DOI: 10.3389/fonc.2023.1289366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/16/2023] [Indexed: 12/19/2023] Open
Abstract
Objective Developing a non-invasive and reliable triage test for endometrial malignant lesions is an important goal, as it could help to reduce the number of invasive diagnostic procedures required and improve patient survival. We aimed to estimate the diagnostic value of DNA methylation levels in cervical cytological samples of endometrial cancer (EC) and endometrial atypical hyperplasia (AH). Methods A total of 607 women who had indications for endometrial biopsy in the Department of Obstetrics and Gynecology of Cangzhou Central Hospital from October 2022 to April 2023 were enrolled in this study. The cervical exfoliated cells were collected for gene methylation before endometrial biopsy. Clinical information, tumor biomarkers, and endometrial thickness (ET) of transvaginal ultrasonography (TVS) were also collected. With endometrial histopathology as the gold standard, multivariate unconditional logistic regression was applied to analyze the risk factors of endometrial malignant lesions. The role of cysteine dioxygenase type 1 (CDO1) and CUGBP Elav-like family member 4 (CELF4) gene methylation as a triage strategy biomarker in endometrial malignant lesions was specifically explored. Results Multivariate logistic regression analysis showed that premenopausal ET ≥ 11 mm or postmenopausal ET ≥ 5 mm, CDO1 ΔCt ≤ 8.4, or CELF4 ΔCt ≤ 8.8 were the risk factors for AH and EC, with odds ratios (ORs) (95%CI) of 5.03 (1.83-13.82) and 6.92 (1.10-43.44), respectively (p-values < 0.05). The sensitivity and specificity of CDO1/CELF4 dual-gene methylation assay for AH and EC reached 84.9% (95%CI: 75.3%-94.5%) and 86.6% (95%CI: 83.8%-89.5%), respectively. ET combined with DNA methylation detection further improved the specificity to (94.9%, 95%CI: 93.1%-96.8%). Conclusion The accuracy of cervical cytology DNA methylation is superior to that of other clinical indicators in the non-invasive examination of endometrial malignant lesions. DNA methylation combined with TVS can further improve the specificity and is a promising biomarker triage strategy in women with suspected endometrial lesions.
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Affiliation(s)
- Bingli Qi
- Department of Gynecologic Oncology and Surgery, Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - Ye Sun
- Department of Gynecologic Oncology and Surgery, Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - Yaohua Lv
- Department of Gynecologic Oncology and Surgery, Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - Pei Hu
- Department of Gynecologic Oncology and Surgery, Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - Yanli Ma
- Department of Pharmacy, Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - Wenying Gao
- Department of Gynecologic Oncology and Surgery, Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - Shumei Li
- Department of Gynecologic Oncology and Surgery, Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - Xin Zhang
- Department of Gynecologic Oncology and Surgery, Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - Xitong Jin
- Department of Medical Laboratory, Beijing Origin-Poly Bio-Tec Co., Ltd., Beijing, China
| | - Yuligh Liou
- Department of Medical Laboratory, Beijing Origin-Poly Bio-Tec Co., Ltd., Beijing, China
| | - Pei Liu
- Department of Medical Laboratory, Beijing Origin-Poly Bio-Tec Co., Ltd., Beijing, China
| | - Shikai Liu
- Department of Gynecologic Oncology and Surgery, Cangzhou Central Hospital, Cangzhou, Hebei, China
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8
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St Laurent J, Elias KM. Non-invasive DNA methylation-based testing for the diagnosis of endometrial cancer. Lancet Oncol 2023; 24:1291-1292. [PMID: 37944539 DOI: 10.1016/s1470-2045(23)00522-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Jessica St Laurent
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute and Harvard Medical School, Boston 02115, MA, USA
| | - Kevin M Elias
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute and Harvard Medical School, Boston 02115, MA, USA.
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9
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Bramblet RM, Bakkum-Gamez JN, Slettedahl SW, Foote PH, Taylor WR, Berger CK, Gysbers BJ, Arndt J, Chen L, Doering KA, Burger KN, Mahoney DW, Sherman ME, Kisiel JB, Samadder NJ. Methylated DNA Markers for Sporadic Colorectal and Endometrial Cancer Are Strongly Associated with Lynch Syndrome Cancers. Cancer Prev Res (Phila) 2023; 16:611-620. [PMID: 37728516 PMCID: PMC10870731 DOI: 10.1158/1940-6207.capr-23-0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/21/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023]
Abstract
Lynch syndrome (LS) markedly increases risks of colorectal and endometrial cancers. Early detection biomarkers for LS cancers could reduce the needs for invasive screening and surgical prophylaxis.To validate a panel of methylated DNA markers (MDM) previously identified in sporadic colorectal cancer and endometrial cancer for discrimination of these cancers in LS.In a case-control design, previously identified MDMs for the detection of colorectal cancer and endometrial cancer were assayed by qMSP on tissue-extracted DNA. Results were normalized to ACTB values within each sample. Least absolute shrinkage and selection operator models to classify colorectal cancer and endometrial cancer were trained on sporadic cases and controls and then applied to classify colorectal cancer and endometrial cancer, in those with LS, and cross-validated.We identified colorectal cancer cases (23 with LS, 48 sporadic), colorectal controls (32 LS, 48 sporadic), endometrial cancer cases (30 LS, 48 sporadic), and endometrial controls (29 LS, 37 sporadic). A 3-MDM panel (LASS4, LRRC4, and PPP2R5C) classified LS-CRC from LS controls with an AUC of 0.92 (0.84-0.99); results were similar for sporadic colorectal cancer. A 6-MDM panel (SFMBT2, MPZ, CYTH2, DIDO1, chr10.4479, and EMX2OS) discriminated LS-EC from LS controls with an AUC of 0.92 (0.83-1.0); the AUC for sporadic endometrial cancer versus sporadic controls was nominally higher, 0.99 (0.96-1.0).MDMs previously identified in sporadic endometrial cancer and colorectal cancer discriminate between endometrial cancer and benign endometrium and colorectal cancer and benign colorectum in LS. This supports the inclusion of patients with LS within future prospective clinical trials evaluating endometrial cancer and colorectal cancer MDMs and may provide a new avenue for cancer screening or surveillance in this high-risk population. PREVENTION RELEVANCE Lynch syndrome (LS) markedly increases risks of colorectal and endometrial cancers. Early detection biomarkers for LS cancers could reduce the needs for invasive screening and surgery. Methylated DNA markers previously identified in sporadic endometrial cancer and colorectal cancer discriminate between benign and cancer tissue in LS.
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Affiliation(s)
| | | | | | - Patrick H. Foote
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - William R. Taylor
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Calise K. Berger
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Brianna J. Gysbers
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Jacquelyn Arndt
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Longwen Chen
- Division of Anatomic Pathology, Mayo Clinic, Scottsdale, AZ
| | - Karen A. Doering
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Kelli N. Burger
- Department of Quantitative Health Sciences, Mayo Clinic Rochester, MN
| | | | - Mark E. Sherman
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL
| | - John B. Kisiel
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - N. Jewel Samadder
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ
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10
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Zhang C, Sheng Y, Sun X, Wang Y. New insights for gynecological cancer therapies: from molecular mechanisms and clinical evidence to future directions. Cancer Metastasis Rev 2023; 42:891-925. [PMID: 37368179 PMCID: PMC10584725 DOI: 10.1007/s10555-023-10113-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/22/2023] [Indexed: 06/28/2023]
Abstract
Advanced and recurrent gynecological cancers lack effective treatment and have poor prognosis. Besides, there is urgent need for conservative treatment for fertility protection of young patients. Therefore, continued efforts are needed to further define underlying therapeutic targets and explore novel targeted strategies. Considerable advancements have been made with new insights into molecular mechanisms on cancer progression and breakthroughs in novel treatment strategies. Herein, we review the research that holds unique novelty and potential translational power to alter the current landscape of gynecological cancers and improve effective treatments. We outline the advent of promising therapies with their targeted biomolecules, including hormone receptor-targeted agents, inhibitors targeting epigenetic regulators, antiangiogenic agents, inhibitors of abnormal signaling pathways, poly (ADP-ribose) polymerase (PARP) inhibitors, agents targeting immune-suppressive regulators, and repurposed existing drugs. We particularly highlight clinical evidence and trace the ongoing clinical trials to investigate the translational value. Taken together, we conduct a thorough review on emerging agents for gynecological cancer treatment and further discuss their potential challenges and future opportunities.
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Affiliation(s)
- Chunxue Zhang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030 People’s Republic of China
- Shanghai Municipal Key Clinical Specialty, Female Tumor Reproductive Specialty, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Yaru Sheng
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030 People’s Republic of China
- Shanghai Municipal Key Clinical Specialty, Female Tumor Reproductive Specialty, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Xiao Sun
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030 People’s Republic of China
- Shanghai Municipal Key Clinical Specialty, Female Tumor Reproductive Specialty, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Yudong Wang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030 People’s Republic of China
- Shanghai Municipal Key Clinical Specialty, Female Tumor Reproductive Specialty, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
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11
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Tejedor JR, Peñarroya A, Gancedo-Verdejo J, Santamarina-Ojeda P, Pérez RF, López-Tamargo S, Díez-Borge A, Alba-Linares JJ, González-Del-Rey N, Urdinguio RG, Mangas C, Roberti A, López V, Morales-Ruiz T, Ariza RR, Roldán-Arjona T, Meijón M, Valledor L, Cañal MJ, Fernández-Martínez D, Fernández-Hevia M, Jiménez-Fonseca P, García-Flórez LJ, Fernández AF, Fraga MF. CRISPR/dCAS9-mediated DNA demethylation screen identifies functional epigenetic determinants of colorectal cancer. Clin Epigenetics 2023; 15:133. [PMID: 37612734 PMCID: PMC10464368 DOI: 10.1186/s13148-023-01546-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/03/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Promoter hypermethylation of tumour suppressor genes is frequently observed during the malignant transformation of colorectal cancer (CRC). However, whether this epigenetic mechanism is functional in cancer or is a mere consequence of the carcinogenic process remains to be elucidated. RESULTS In this work, we performed an integrative multi-omic approach to identify gene candidates with strong correlations between DNA methylation and gene expression in human CRC samples and a set of 8 colon cancer cell lines. As a proof of concept, we combined recent CRISPR-Cas9 epigenome editing tools (dCas9-TET1, dCas9-TET-IM) with a customized arrayed gRNA library to modulate the DNA methylation status of 56 promoters previously linked with strong epigenetic repression in CRC, and we monitored the potential functional consequences of this DNA methylation loss by means of a high-content cell proliferation screen. Overall, the epigenetic modulation of most of these DNA methylated regions had a mild impact on the reactivation of gene expression and on the viability of cancer cells. Interestingly, we found that epigenetic reactivation of RSPO2 in the tumour context was associated with a significant impairment in cell proliferation in p53-/- cancer cell lines, and further validation with human samples demonstrated that the epigenetic silencing of RSPO2 is a mid-late event in the adenoma to carcinoma sequence. CONCLUSIONS These results highlight the potential role of DNA methylation as a driver mechanism of CRC and paves the way for the identification of novel therapeutic windows based on the epigenetic reactivation of certain tumour suppressor genes.
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Affiliation(s)
- Juan Ramón Tejedor
- Nanomaterials and Nanotechnology Research Center (CINN), Spanish National Research Council (CSIC), 33940, El Entrego, Asturias, Spain
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Spanish Biomedical Research Network in Rare Diseases (CIBERER), 28029, Madrid, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
| | - Alfonso Peñarroya
- Nanomaterials and Nanotechnology Research Center (CINN), Spanish National Research Council (CSIC), 33940, El Entrego, Asturias, Spain
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
| | - Javier Gancedo-Verdejo
- Nanomaterials and Nanotechnology Research Center (CINN), Spanish National Research Council (CSIC), 33940, El Entrego, Asturias, Spain
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Spanish Biomedical Research Network in Rare Diseases (CIBERER), 28029, Madrid, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
| | - Pablo Santamarina-Ojeda
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Spanish Biomedical Research Network in Rare Diseases (CIBERER), 28029, Madrid, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
| | - Raúl F Pérez
- Nanomaterials and Nanotechnology Research Center (CINN), Spanish National Research Council (CSIC), 33940, El Entrego, Asturias, Spain
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Spanish Biomedical Research Network in Rare Diseases (CIBERER), 28029, Madrid, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
| | - Sara López-Tamargo
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
| | - Ana Díez-Borge
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Viralgen Vector Core, 20009, San Sebastián, Gipuzkoa, Spain
| | - Juan J Alba-Linares
- Nanomaterials and Nanotechnology Research Center (CINN), Spanish National Research Council (CSIC), 33940, El Entrego, Asturias, Spain
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
| | - Nerea González-Del-Rey
- Department of Organisms and Systems Biology, Institute of Biotechnology of Asturias, University of Oviedo, 33071, Oviedo, Asturias, Spain
- Institute for Research in Biomedicine, The Barcelona Institute of Science and Technology, 08028, Barcelona, Spain
| | - Rocío G Urdinguio
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Spanish Biomedical Research Network in Rare Diseases (CIBERER), 28029, Madrid, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
| | - Cristina Mangas
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
| | - Annalisa Roberti
- Nanomaterials and Nanotechnology Research Center (CINN), Spanish National Research Council (CSIC), 33940, El Entrego, Asturias, Spain
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
| | - Virginia López
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
| | - Teresa Morales-Ruiz
- Maimónides Biomedical Research Institute of Córdoba (IMIBIC), 14071, Córdoba, Spain
- Department of Genetics, University of Córdoba, 14071, Córdoba, Spain
| | - Rafael R Ariza
- Maimónides Biomedical Research Institute of Córdoba (IMIBIC), 14071, Córdoba, Spain
- Department of Genetics, University of Córdoba, 14071, Córdoba, Spain
| | - Teresa Roldán-Arjona
- Maimónides Biomedical Research Institute of Córdoba (IMIBIC), 14071, Córdoba, Spain
- Department of Genetics, University of Córdoba, 14071, Córdoba, Spain
| | - Mónica Meijón
- Department of Organisms and Systems Biology, Institute of Biotechnology of Asturias, University of Oviedo, 33071, Oviedo, Asturias, Spain
| | - Luis Valledor
- Department of Organisms and Systems Biology, Institute of Biotechnology of Asturias, University of Oviedo, 33071, Oviedo, Asturias, Spain
| | - María Jesús Cañal
- Department of Organisms and Systems Biology, Institute of Biotechnology of Asturias, University of Oviedo, 33071, Oviedo, Asturias, Spain
| | - Daniel Fernández-Martínez
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
- Division of General Surgery, Department of Colorectal Surgery, Central University Hospital of Asturias (HUCA), 33011, Oviedo, Asturias, Spain
| | - María Fernández-Hevia
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
- Division of General Surgery, Department of Colorectal Surgery, Central University Hospital of Asturias (HUCA), 33011, Oviedo, Asturias, Spain
| | - Paula Jiménez-Fonseca
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Division of Oncology, Department of Medical Oncology, Central University Hospital of Asturias (HUCA), 33011, Oviedo, Asturias, Spain
| | - Luis J García-Flórez
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain
- Division of General Surgery, Department of Colorectal Surgery, Central University Hospital of Asturias (HUCA), 33011, Oviedo, Asturias, Spain
- Department of Surgery and Medical Surgical Specialties, University of Oviedo, 33006, Oviedo, Asturias, Spain
| | - Agustín F Fernández
- Nanomaterials and Nanotechnology Research Center (CINN), Spanish National Research Council (CSIC), 33940, El Entrego, Asturias, Spain.
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain.
- Spanish Biomedical Research Network in Rare Diseases (CIBERER), 28029, Madrid, Spain.
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain.
| | - Mario F Fraga
- Nanomaterials and Nanotechnology Research Center (CINN), Spanish National Research Council (CSIC), 33940, El Entrego, Asturias, Spain.
- Health Research Institute of the Principality of Asturias (ISPA), Avenida de Roma S/N, 33011, Oviedo, Asturias, Spain.
- Spanish Biomedical Research Network in Rare Diseases (CIBERER), 28029, Madrid, Spain.
- Institute of Oncology of Asturias (IUOPA), University of Oviedo, 33006, Oviedo, Asturias, Spain.
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12
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Pelegrina B, Paytubi S, Marin F, Martínez JM, Carmona Á, Frias-Gomez J, Peremiquel-Trillas P, Dorca E, Zanca A, López-Querol M, Onieva I, Benavente Y, Barahona M, Fernandez-Gonzalez S, De Francisco J, Caño V, Vidal A, Pijuan L, Canet-Hermida J, Dueñas N, Brunet J, Pineda M, Matias-Guiu X, Ponce J, Bosch FX, De Sanjosé S, Alemany L, Costas L. Evaluation of somatic mutations in cervicovaginal samples as a non-invasive method for the detection and molecular classification of endometrial cancer. EBioMedicine 2023; 94:104716. [PMID: 37480623 PMCID: PMC10393602 DOI: 10.1016/j.ebiom.2023.104716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/30/2023] [Accepted: 06/30/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND The incidence of endometrial cancer is increasing worldwide. While delays in diagnosis reduce survival, case molecular misclassification might be associated with under- and over-treatment. The objective of this study was to evaluate genetic alterations to detect and molecularly classify cases of endometrial cancer using non-invasive samples. METHODS Consecutive patients with incident endometrial cancer (N = 139) and controls (N = 107) from a recent Spanish case-control study were included in this analysis. Overall, 339 cervicovaginal samples (out of which 228 were clinician-collected and 111 were self-collected) were analysed using a test based on next-generation sequencing (NGS), which targets 47 genes. Immunohistochemical markers were evaluated in 133 tumour samples. A total of 159 samples were used to train the detection algorithm and 180 samples were used for validation. FINDINGS Overall, 73% (N = 94 out of 129 clinician-collected samples, and N = 66 out of 90 self-collected samples) of endometrial cancer cases had detectable mutations in clinician-collected and self-collected samples, while the specificity was 80% (79/99) for clinician-collected samples and 90% (19/21) for self-collected samples. The molecular classifications obtained using tumour samples and non-invasive gynaecologic samples in our study showed moderate-to-good agreement. The molecular classification of cases of endometrial cancer into four groups using NGS of both clinician-collected and self-collected cervicovaginal samples yielded significant differences in disease-free survival. The cases with mutations in POLE had an excellent prognosis, whereas the cases with TP53 mutations had the poorest clinical outcome, which is consistent with the data on tumour samples. INTERPRETATION This study classified endometrial cancer cases into four molecular groups based on the analysis of cervicovaginal samples that showed significant differences in disease-free survival. The molecular classification of endometrial cancer in non-invasive samples may improve patient care and survival by indicating the early need for aggressive surgery, as well as reducing referrals to highly specialized hospitals in cancers with good prognosis. Validation in independent sets will confirm the potential for molecular classification in non-invasive samples. FUNDING This study was funded by a competitive grant from Instituto de Salud Carlos III through the projects PI19/01835, PI23/00790, and FI20/00031, CIBERESP CB06/02/0073 and CIBERONC CB16/12/00231, CB16/12/00234 (Co-funded by European Regional Development Fund. ERDF: A way to build Europe). Samples and data were provided by Biobank HUB-ICO-IDIBELL, integrated into the Spanish Biobank Network, and funded by the Instituto de Salud Carlos III (PT20/00171) and by Xarxa de Bancs de Tumors de Catalunya (XBTC) sponsored by Pla Director d'Oncologia de Catalunya. This work was supported in part by the AECC, Grupos estables (GCTRA18014MATI). It also counts with the support of the Secretariat for Universities and Research of the Department of Business and Knowledge of the Generalitat de Catalunya, and grants to support the activities of research groups 2021SGR01354 and 2021SGR1112.
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Affiliation(s)
- Beatriz Pelegrina
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, Av Gran Vía 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Consortium for Biomedical Research in Epidemiology and Public Health - CIBERESP, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain
| | - Sonia Paytubi
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, Av Gran Vía 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Consortium for Biomedical Research in Epidemiology and Public Health - CIBERESP, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain
| | - Fátima Marin
- Consortium for Biomedical Research in Cancer - CIBERONC, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Hereditary Cancer Program, Catalan Institute of Oncology, IDIBELL, ONCOBELL Program, L'Hospitalet, Barcelona, Spain
| | - José Manuel Martínez
- Department of Gynecology, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain; Faculty of Medicine, University of Barcelona, Spain
| | | | - Jon Frias-Gomez
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, Av Gran Vía 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Consortium for Biomedical Research in Epidemiology and Public Health - CIBERESP, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Faculty of Medicine, University of Barcelona, Spain
| | - Paula Peremiquel-Trillas
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, Av Gran Vía 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Consortium for Biomedical Research in Epidemiology and Public Health - CIBERESP, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Faculty of Medicine, University of Barcelona, Spain
| | - Eduard Dorca
- Department of Pathology, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Alba Zanca
- Consortium for Biomedical Research in Cancer - CIBERONC, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Department of Pathology, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Marta López-Querol
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, Av Gran Vía 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Irene Onieva
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, Av Gran Vía 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Faculty of Medicine, University of Barcelona, Spain
| | - Yolanda Benavente
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, Av Gran Vía 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Consortium for Biomedical Research in Epidemiology and Public Health - CIBERESP, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain
| | - Marc Barahona
- Department of Gynecology, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Sergi Fernandez-Gonzalez
- Department of Gynecology, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Javier De Francisco
- Department of Anesthesiology, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Víctor Caño
- Department of Anesthesiology, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - August Vidal
- Consortium for Biomedical Research in Cancer - CIBERONC, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Department of Pathology, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Lara Pijuan
- Consortium for Biomedical Research in Cancer - CIBERONC, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Department of Pathology, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Júlia Canet-Hermida
- Consortium for Biomedical Research in Cancer - CIBERONC, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Hereditary Cancer Program, Catalan Institute of Oncology, IDIBELL, ONCOBELL Program, L'Hospitalet, Barcelona, Spain
| | - Núria Dueñas
- Consortium for Biomedical Research in Cancer - CIBERONC, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Hereditary Cancer Program, Catalan Institute of Oncology, IDIBELL, ONCOBELL Program, L'Hospitalet, Barcelona, Spain
| | - Joan Brunet
- Consortium for Biomedical Research in Cancer - CIBERONC, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Hereditary Cancer Program, Catalan Institute of Oncology, IDIBELL, ONCOBELL Program, L'Hospitalet, Barcelona, Spain; Hereditary Cancer Program, Catalan Institute of Oncology, IDIBGI, Girona, Spain; Medical Oncology Department, Catalan Institute of Oncology, Doctor Josep Trueta Girona University Hospital, Girona, Spain
| | - Marta Pineda
- Consortium for Biomedical Research in Cancer - CIBERONC, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Hereditary Cancer Program, Catalan Institute of Oncology, IDIBELL, ONCOBELL Program, L'Hospitalet, Barcelona, Spain
| | - Xavier Matias-Guiu
- Consortium for Biomedical Research in Cancer - CIBERONC, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Department of Pathology, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Ponce
- Department of Gynecology, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Francesc Xavier Bosch
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, Av Gran Vía 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Consortium for Biomedical Research in Epidemiology and Public Health - CIBERESP, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Universitat Oberta de Catalunya, Barcelona, Spain
| | - Silvia De Sanjosé
- Consortium for Biomedical Research in Epidemiology and Public Health - CIBERESP, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Consultant, National Cancer Institute, Bethesda, MD, 20814, USA; ISGlobal, Barcelona, Spain
| | - Laia Alemany
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, Av Gran Vía 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Consortium for Biomedical Research in Epidemiology and Public Health - CIBERESP, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Faculty of Medicine, University of Barcelona, Spain
| | - Laura Costas
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, Av Gran Vía 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Consortium for Biomedical Research in Epidemiology and Public Health - CIBERESP, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029, Madrid, Spain; Faculty of Medicine, University of Barcelona, Spain.
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13
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Bakkum-Gamez JN, Sherman ME, Slettedahl SW, Mahoney DW, Lemens MA, Laughlin-Tommaso SK, Hopkins MR, VanOosten A, Shridhar V, Staub JK, Cao X, Foote PH, Clarke MA, Burger KN, Berger CK, O'Connell MC, Doering KA, Podratz KC, DeStephano CC, Schoolmeester JK, Kerr SE, Wentzensen N, Taylor WR, Kisiel JB. Detection of endometrial cancer using tampon-based collection and methylated DNA markers. Gynecol Oncol 2023; 174:11-20. [PMID: 37141817 DOI: 10.1016/j.ygyno.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 04/16/2023] [Accepted: 04/16/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE Alterations in DNA methylation are early events in endometrial cancer (EC) development and may have utility in EC detection via tampon-collected vaginal fluid. METHODS For discovery, DNA from frozen EC, benign endometrium (BE), and benign cervicovaginal (BCV) tissues underwent reduced representation bisulfite sequencing (RRBS) to identify differentially methylated regions (DMRs). Candidate DMRs were selected based on receiver operating characteristic (ROC) discrimination, methylation level fold-change between cancers and controls, and absence of background CpG methylation. Methylated DNA marker (MDM) validation was performed using qMSP on DNA from independent EC and BE FFPE tissue sets. Women ≥45 years of age with abnormal uterine bleeding (AUB) or postmenopausal bleeding (PMB) or any age with biopsy-proven EC self-collected vaginal fluid using a tampon prior to clinically indicated endometrial sampling or hysterectomy. Vaginal fluid DNA was assayed by qMSP for EC-associated MDMs. Random forest modeling analysis was performed to generate predictive probability of underlying disease; results were 500-fold in-silico cross-validated. RESULTS Thirty-three candidate MDMs met performance criteria in tissue. For the tampon pilot, 100 EC cases were frequency matched by menopausal status and tampon collection date to 92 BE controls. A 28-MDM panel highly discriminated between EC and BE (96% (95%CI 89-99%) specificity; 76% (66-84%) sensitivity (AUC 0.88). In PBS/EDTA tampon buffer, the panel yielded 96% (95% CI 87-99%) specificity and 82% (70-91%) sensitivity (AUC 0.91). CONCLUSION Next generation methylome sequencing, stringent filtering criteria, and independent validation yielded excellent candidate MDMs for EC. EC-associated MDMs performed with promisingly high sensitivity and specificity in tampon-collected vaginal fluid; PBS-based tampon buffer with added EDTA improved sensitivity. Larger tampon-based EC MDM testing studies are warranted.
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Affiliation(s)
- Jamie N Bakkum-Gamez
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology Surgery, Mayo Clinic, Rochester, MN, United States of America.
| | - Mark E Sherman
- Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, United States of America
| | - Seth W Slettedahl
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States of America
| | - Douglas W Mahoney
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States of America
| | - Maureen A Lemens
- Surgery Research, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, United States of America
| | - Shannon K Laughlin-Tommaso
- Department of Obstetrics and Gynecology, Division of Gynecology, Mayo Clinic, Rochester, MN, United States of America
| | - Matthew R Hopkins
- Department of Obstetrics and Gynecology, Division of Gynecology, Mayo Clinic, Rochester, MN, United States of America
| | - Ann VanOosten
- Surgery Research, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, United States of America
| | - Viji Shridhar
- Department of Laboratory Medicine and Pathology, Experimental Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Julie K Staub
- Department of Laboratory Medicine and Pathology, Experimental Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Xiaoming Cao
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States of America
| | - Patrick H Foote
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States of America
| | - Megan A Clarke
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, United States of America
| | - Kelli N Burger
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States of America
| | - Calise K Berger
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States of America
| | - Maria C O'Connell
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States of America
| | - Karen A Doering
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States of America
| | - Karl C Podratz
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology Surgery, Mayo Clinic, Rochester, MN, United States of America
| | - Christopher C DeStephano
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecology, Mayo Clinic, Jacksonville, FL, United States of America
| | - J Kenneth Schoolmeester
- Department of Laboratory Medicine and Pathology, Anatomic Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Sarah E Kerr
- Hospital Pathology Associates, Minneapolis, MN, United States of America
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, United States of America
| | - William R Taylor
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States of America
| | - John B Kisiel
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States of America
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14
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Barrett JE, Jones A, Evans I, Herzog C, Reisel D, Olaitan A, Mould T, MacDonald N, Doufekas K, Newton C, Crosbie EJ, Bjørge L, Colombo N, Dostalek L, Costas L, Peremiquel-Trillas P, Ponce J, Matias-Guiu X, Zikan M, Cibula D, Wang J, Sundström K, Dillner J, Widschwendter M. The WID-EC test for the detection and risk prediction of endometrial cancer. Int J Cancer 2023; 152:1977-1988. [PMID: 36533702 DOI: 10.1002/ijc.34406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/15/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022]
Abstract
The incidence of endometrial cancer is rising. Measures to identify women at risk and to detect endometrial cancer earlier are required to reduce the morbidity triggered by the aggressive treatment required for advanced endometrial cancer. We developed the WID-EC (Women's cancer risk IDentification-Endometrial Cancer) test, which is based on DNA methylation at 500 CpG sites, in a discovery set of cervical liquid-based cytology samples from 1086 women with and without an endometrial cancer (217 cancer cases and 869 healthy controls) with a worse prognosis (grade 3 or ≥stage IB). We validated the WID-EC test in an independent external validation set of 64 endometrial cancer cases and 225 controls. We further validated the test in 150 healthy women (prospective set) who provided a cervical sample as part of the routine Swedish cervical screening programme, 54 of whom developed endometrial cancer within 3 years of sample collection. The WID-EC test identified women with endometrial cancer with a receiver operator characteristic area under the curve (AUC) of 0.92 (95% CI: 0.88-0.97) in the external set and of 0.82 (95% CI: 0.74-0.89) in the prospective validation set. Using an optimal cutoff, cancer cases were detected with a sensitivity of 86% and a specificity of 90% in the external validation set, and a sensitivity and specificity of 52% and 98% respectively in the prospective validation set. The WID-EC test can identify women with or at risk of endometrial cancer.
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Affiliation(s)
- James E Barrett
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Hall in Tirol, Austria.,Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK.,Research Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Austria
| | - Allison Jones
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Iona Evans
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Chiara Herzog
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Hall in Tirol, Austria
| | - Daniel Reisel
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Adeola Olaitan
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Tim Mould
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Nicola MacDonald
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Konstantinos Doufekas
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Claire Newton
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,University of Bristol, Bristol, UK
| | - Emma J Crosbie
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Division of Gynaecology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Line Bjørge
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway.,Centre for Cancer Biomarkers CCBIO, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Nicoletta Colombo
- Istituto Europeo di Oncologia, Milan, Italy.,University of Milano-Bicocca, Milan, Italy
| | - Lukas Dostalek
- Hospital Na Bulovce, Prague, Czech Republic.,Department of Obstetrics and Gynecology, General University Hospital in Prague, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Laura Costas
- Unit of Molecular Epidemiology and Genetics in Infections and Cancer, Cancer Epidemiology Research Programme, IDIBELL, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Paula Peremiquel-Trillas
- Unit of Molecular Epidemiology and Genetics in Infections and Cancer, Cancer Epidemiology Research Programme, IDIBELL, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Ponce
- Department of Gynecology and Obstetrics, Hospital Universitari de Bellvitge, IDIBELL. Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Matias-Guiu
- Department of Pathology, Hospital Universitari de Bellvitge, IDIBELL, CIBERONC. Hospitalet de Llobregat, Barcelona, Spain
| | - Michal Zikan
- Hospital Na Bulovce, Prague, Czech Republic.,Department of Obstetrics and Gynecology, General University Hospital in Prague, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - David Cibula
- Department of Obstetrics and Gynecology, General University Hospital in Prague, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jiangrong Wang
- Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Karin Sundström
- Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Joakim Dillner
- Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Martin Widschwendter
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Hall in Tirol, Austria.,Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK.,Research Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Austria
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15
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Shen Y, Yang W, Liu J, Zhang Y. Minimally invasive approaches for the early detection of endometrial cancer. Mol Cancer 2023; 22:53. [PMID: 36932368 PMCID: PMC10022290 DOI: 10.1186/s12943-023-01757-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 03/07/2023] [Indexed: 03/19/2023] Open
Abstract
Endometrial cancer (EC) is one of the most common gynecologic cancers and its incidence is rising globally. Although advanced EC has a poor prognosis; diagnosing EC at an earlier stage could improve long-term patient outcomes. However, there is no consensus on the early detection strategies for EC and the current diagnostic practices such as transvaginal ultrasound, hysteroscopy and endometrial biopsy are invasive, costly and low in specificity. Thus, accurate and less invasive screening tests that detect EC in women with early stages of the disease are needed. Current research has revolutionized novel EC early detection methodologies in many aspects. This review aims to comprehensively characterizes minimally invasive screening techniques that can be applied to EC in the future, and fully demonstrate their potential in the early detection of EC.
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Affiliation(s)
- Yufei Shen
- Department of Gynecology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wenqing Yang
- Department of Gynecology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Gynaecology Oncology Research and Engineering Central of Hunan Province, Changsha, Hunan, China
| | - Jiacheng Liu
- The Center of Systems Biology and Data Science, School of Basic Medical Science, Central South University, Changsha, Hunan, China.
| | - Yu Zhang
- Department of Gynecology, Xiangya Hospital, Central South University, Changsha, Hunan, China.
- Gynaecology Oncology Research and Engineering Central of Hunan Province, Changsha, Hunan, China.
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16
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Schreiberhuber L, Herzog C, Vavourakis CD, Redl E, Kastner C, Jones A, Evans I, Zikan M, Cibula D, Widschwendter P, Pfau K, Math B, Seewald M, Amory S, Obrist P, Widschwendter M. The WID-qEC test: Performance in a hospital-based cohort and feasibility to detect endometrial and cervical cancers. Int J Cancer 2023; 152:1269-1274. [PMID: 36056582 PMCID: PMC10092332 DOI: 10.1002/ijc.34275] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 01/21/2023]
Abstract
The majority of endometrial and cervical cancers present with abnormal vaginal bleeding but only a small proportion of women suffering from vaginal bleeding actually have such a cancer. A simple, operator-independent and accurate test to correctly identify women presenting with abnormal bleeding as a consequence of endometrial or cervical cancer is urgently required. We have recently developed and validated the WID-qEC test, which assesses DNA methylation of ZSCAN12 and GYPC via real-time PCR, to triage women with symptoms suggestive of endometrial cancer using ThinPrep-based liquid cytology samples. Here, we investigated whether the WID-qEC test can additionally identify women with cervical cancer. Moreover, we evaluate the test's applicability in a SurePath-based hospital-cohort by comparing its ability to detect endometrial and cervical cancer to cytology. In a set of 23 cervical cancer cases and 28 matched controls the receiver operating characteristic (ROC) area under the curve (AUC) is 0.99 (95% confidence interval [CI]: 0.97-1.00) with a sensitivity and specificity of 100% and 92.9%, respectively. Amongst the hospital-cohort (n = 330), the ROC AUC is 0.99 (95% CI: 0.98-1) with a sensitivity and specificity of 100% and 82.5% for the WID-qEC test, respectively, and 33.3% and 96.9% for cytology (considering PAP IV/V as positive). Our data suggest that the WID-qEC test detects both endometrial and cervical cancer with high accuracy.
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Affiliation(s)
- Lena Schreiberhuber
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Innsbruck, Austria.,Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Austria
| | - Chiara Herzog
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Innsbruck, Austria.,Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Austria
| | - Charlotte D Vavourakis
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Innsbruck, Austria.,Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Austria
| | - Elisa Redl
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Innsbruck, Austria.,Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Austria
| | - Christine Kastner
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Innsbruck, Austria.,Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Austria
| | - Allison Jones
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Iona Evans
- Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Michal Zikan
- Department of Gynecology and Obstetrics, Charles University in Prague, First Faculty of Medicine and Bulovka University Hospital, Prague, Czech Republic
| | - David Cibula
- Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University in Prague, General University Hospital in Prague, Prague, Czech Republic
| | - Peter Widschwendter
- Department of Gynecology and Obstetrics, General Hospital Hall, Tirol Kliniken, Hall in Tirol, Austria.,Danube Private University (DPU), Krems an der Donau, Austria
| | - Karin Pfau
- Department of Gynecology and Obstetrics, General Hospital Hall, Tirol Kliniken, Hall in Tirol, Austria
| | | | | | | | | | - Martin Widschwendter
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Innsbruck, Austria.,Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Austria.,Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK.,Department of Gynecology and Obstetrics, General Hospital Hall, Tirol Kliniken, Hall in Tirol, Austria.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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17
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Highly Sensitive Microsatellite Instability and Immunohistochemistry Assessment in Endometrial Aspirates as a Tool for Cancer Risk Individualization in Lynch Syndrome. Mod Pathol 2023; 36:100158. [PMID: 36918055 DOI: 10.1016/j.modpat.2023.100158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/22/2023] [Accepted: 03/01/2023] [Indexed: 03/13/2023]
Abstract
Women with Lynch syndrome (LS) are at increased risk of endometrial cancer (EC), among other tumors, and are characterized by mismatch repair (MMR) deficiency and microsatellite instability (MSI). While risk-reducing gynecological surgeries are effective in decreasing EC incidence, doubts arise regarding the appropriate timing of the surgery. We explored the usefulness of highly-sensitive MSI (hs-MSI) assessment in endometrial aspirates for the individualization of gynecological surveillance in LS carriers. Ninety-three women with LS, 25 sporadic EC patients (9 MMR-proficient and 16 MMR-deficient), and 30 women with benign gynecological disease were included in this study. Hs-MSI was assessed in prospectively collected endometrial aspirates in 67 LS carriers, EC cases, and controls. MMR, PTEN, ARID1A, and PAX2 expression patterns were evaluated in LS samples. Follow-up aspirates from eight LS carriers were also analyzed. Elevated hs-MSI scores were detected in all aspirates from MMR-deficient EC cases (3 LS and 16 sporadic), being negative in aspirates from controls and MMR-proficient EC cases. Positive hs-MSI scores were also detected in all four LS aspirates reported as complex hyperplasia. High hs-MSI was also present in 10 of 49 aspirates (20%) from LS carriers presenting a morphologically normal endometrium, where MMR expression loss was detected in 69% of the samples. Interestingly, the hs-MSI score was positively correlated with MMR-deficient gland density and the presence of MMR-deficient clusters, colocalizing with PTEN and ARID1A expression loss. High hs-MSI scores and clonality were evidenced in two samples collected up to four months before EC diagnosis; hs-MSI scores increased over time in five LS carriers, whereas they decreased in a patient with endometrial hyperplasia after progestin therapy. In LS carriers, elevated hs-MSI scores were detected in aspirates from premalignant and malignant lesions and normal endometrium, correlating with MMR protein loss. Hs-MSI assessment and MMR immunohistochemistry may help individualize EC risk assessment in women with LS.
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18
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Cervical Fluids Are a Source of Protein Biomarkers for Early, Non-Invasive Endometrial Cancer Diagnosis. Cancers (Basel) 2023; 15:cancers15030911. [PMID: 36765869 PMCID: PMC9913506 DOI: 10.3390/cancers15030911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/19/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Abnormal uterine bleeding is the main symptom of endometrial cancer (EC), but it is highly nonspecific. This represents a huge burden for women's health since all women presenting with bleeding will undergo sequential invasive tests, which are avoidable for 90-95% of those women who do not have EC. METHODS This study aimed to evaluate the potential of cervical samples collected with five different devices as a source of protein biomarkers to diagnose EC. We evaluated the protein quantity and the proteome composition of five cervical sampling methods. RESULTS Samples collected with a Rovers Cervex Brush® and the HC2 DNA collection device, Digene, were the most suitable samples for EC proteomic studies. Most proteins found in uterine fluids were also detected in both cervical samples. We then conducted a clinical retrospective study to assess the expression of 52 EC-related proteins in 41 patients (22 EC; 19 non-EC), using targeted proteomics. We identified SERPINH1, VIM, TAGLN, PPIA, CSE1L, and CTNNB1 as potential protein biomarkers to discriminate between EC and symptomatic non-EC women with abnormal uterine bleeding in cervical fluids (AUC > 0.8). CONCLUSIONS This study opens an avenue for developing non-invasive protein-based EC diagnostic tests, which will improve the standard of care for gynecological patients.
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19
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Herzog C, Sundström K, Jones A, Evans I, Barrett JE, Wang J, Redl E, Schreiberhuber L, Costas L, Paytubi S, Dostalek L, Zikan M, Cibula D, Sroczynski G, Siebert U, Dillner J, Widschwendter M. DNA methylation-based detection and prediction of cervical intraepithelial neoplasia grade 3 and invasive cervical cancer with the WID™-qCIN test. Clin Epigenetics 2022; 14:150. [PMID: 36414968 PMCID: PMC9682674 DOI: 10.1186/s13148-022-01353-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 10/10/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Cervical screening using primary human papilloma virus (HPV) testing and cytology is being implemented in several countries. Cytology as triage for colposcopy referral suffers from several shortcomings. HPV testing overcomes some of these but lacks specificity in women under 30. Here, we aimed to develop and validate an automatable triage test that is highly sensitive and specific independently of age and sample heterogeneity, and predicts progression to CIN3+ in HPV+ patients. RESULTS The WID™-qCIN, assessing three regions in human genes DPP6, RALYL, and GSX1, was validated in both a diagnostic (case-control) and predictive setting (nested case-control), in a total of 761 samples. Using a predefined threshold, the sensitivity of the WID™-qCIN test was 100% and 78% to detect invasive cancer and CIN3, respectively. Sensitivity to detect CIN3+ was 65% and 83% for women < and ≥ 30 years of age. The specificity was 90%. Importantly, the WID™-qCIN test identified 52% of ≥ 30-year-old women with a cytology negative (cyt-) index sample who were diagnosed with CIN3 1-4 years after sample donation. CONCLUSION We identified suitable DNAme regions in an epigenome-wide discovery using HPV+ controls and CIN3+ cases and established the WID™-qCIN, a PCR-based DNAme test. The WID™-qCIN test has a high sensitivity and specificity that may outperform conventional cervical triage tests and can in an objective, cheap, and scalable fashion identify most women with and at risk of (pre-)invasive cervical cancer. However, evaluation was limited to case-control settings and future studies will assess performance and generalisability in a randomised controlled trial.
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Affiliation(s)
- Chiara Herzog
- grid.5771.40000 0001 2151 8122European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Milser Straße 10, 6060 Hall in Tirol, Austria ,grid.5771.40000 0001 2151 8122Research Institute for Biomedical Aging Research, Universität Innsbruck, 6020 Innsbruck, Austria
| | - Karin Sundström
- grid.4714.60000 0004 1937 0626Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Medical Diagnostics Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Allison Jones
- grid.83440.3b0000000121901201Department of Women’s Cancer, UCL EGA Institute for Women’s Health, University College London, 74 Huntley Street, London, WC1E 6AU UK
| | - Iona Evans
- grid.83440.3b0000000121901201Department of Women’s Cancer, UCL EGA Institute for Women’s Health, University College London, 74 Huntley Street, London, WC1E 6AU UK
| | - James E. Barrett
- grid.5771.40000 0001 2151 8122European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Milser Straße 10, 6060 Hall in Tirol, Austria ,grid.5771.40000 0001 2151 8122Research Institute for Biomedical Aging Research, Universität Innsbruck, 6020 Innsbruck, Austria
| | - Jiangrong Wang
- grid.4714.60000 0004 1937 0626Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Elisa Redl
- grid.5771.40000 0001 2151 8122European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Milser Straße 10, 6060 Hall in Tirol, Austria ,grid.5771.40000 0001 2151 8122Research Institute for Biomedical Aging Research, Universität Innsbruck, 6020 Innsbruck, Austria
| | - Lena Schreiberhuber
- grid.5771.40000 0001 2151 8122European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Milser Straße 10, 6060 Hall in Tirol, Austria ,grid.5771.40000 0001 2151 8122Research Institute for Biomedical Aging Research, Universität Innsbruck, 6020 Innsbruck, Austria
| | - Laura Costas
- grid.418701.b0000 0001 2097 8389Cancer Epidemiology Research Programme, Catalan Institute of Oncology. IDIBELL, Av Gran Vía 199-203, 08908 L’Hospitalet de Llobregat, Barcelona, Spain ,grid.466571.70000 0004 1756 6246Consortium for Biomedical Research in Epidemiology and Public Health - CIBERESP, Carlos III Institute of Health, Av. De Monforte de Lemos 5, 28029 Madrid, Spain
| | - Sonia Paytubi
- grid.418701.b0000 0001 2097 8389Cancer Epidemiology Research Programme, Catalan Institute of Oncology. IDIBELL, Av Gran Vía 199-203, 08908 L’Hospitalet de Llobregat, Barcelona, Spain
| | - Lukas Dostalek
- grid.411798.20000 0000 9100 9940Gynaecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University in Prague, General University Hospital in Prague, Prague, Czech Republic
| | - Michal Zikan
- grid.4491.80000 0004 1937 116XDepartment of Gynecology and Obstetrics, First Faculty of Medicine and Hospital Na Bulovce, Charles University in Prague, Prague, Czech Republic
| | - David Cibula
- grid.411798.20000 0000 9100 9940Gynaecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University in Prague, General University Hospital in Prague, Prague, Czech Republic
| | - Gaby Sroczynski
- grid.41719.3a0000 0000 9734 7019Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL – University for Health Sciences and Technology, Hall in Tirol, Austria
| | - Uwe Siebert
- grid.41719.3a0000 0000 9734 7019Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL – University for Health Sciences and Technology, Hall in Tirol, Austria ,Center for Health Decision Science, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA USA ,grid.38142.3c000000041936754XInstitute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Joakim Dillner
- grid.4714.60000 0004 1937 0626Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Medical Diagnostics Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Widschwendter
- grid.5771.40000 0001 2151 8122European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Milser Straße 10, 6060 Hall in Tirol, Austria ,grid.5771.40000 0001 2151 8122Research Institute for Biomedical Aging Research, Universität Innsbruck, 6020 Innsbruck, Austria ,grid.83440.3b0000000121901201Department of Women’s Cancer, UCL EGA Institute for Women’s Health, University College London, 74 Huntley Street, London, WC1E 6AU UK ,grid.4714.60000 0004 1937 0626Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
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