Benign Reproductive Tissue Analysis for Endometrial Cancer Markers

Our hypothesis is that silent molecular lesions, defined as molecular alterations

detectable in histologically normal endometrial, ovarian, and tubal tissues, represent
markers of cancer risk. Incessant ovulation represents one of the most widely-recognized
models to explain the pathogenesis of ovarian cancer, with women who have had a high number
of lifetime ovulatory menstrual cycles being at increased cancer risk because of repeated
ovulation-related injury to, and repair of, ovarian surface epithelium (OSE). This extremely
delicate single layer of cells exfoliates easily on handling, with the majority of cells
typically being lost in routine handling, when collected post-operatively. Furthermore, the
identification of early stage ovarian cancer is uncommon, and the vast majority of ovarian
cancers are not associated with recognizable precursors. The lack of effective techniques for
collecting and studying OSE in the laboratory represents a major barrier to molecular studies
designed to uncover the etiology and early pathogenesis of ovarian cancer. This proposal will
develop a collection method for OSE, and demonstrate its utility for various molecular
analyses. Recent evidence suggests that a subset of ovarian cancers may originate in the
fallopian tubes. Therefore, we will pilot the collection of cells from the fallopian tubes.
If successful, the collection of OSE and fallopian tube cells will provide the basis for
larger studies aimed at identifying early molecular events in ovarian carcinogenesis.

In this pilot, we will collect endometrial and ovarian tissues (that would otherwise have
been discarded without histopathologic examination) from 125 hysterectomy and/or unilateral
or bilateral oophorectomy specimens obtained from women ages 18 and older who were operated
on for benign indications. As an amendment to this active protocol, we propose demonstrating
the feasibility of obtaining intra-operative cytobrushings of ovarian surface epithelial
cells on 50 women to be accrued onto the study, which will include women having hysterectomy
(or unilateral oophorectomy) alone without removal of the ovaries at the time of surgery.
Furthermore, we will extend the collection to cells from the fallopian tubes in 225 women for
a total population of 400.

We will administer a questionnaire assessing endometrial and ovarian cancer risk factors and
gynecologic history; obtain blood and urine; and obtain carefully-mapped frozen and fixed
endometrial and ovarian tissues. We will immunostain endometrial tissues to assess the
presence, number, location, and size of foci containing PTEN-null glands, which represents a
validated surrogate of mutations in the PTEN tumor suppressor gene. This pilot will
demonstrate the feasibility of executing this complex protocol; determine the number and
spacing of sections required to accurately and efficiently assess the PTEN status of the
endometrium; and provide data for developing power estimates needed to propose a full-scale
study with a sufficient number of subjects to test our hypothesis that PTEN abnormalities
account for a substantial proportion of the risk associated with recognized epidemiologic
endometrial cancer risk factors. It will assess the feasibility of performing molecular
analyses on ovarian surface epithelial cells and tubal cells collected intra-operatively, and
correlating molecular findings with known ovarian cancer risk factors. If successful, this
will provide the basis for larger studies aimed at identifying early molecular events in

ovarian carcinogenesis, particularly in the setting of women at increased genetic

risk of ovarian cancer. The pilot itself will also provide an extremely valuable

repository for future biomarker pilot studies.

- INCLUSION CRITERIA:

- Inclusion criteria include: 18 years of age and older with:

- a benign condition for which subject has decided to have a hysterectomy (removal
of the uterus), performed through an abdominal incision (open procedure) or
through a laparoscope (minimally invasive procedure). The hysterectomy can be
performed with or without removal of the tubes, ovaries or cervix.

- a benign cyst on the ovary(s) which subject has decided to have removed, with or
without removal of the entire ovary. The surgery will be done with either an
abdominal incision (open) or through a laparoscope (minimally invasive
procedure).

- positive test for the BRCA 1 or 2 gene, which puts subject at an increased risk
for breast cancer, and subject has decided to undergo surgery (either with an
abdominal incision or through a laparoscope) to remove the uterus, tubes and
ovaries, or any combination

- diagnosis of ovarian cancer or possible ovarian cancer and subject has been
advised to undergo a hysterectomy (removal of the uterus), removal of the tubes
and ovaries or any combination, with an abdominal incision or through a
laparoscope.

EXCLUSION CRITERIA:

Evidence on gross examination of the surgically removed uterus that there is a carcinoma
invading the myometrium; however, post-operative diagnosis of early endometrial carcinoma
will not be a cause for post-hoc exclusion after specimen and data collection. We will
exclude women with a previous gynecologic or gastrointestinal cancer. At the discretion of
the surgeon, we will exclude women with cancer in whom the study procedures may interfere
with clinical management (e.g. staging of the cancer). We will exclude women who had
neo-adjuvant chemotherapy and women who underwent chemoprevention of ovarian or breast
cancer. We will also exclude women currently wearing an intrauterine device.