1

The Detection of Early Stage The Detection of Early Stage Epithelial Ovarian CancerEpithelial Ovarian Cancer

David A Fishman MDDavid A Fishman MD-- Director NCI Ovarian Cancer Early Detection Program,Director NCI Ovarian Cancer Early Detection Program,ProfessorProfessor-- Ob/Ob/GynGyn, Director, Director-- Gynecologic Oncology and Cancer Prevention and Early Gynecologic Oncology and Cancer Prevention and Early Detection Program New York University School of MedicineDetection Program New York University School of Medicine

Supported by NCI UO1CA85133, Supported by NCI UO1CA85133, NCI P50 CA83639,NCI P50 CA83639, NIH NIH R01 CA89503,R01 CA89503, NIHNIH--RO1CA82562, RO1CA82562, NIH RO1 NIH RO1 CA01015,CA01015, NCI NCI CA125227CA125227--0101, NYU Cancer Institute, , NYU Cancer Institute, Greenberg Foundation, Kaleidoscope of Hope Foundation, 100 WomenGreenberg Foundation, Kaleidoscope of Hope Foundation, 100 Women’’s Hedge Fund s Hedge Fund Foundation, SAC Foundation, NYU School of MedicineFoundation, SAC Foundation, NYU School of Medicine

22%

18%54%

6%

CervixUterineOvaryOther

Estimated Gynecologic Cancer Deaths 2007

27,100 (10%)

Ovary

15,280

The problem:Epithelial Ovarian Carcinoma

• 70-75% women are diagnosed with advanced disease (as in 1960)

• Poor 5-year survival (12-15%) for advanced stage EOC

• 90% 5-year survival for stage I disease-yet often detected serendipitously

• Therefore intentional detection of earlystage disease is critical

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The Cause: Epithelial Ovarian Cancer

The Cause: Epithelial Ovarian Cancer

• Serous (45%)• Mucinous (13%)• Endometrioid (15%)• Clear Cell (3%)• Brenner (2%)• Mixed Carcinoma• Undifferentiated Carcinoma

How to Detect Early Stage EOC???

• Annual CA125 and US do not achieve detection of early stage disease

• Both can provide false security or inappropriate anxiety

• Accuracy approximates 50% for early stage disease

CA125• increased in 80%

postmenopausal women with OVCA, yet at best 50% with Stage I disease.

• many causes of false elevations; fibroids, benign ovarian cysts, pelvic inflammation, pregnancy, ovulation, endometriosis

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Who is at Risk?

• Increased risk based on: personal history, family cancer pedigree, known mutation carrier, prolonged use of infertility Rx

NOCEDP Clinical Experience

•• Formal Genetic evaluation and TestingFormal Genetic evaluation and Testing•• 3D US and Microvascular Index (MVI)3D US and Microvascular Index (MVI)•• Physical examination q 6mPhysical examination q 6m•• Health Services, QOL, EducationHealth Services, QOL, Education•• Ovarian Pap TestOvarian Pap Test-- outpatient 0.9 mm

miniscope• Biomarkers unique to ovarian

carcinogenesis, invasion, metastasis

Clinical Risk Assessment• Nulliparity???? (92% parous > 1 child)• Personal and Family History- critical • Ashkenazi descent ? (why me?)• 38% Jewish women with ovarian carcinoma-

+ BRCA 1 or 2• 20% Jewish women with premenopausal Breast

carcinoma- + BRCA 1 or 2 • All affected Jewish women should be

offered genetic testingAm. J. Human Genetics-2001, 2003, Lancet-2001

4

What is Hereditary Cancer?

60% 10%

30%

Hereditary Cancers

52%32%

16%

BRCA1

BRCA2

Other genes

Sporadic

Familial

Hereditary

Who is at Risk for a Hereditary Ovarian Cancer Syndrome?

• Any person with a personal history or family history of:– Breast, Colon, or Uterine cancer diagnosis under the age of 50– Ovarian cancer diagnosed at any age– Male breast cancer at any age– Multiple primary cancers: (i.e. breast and ovarian cancer, bilateral

breast cancer, ovarian and uterine cancer, colon and uterine cancer)– 2 or more family members with the same or related cancer

diagnosis in the family– Ashkenazi Jewish ancestry (with breast or ovarian cancer)– Relatives of mutation carrier

A BRCA Mutation Increases Breast and Ovarian Cancer Risks

Lancet 1994;343:692-695NEJM 1997;336:1401-1408AJHG 2003;72:1117-1130AJHG 1995;56:265-271Science 2003: 643-646

20

40

60

80

100

Breast cancerby age 50

Breast cancerby age 70

Ovarian cancerby age 70

2%

Up to 50%

7%

Up to 87%

Ris

k of

Can

cer

(%)

<2%

Up to 44%

General PopulationBRCA Mutation

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A BRCA Mutation Increases Risk of Second Cancer

JNCI 1999;15:1310-6JCO 1998;16:2417-25

Lancet 1998;351:316-21JCO 2004;22:2328-35

Lancet 1994;3343:692-5

0

20

40

60

Ovarian Cancer Breast Cancerafter 5 yrs

Breast Cancer by age 70

General PopulationBRCA Mutation

16% Up to 11%

Up to 27%

Up to 11%

Up to 64%

Ris

k of

Can

cer (

%)

* no statistic available

*

Risks in Men With a BRCA Mutation

JCO 2004;22: 735-42

5

10

15

20

25

Breast Cancer Prostate Cancer

General PopulationBRCA Mutation

<1%

7% 7%

20%

Ris

k of

Can

cer (

%)

Management/ Surveillance

Yearly beginning at age 25-35

Yearly beginning at age 40

Mammogram

Yearly (6 months after mammo) beginning at age 25

PRNBreast U/S and/or MRI

2-4 x/yr beginning at age 25

Every 1-3yrs beginning at age 20 and yearly at age 40

Clinical Breast Exam

Monthly beginning at age 18

Monthly beginning at age 18

Self Breast Exam

High RiskGeneral Population

Breast Screening

6

Management/ Surveillance

Colonoscopy every 3-5 yrs beginning at age 40

Colonoscopy every 5-10 years beginning at age 50*

Colon

Concurrent transvaginalultrasound with color Doppler, pelvic exam, and CA-125 2x/yr

Not routinely recommended

Ovarian

High RiskGeneral Population

Other Screening

Management/ Surveillance• Surgical Options

– Prophylactic Bilateral Salpingo-Oophorectomy• Reduces the risk for Ovarian cancer by 96%• Reduces the risk for Breast Cancer by 50-68%

– Prophylactic Mastectomy: Reduces the risk for breast cancer by 90%

• Tamoxifen:– Affected: reduces contralateral Br ca by 75%– Unaffected: BRCA2: 62%; High Risk: 45%

• Oral Contraceptives: Reduces the risk for Ovarian Cancer by 60% (if used for >5yrs)

Other Hereditary Cancer Syndromes Associated with Breast or Ovarian Cancer

• HNPCC: Hereditary Non-Polyposis Colorectal Cancer:– Colon Cancer (75%); Endometrial (39%); Ovarian

(5-10%); Others- GI area• Li-Fraumeni:

– Leukemia; breast; brain tumor; adrenocorticalcarcinoma; bone and soft tissue sarcoma; early onset adenocarcinomas or other childhood cancers.

• Cowden:– Breast, thyroid, endometrial

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REVIEW of RED FLAGS FOR HBOC

• Early age onset breast cancer• Bilateral breast cancer or both breast and

ovarian cancer in same individual (regardless of age)

• Both breast and ovarian cancer occurring in one family regardless of age

• Member of BRCA mutation family• Ashkenazi Jewish

Ovarian Cancer Syndromes

• Site-specific ovarian• Breast-Ovarian• Lynch type II - hereditary

nonpolyposis colorectal cancer (HNPCC) – 9- 12%

• Mutations of unknown significance

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Risk Assessment• Formal pedigree analysis and genetic

testing and counseling by a team including board certified geneticists and gynecologic oncologists identified 981 women

• 919 BRCA1/2 +, 62 + pedigree assessment

• Prophylactic surgery consisted of a laparoscopic BSO, peritoneal washings, and comprehensive evaluation of pelvis and abdomen

Demographics• 981 High Risk women• 517 BRCA 1 + (55%)• 402 BRCA 2+ (39%)• 62 BRCA- (5%) yet pedigree c/w

Inherited Cancer Syndrome• Evaluation from 1990-present• Average Clinical follow-up 5 years

BRCA 1• 517 women• 7 Gynecologic malignancies

–PPC- 2- Stage IIIC and IIIB–FT- 2- Stage IIB and IIIB–OVCa- 3- 1-Stage IA, 2-IIIA

–No PPC in all women s/p BSO

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BRCA 2• 402 women• 3 Gynecologic Malignancies

–PPC- 1 Stage IIIB–FT- 1 Stage IIIA–OVCA- 1 Stage IB

–No PPC in women s/p BSO

Cancer Detection• 971 Benign • 3 Primary Peritoneal Cancer- all Stage III• 3 Fallopian Tube Cancer- Stage II/III(2)• 4 Ovarian Cancer- 2- Stage I, 2- Stage III• 10 Cancers –

– 2- Stage I– 1- Stage II – 7- Stage III

Abdominal UltrasoundThe Role of US

Best Visualization of the Fetus and Adnexa

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Three Dimensional Ultrasound

Can Treat & Res 2002

Recent Advances In Ultrasound• Power Doppler Energy- improved

specificity as secondary test (83-92%)• 3-Dimensional volume acquisition and

power Doppler- identifies architectural and vascular changes in observed mass, increases specificity from 54% to 75% as a secondary test

• Microvascular Imaging (MVI)- capillaries visualized with nanoparticles

Gyn Onc 2001, Gyn Onc 2002, Lancet 2003

Simple ovarian cyst demonstrating peripheral flow

Vaginal U/S with Color DopplerVaginal U/S with Color Doppler

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Complex adnexal mass with multiple septations with central flow suggestive of malignancy

serous cystadenocarcinoma - confirmed by pathology

3-D U/S Power Doppler

Gyn Onc 2002

NOCEDP• 47,356 gynecologic U/S on

13,646 asymptomatic high-risk women (normal exam and U/S)

• 297 aberrant masses identified• 127 surgical interventions • 113 benign tumors, 14 cancers

AJOG 2005

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NOCEDP• 14 asymptomatic gynecologic cancers

detected (4 fallopian tube, 4 primary peritoneal, 2 epithelial ovarian carcinoma, 2 uterine, 2 metastatic Br)

• all Stage III/IV (A, B, and C) except uterine (both stage1A G1)

• all normal US and PE 12 and 6 months prior to abnormal scan

• FT/PPC - normal ovaries

Conclusion• US was effective in detecting

asymptomatic advanced stage adnexal disease

• US is ineffective as an independent modality in the detection of early stage EOC in the high-risk population

The Future:Microvascular Imaging

• Combination of high resolution ultrasound with vascular mapping and quantification of aberrant capillary influx from pre-existing host venules stimulated by tumor neovascularization

• IV contrast agents (micro- and nanoparticles) to illuminate the extravasation associated with the influx of new “leaky” vessels

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Demonstration of normal ovarian vascularization (left) as compared to a morphologically “normal” ovary with Stage I EOC (papillary serous) (right). Note the significant increase in tumor vascularity as well as RBC extravasation throughout the parenchyma, both of which were perfused by contrast agents and therefore detected by contrast sonography. (H&E stain, x200 magnification)

• Designed to increase the backscatter of the echoes coming from the blood

• 1-10μ microbubbles can pass through the smallest capillaries.

Sonographic Contrast AgentsMicrobubble Destruction

• At diagnostic output levels, bubble can expand a few times original radius

• Most stabilizing coatings give way, leaving a free bubble to dissolve

• After insonification at normal imaging levels, most agents are destroyed

• This can be avoided with new sensitive imaging modes, or can be used to advantage Animation adapted from Dr. K Ferrara, UC Davis.

© Becher H and Burns PN, Handbook of Contrast Echocardiography,Springer 2000,

www.Sunnybrook.utoronto.ca/EchoHandbook/

5μ

Sonographic contrast agents can diffuse into the leaky capillary beds associated with tumor neovascularization

which translates into enhanced sonographic visualization of early stage EOC.

Tumor EnhancementMicrobubble Tumor Perfusion

0

2

4

6

8

10

12

0 2 4 6 8 10 12 14Seconds after injection

Sig

nal i

nten

sity

Mouse 4b with LLC tumor

MVI Quantification

QLAB Software (Version 2)

In vivo model demonstrating sonographic detection of aberrant tumor vascularity. Time activity curve showing time to peak and full-width half maximum points used to quantify

perfusion.

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Mass Spectrometry as a Discovery Tool for Mass Spectrometry as a Discovery Tool for Cancer BiomarkersCancer Biomarkers

•• Low resolution mass spectrometry profiles Low resolution mass spectrometry profiles segregate cancer from nonsegregate cancer from non--cancer controlcancer control•• Sensitivity 100% and specificity 95% Sensitivity 100% and specificity 95%

•• Low molecular weight archive Low molecular weight archive

•• Small proteins associate with high abundance Small proteins associate with high abundance carrier proteins carrier proteins

•• Extraction and analysis of carrierExtraction and analysis of carrier--bound peptides a bound peptides a rich source of novel biomarkers rich source of novel biomarkers

More specialized knowledge required…?Limited m/z range? (5-12,000 – XL to 40,000)High resolution (>9000 at m/z 1500)High mass accuracy (>50 ppm - external cal)Able to conduct CID of peptides

WCX2 ProteinChip Array

Ciphergen SELDI-TOF MS ABI QSTAR Pulsar QqTOF MS

WCX2 ProteinChip Array

Validation and Implementation of SELDI-QqTOF for Diagnostic Proteomics

Widely accessibleExtensive m/z range (5-300,000)Low Resolution (~ 100-200)Low Mass Accuracy (~1000 ppm)

EDRN 2002

15

m /z2 0 0 0 6 0 0 0 8 0 0 0 1 0 0 0 0 1 2 0 0 04 0 0 0

1 0 0

2 0 0

0

3 0 0

4 0 0

Inte

nsity

(cps

)

3 8 8 3 .5 73 9 7 7 .7 6 4 0 7 1 .8 1

4 4 6 7 .2 2

7 7 6 6 .0 2

7 9 5 5 .3 8

8 1 4 2 .9 8

8 3 3 3 .5 98 6 0 2 .8 3

8 9 3 3 .4 67 1 9 3 .7 8

0

2 5

5 0

7 5

1 0 0

m /z2 0 0 0 6 0 0 0 8 0 0 0 1 0 0 0 0 1 2 0 0 04 0 0 0

3 8 8 5 .3

4 0 7 2 .8

4 4 7 1 .9

7 7 7 1 .4

7 9 2 3 .0

8 1 4 9 .8

8 9 4 5 .7

1 0 2 7 6

Rel

ativ

e In

tens

ity

A .

B .

C o n r a d s e t a l., F ig . 1

Comparison of the mass spectra from control serum prepared on a WCX2 Protein Chip array and analyzed with a PBS-II TOF (panel A) or a Qq-TOF mass spectrometer (panel B).

ERC 2004

PrOTOF 2000PrOTOF 2000™™

MALDI Orthogonal-TOF Mass Spectrometry

prOTOF orthogonal high resolution MALDI TOF detector…

Mass accuracy:

5-10 ppm external calibration

2-5 ppm internal calibration

Mass stability: 10 ppm over several hours using external calibration

Resolution: 10,000-15,000

Detection limits: sub femtomole

Throughput: 15,000 samples/day

Independence of operating parameters

Disposable sample plates

Mass accuracy:

5-10 ppm external calibration

2-5 ppm internal calibration

Mass stability: 10 ppm over several hours using external calibration

Resolution: 10,000-15,000

Detection limits: sub femtomole

Throughput: 15,000 samples/day

Independence of operating parameters

Disposable sample plates

0

25

50

75

100

m/z2000 6000 8000 10000 120004000

3885.34072.8

4471.9

7771.47923.0

8149.8

8945.710276

Rel

ativ

e In

tens

ity

Year 2002= Low Resolution SELDI-TOFLancet 2002

Year 2004= High Resolution SELDI-TOFERC 2004

Year 2005= Ultra High Resolution Orthogonal MALDI-TOF and FT-ICRDirect Accurate Mass Tagging Based IDJNCI 2005

The Rapid Evolution of MS Instrumentation

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Rapid Identification of Biomarkers in Ovarian Cancer Serum Samples:

• Carrier protein-bound affinity enrichment• High resolution MALDI OTOF MS• Decision rule analysis and FTICR de

novo sequencing

Albumin trap Albumin trap and elution of bound proteins/peptidesand elution of bound proteins/peptides

1D protein gel separation and digestion1D protein gel separation and digestion

InIn--gel gel tryptictryptic digestion and excision gel lanesdigestion and excision gel lanes

µµLC MS/MS analysis LC MS/MS analysis Data analysis and repetitive sequencingData analysis and repetitive sequencing

Albumin-Bound Peptide Purification and Biomarker Identification

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7 T Actively ShieldedSuperconducting Magnet

FTMS Data

210L/s

Linear Ion Trap Data

60m3/hr 300L/s 400L/s 210L/s15L/s

Triple Ported Turbo Pump

ECD Assembly

IRMPD Laser Assembly

Finnigan LTQ FT

Accurate mass, isotopically-resolved, differentially-expressed BioXPRESSION processed peptides are selected for LC-MS/MS

De novo sequencing of putative marker peptides…

Peptide Identification from MicrocapillaryReverse-phase Tandem MS

•• Data analysis through the Data analysis through the SequestSequest BioworksBioworks Browser Browser •• European Bioinformatics Institute nonEuropean Bioinformatics Institute non--redundant proteome set redundant proteome set

•• SwissSwiss--ProtProt •• TrEMBLTrEMBL •• EnsemblEnsembl

•• Mascot version 1.9.0 and NCBI BLASTCLUSTMascot version 1.9.0 and NCBI BLASTCLUST

Protein IdentificationProtein Identification

• Over 800 distinct proteins identified in data set

• 618 previously unknown to exist in human sera

• Stage-specific proteins identified• 215 unique to Stage I• 127 unique to Stage III and IV• 30 found in both early and late stage

• 96 of novel proteins identified by ≥ 2 peptide matches• Indicates greater than 99% confidence of correct identification

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AlbuminAlbumin--bound Candidate Biomarkersbound Candidate Biomarkers

Prominent SELDI-TOF ionic species (m/z 6631.7043) identified to correlate with the presence of ovarian cancer were amplified by albumin capture

• 456 Albumin Binding Fragments: Ovarian Cancer

• 3’, 5’ –cyclic-GMP phosphodiesterase• A Chain A, Crystal Structure of Human Apolipoprotein• A Chain A, Transthyretin (Prealbumin)• A1AG Human Alpha 1 Acid Glycoprotein 1 Precursor (AGP 1)• A1AT Human Alpha-1-Antitrypsin Precursor, Alpha-1 Protease

Inhibitor, Alpha-1-Antiproteinase• A1BG Human Alpha 1B Glycoprotein • A2MG Human Alpha 2 Macroglobulin Precursor • ADP-Ribosylation Factor Binding Protein 3, golgi localized gamma ear

containing, ARF binding protein 3, KIAA0154 gene product• AF070710 envelope glycoprotein (Human Immunodeficiency Virus

Type 1)• AF077721 Pol Protein (Human Immunodeficiency Virus Type 1)• AF094250 envelope glycoprotein (Human Immunodeficiency Virus

Type 1)• AF099171 protease (Human Immunodeficiency Virus Type 1)• AF190128 Rev (Human Immunodeficiency Virus Type 1)• AJ228172 gp120 (Human Immunodeficiency Virus Type 1)• ALC1 Human Ig Alpha-1 Chain C Region

• Alpha 1 & 2 Hemoglobin, HBA Human Hemoglobin Alpha Chain

• APA1 Human Apolipoprotein A-I Precursor, Apolipoprotein A-I

• APA2 Human Apolipoprotein A-II Precursor, ApolipoproteinA-II

• APC1 Human Apolipoprotein C-I Precursor, Apolipoprotein C-I

• APC3 Human Apolipoprotein C-III Precursor, ApolipoproteinC-III

• LPHUB apolipoprotein B-100 precursor – human• apolipoprotein D, apoD (human, plasma)• apolipoprotein E (homo sapien)• ASNS Human Asparagine Synthetase (glutamine hydrolyzing),

TS11 Cell Cycle Control Protein • AT Human Alpha-1-Antitrypsin (Internal Fragment)• B Chain B, Crystal Structure of A Human Fcg• B Chain B, Crystal Structure of S-Nitroso-Nit• BBHU CFAB Human Complement factor B Precursor, C3/C5

Convertase, Properdin Factor B, Glycine Rich Beta Glycoprotein GBG

• BRS3 Human Bombesin Receptor Subtype 3, Uterine BombesinReceptor

• C Chain C, Human Serum Transferrin, Recombinant• C1HUQB Complement Subcomponent C1q Chain B Precursor• C4HU complement precursor (validated)• Ceruloplasmin, Ferroxidase Human• CFA1 Human Complement Factor I Precursor, C3B• Clusterin, Complement Cytolysis Inhibitor (CLI), SP-40,

Sulfated Glycoprotein 2, testosterone Repressed Prostate Message 2JNCI-2005, JBC-2005

Candidate Biomarkers in Stage I EOCCandidate Biomarkers in Stage I EOC

Zinc finger Zinc finger homeoboxhomeobox ProteinProteinRho GDPRho GDP--dissociation dissociation inhibitor 1inhibitor 1

CHORD containing protein 1CHORD containing protein 1

Vascular nonVascular non--inflamatorinflamator molecule 2molecule 2RB associated factor 600RB associated factor 600cGMPcGMP gated gated cationcation channelchannel

UNC5C UNC5C transmembranetransmembrane receptor 2receptor 2ProtoProto--oncogene TKoncogene TKCentrosomalCentrosomal protein 2protein 2

UbiquitinUbiquitin--activating enzyme E1activating enzyme E1PhosphodiesterasePhosphodiesterase gammagammaCaspaseCaspase recruitment protein 12recruitment protein 12

Tyrosine protein Tyrosine protein kinasekinase CSKCSKPannexinPannexin 22BrCaBrCa antigen NUantigen NU--BRBR--11

Tumor associated Ca signal transducerTumor associated Ca signal transducerMelanoma antigen B4Melanoma antigen B4BRCA 2BRCA 2

TuftelinTuftelin--interacting protein 11interacting protein 11MDM4 proteinMDM4 proteinBAI 1 BAI 1

TransmembraneTransmembrane FLRT1 precursorFLRT1 precursorKinaseKinase suppressor of rassuppressor of ras--11BAGBAG--11

Transcription factor SOXTranscription factor SOX--33JunctophilinJunctophilin 11BaculoviralBaculoviral IAP domain protein 1IAP domain protein 1

TitinTitinInterleukinInterleukin--17 precursor17 precursorAPC proteinAPC protein

TenacinTenacin--RRIGF complexIGF complexAlpha Alpha tectorintectorin

SRp25 nuclear proteinSRp25 nuclear proteinEMILIN precursorEMILIN precursorALK TK receptor precursorALK TK receptor precursorRyanodineRyanodine receptor 3receptor 3Disks largeDisks large--assoc protein 2assoc protein 2AdlicanAdlican TK receptorTK receptor

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Conclusions

• High resolution mass spectral analysis of albumin-enriched serum fraction effectively segregates while Microcapillary HPLC tandem MS identifies novel biomarker candidates• Normal from malignant , Early from late stage

disease• Disease recurrence• Optimization of chemotherapeutics-

chemosensitivity assays

• Lysophospholipds (LPA) -LC/MS/MS• Growth factors (p110, p60)• Proteases (MMPs, Kallikreins) • Proteomics- SELDI/ MALDI-TOF, ABI

QqTOF, ESI-MS • Many other proteins … Prolactin, Leptin,

Osteopontin, IGF-II..

Clinically Relevant Biological Markers for Early Detection

Ovarian Pap Test

• Minimally invasive office laparoscopy- outpatient procedure

• Genomics and proteomics can detect precancer/cancer years before cytology- Prevention

Cont Ob/Gyn 2003, NEJM 2003

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Array CGH Analysis

- 0 .7 5

- 0 .5

- 0 .2 5

0

0 .2 5

0 .5

0 .7 5

0 5 0 0 1 0 0 0 1 5 0 0 2 0 0 0 2 5 0 0 3 0 0 0

D i s t a n c e a l o n g g e n o m e

Freq

uenc

y

Summary of array CGH analyses of 54 serous ovarian cancers. Data are represented from 1pter (left) to 22qter and X (right). Vertical lines indicate chromosome boundaries. Red spots indicate regions that are homozygouslydeleted or highly amplified in some tumors. Regions most frequently increased in copy number are apparent on chromosomes 3q26 (EVI1) and 8q24 (MYC).

FISH assay: EVI1 and MYC for EOC detection

EVI1 FISH Contig (550 kb)

MYC FISH Contg (500 kb)

BRCA1+ Mutation with Normal Cytology

Prophylactic BSO

Normal histology

Abnormal Copy Number of EVI1 and MYC

21

Asymptomatic Patient

Serum/Plasma Protein and Lipid Analysis

Diagnostic Imaging-USMVI

Ovarian Pap Test/ Biopsy- Cytopathology- Gene/Protein Profile

Detection of Early Stage Disease

New Paradigm for Cancer Detection

New York Univ. New York Univ. FDAFDANational Cancer InstituteNational Cancer Institute George MasonGeorge MasonMD Anderson Cancer Center MD Anderson Cancer Center Roswell ParkRoswell ParkMayo ClinicMayo Clinic Duke Univ.Duke Univ.Johns Hopkins Johns Hopkins Creighton Univ.Creighton Univ.Yale Univ.Yale Univ. Univ. TorontoUniv. TorontoUniv.CaliforniaUniv.California-- San FranciscoSan Francisco Univ. ArizonaUniv. ArizonaUniv.CaliforniaUniv.California-- Los Angles Los Angles Univ. ChicagoUniv. ChicagoUniv. Southern California Univ. Southern California Northwestern Univ.Northwestern Univ.Univ. Utah Univ. Utah Stanford Univ.Stanford Univ.Univ. PittsburghUniv. Pittsburgh Wayne State Univ.Wayne State Univ.Harvard Univ.Harvard Univ. TuftsTufts-- BaystateBaystateUniv. TexasUniv. Texas-- SouthwesternSouthwestern Univ. MichiganUniv. MichiganPhilips CorpPhilips Corp Univ. HawaiiUniv. HawaiiPerkinPerkin Elmer Univ. AlabamaElmer Univ. AlabamaAustralia, Israel, Hungary, Canada, Japan, Sweden, Finland, Germany, Holland

Collaborating InstitutionsCollaborating Institutions