Patent Application
20170292954
The present invention relates to an ex vivo method for detecting and quantifying plural oral biomarkers within biological material present in a human oral cavity when oral cancerous activity is present.
Oral cancer has emerged as an alarming public health problem with increasing incidence and mortality rates all over the world. Oral cancer (predominantly oral squamous cell carcinoma, OSCC) is the sixth most common human malignancy, with a high rate of morbidity and a 5-year mortality rate of approximately 50% which has not changed significantly in more than 50 years. Therefore, the implementation of newer screening and early detection approaches are of utmost importance which could reduce the morbidity and mortality associated with this disease. The therapeutic modality currently offered to OSCC patients is based on tumour metastasis nodes criteria and on histological grading. Unfortunately, these predictors are subjective and relatively unreliable, as two tumours with identical staging and grading often behave very differently; though one responds to therapy, the other may be lethal. Thus, there has been an ever-growing effort dedicated to the basic research of oral cancer, focusing on the identification of biological indicators for the diagnosis of its biological nature and aggressiveness.
Biomarkers have been suggested previously to be related to OSCC (mostly by tissue analysis) for example: carbonyls, 8-oxoguanine DNA glycosylase (OGG1), mammary serine protease inhibitor (Maspin), Ki67, phosphorylated-Src (phospho-Src), Cyclin D1 (CycD1), metalloproteinase-9 (MMP-9) and lactate dehydrogenase (LDH). An additional target might involve HPV. A review of one set of biomarkers has been described in Cheng et al. Clinical Translational Medicine 2014 3:3.
Plural biomarkers have not been used clinically simultaneously.
Oral cavity sampling, a non-invasive alternative to serum testing, has been identified by the inventors of the present invention as an effective modality for diagnosis and prognosis predicting of oral cancer as well as for monitoring the patient's post-therapy status. However, no oral sample device or test is currently offered commercially to detect, or predict the progression of OSCC.
Proposed herein, is the collection/storage of oral cavity biological material on solid supports consisting of base papers such as Whatman 903 ® cellulose filter paper, which will facilitate oral cancer screening approaches. Alternative sample collection materials could include other solid materials such as alginates and even material coated with non-hazardous chemicals. It is important that a solid support material is used that does not cause the denaturation of the protein as denaturation may restrict immunological detection systems in approaches like ELISA, Western blot etc.
The incorporation of base paper, alginate or similar non-hazardous and non-denaturing solid supports into the oral collection and storage device will permit the following techniques; i) direct sampling of cells from the oral cavity without any significant permanent harm to the patient and ii) during the molecular detection phase, non-coated (and certain chemically-coated) solid supports can be used in direct/punch-in workflows in which a small portion of the collected sample is excised and placed directly into a solution of the detection reagent. These techniques facilitate the direct sampling of saliva potentially containing oral cancer biomarkers.
Herein is described a new swab device and test for monitoring oral cancer. The device and test, as an adjunct to identifying cancer-related changes in salivary tumour markers, may be used as a tool for diagnosis, prognosis and post-operative monitoring. The inventors have established that the proximity of saliva and oral cancer lesions makes the measurement of tumour markers in the oral cavity an attractive alternative to serum and tissue testing. Further the inventors have established that any DNA, RNA, protein molecules, and any other analytes of interest, derived from the living cancer cells can be conveniently obtained from saliva and potentially collected and stored on a novel swab device. Novel testing described herein involves a punch-in system with direct analysis of the biomarker obtained on the swab device (by means of direct PCR, RT PCR, protein, enzyme analysis, capillary electrophoresis, TOF MS, and other known methods).
The invention provides a method according to claim 1 having preferred features defined by claims dependent on claim 1. The invention provides also a swab device according to claim 12, having preferred features defined by claims dependent on claim 12.
The invention extends to any combination of features disclosed herein, whether or not such a combination is mentioned explicitly herein. Further, where two or more features are mentioned in combination, it is intended that such features may be claimed separately without extending the scope of the invention.
The invention can be put into effect in numerous ways, illustrative embodiments of which are described below with reference to the drawings, wherein:
The invention, together with its objects and the advantages thereof, may be understood better by reference to the following description taken in conjunction with the accompanying drawings, in which like reference numerals identify like elements in the Figures.
Detection of specific biomarkers for oral cancer is the most likely effective method for screening, diagnosis, staging and follow-up for this malignancy. Unlike other deep tissue cancers, oral cancer is located only in the oral cavity, which term is herein intended to include mouth, and upper throat (pharynx) in humans. Hence, the direct contact between saliva and cells from the oral cancer lesion makes the measurement of tumour markers in saliva and lesion areas an attractive alternative to invasive serum and tissue testing. The DNA, RNA, protein molecules and other analytes of interest derived from the living cancer cells can be conveniently collected from saliva and lesions on a swab-like device, then stored if required. Herein the term ‘biomarker(s)’ includes that collected DNA, RNA, protein molecules and other analytes of interest, as well as other secondary biological material which results from, or forms as a consequence, of the presence of those biomarkers. The term ‘biomarkers’ also includes OSCC precursors such as viruses which may initiate cancerous activity. Herein ‘cancerous activity’, includes precancerous activity e.g. viral activity, associated with OSCC.
Thus, herein is described a novel method and collection device suitable for collecting oral cancer biomarkers, as a non-invasive alternative to serum, tissue based and biopsy biomarker collection. The method described is an effective method for the early diagnosis, prognosis and monitoring post therapy status.
Various technologies provide opportunities for high-throughput approaches to genomics and proteomics; which can be used to evaluate altered expressions of gene and protein targets in saliva of oral cancer patients. The collection/storage of oral biomarkers for example in saliva, and/or cancerous cells on solid supports can be followed by a simple direct or punch-in technique in which a sample on a solid support is added directly to detection reagents and subjected to biomarker detection methods such as, but not limited to, immunological assays and nucleic acid amplification technologies without the prior purification of the biomarkers or analytes of interest.
An alternative approach to the sampling device describe here is the use of the Whatman Easicollect® device in combination with a non-chemically coated filter paper such as 903®. It is important that a solid support material is used that does not cause the denaturation of the protein as denaturation may restrict immunological detection systems to approaches like Western blot etc. The use of non-chemically-coated solid supports reduces the potential for harm to patients.
The incorporation of a uncoated plain filter paper, alginate or similar non-hazardous and non-denaturing solid supports into a mildly abrasive absorbent matrix into the saliva/cellular collection and storage device will permit direct sampling of the biomarkers, associated with potentially cancerous cells.
The inventors have reviewed the importance of several genomic and proteomic biomarkers and/or other analytes of interest for oral cancer and suggest the collection of these markers on solid supports supplied by Whatman mentioned above. The detection methods contemplated include gene expression or protein expression profiling using RT-PCR and/or the use of untreated paper and downstream protein based assays, as well as polymerase chain reaction (PCR), quantitative PCR (qPCR), microarray assays preceding qPCR, enzyme linked immunosorbent assay (ELISA), other immunological techniques, gel electrophoresis (2DE), capillary electrophoresis (TOF MS), high performance liquid chromatography (HPLC), mass spectrometry (MS), flame photometry, atomic absorption, and spectrophotometry.
Table 1 gives examples of biomarker candidates which are indicative of cancerous or precancerous activity in the oral cavity. Below are described various assays which can be conducted to detect the existence of these biomarkers in biological material collected on solid supports, and in some cases, to quantify them. While the list contains various proteins and enzymes, it is possible to detect these by means of mRNA analyses, rather than detect the protein itself and vice versa. Further below there is shown a swab device including a solid support suitable for the collection of the biological materials.
Recombinant IL-2±carrier (R & D Systems; Cat. 202-IL-CF-10 μg; lot AE4309112 and Cat. 202-IL-10 μg; lot AE4309081 respectively) was dissolved in blood (TCS Biosciences) at 50 pg or 100 pg/μl. Aliquots (1 μl containing, 50 (B) or 100 (A) pg of IL-2) were applied to Whatman 903 filter papers.
These samples were allowed to dry overnight at ambient temperature and humidity. 3 mm diameter punched disks were extracted from each paper type using the appropriately sized punch. Single discs were directly analysed for IL-2 with reagents from a fully 10 configured IL-2 Quantikine ELISA kit (R & D Systems, Cat. D2050, lot 273275). Direct assays were carried out “punch in well”, i.e. where a portion of the 903 filter paper was punched out and deposited in a reaction well of a convention multiwell plate.
On completion of the assay the optical density was monitored at 450 nm. The recovery of IL-2 was determined by comparing values to a standard curve of known IL-2 concentrations. Recovery rates are shown in in
Protein and enzyme testing was carried out with fully configured DNase and RNase Contamination Kits (DNase & RNase Alert QC Systems, catalogue codes AM1970 & AM1966, Life Technologies) according to the manufacturer's instructions.
Dideoxyribonuclease (DNase)
In a first series of experiments, 0.125-0.5 U of DNase was applied to Whatman FTA and 903 papers in 10 μl volumes. DNAse and RNase activity was measured as outlined below.
In a second series of experiments, 1.2 mm punches were taken from 106 human embryonic stem cells (GE Healthcare; cell line ref: WCB307 GEHC 28) which had been applied to FTA and 903 papers in 10 μl volumes as above. DNAse and RNase activity was measured as outlined below.
In a third series of experiments, 1.2 mm punches were taken from 106 human embryonic stem cells (GE Healthcare; cell line ref: WCB307 GEHC 28) containing either 0.5 U of DNase or 10 μU of RNase added to these cells which had been applied to FTA and 903 papers in 10 μl volumes.
Detection of DNase activity was carried out as follows using a cleavable fluorescent-labelled DNase substrate. Each punch was ejected into separate wells of 96-well plates. Lyophilized DNase Alert Substrate was dissolved in TE buffer (1 ml) and dispensed (10 μl) into the test wells of the 96-well plate. 10× DNase Alert Buffer (10 μl) and nuclease-free water (80 μl) was added and the test solution (100 μl) incubated for 60 minutes at 37° C. The DNase Alert QC System Substrate is a modified DNA oligonucleotide that emits a pink fluorescence when cleaved by DNase. For this assay, fluorescence was measured on a Tecan Ultra (excitation/emission 535/595 nm using medium gain). Solutions containing DNase activity produced a pink fluorescence, whereas solutions without DNase activity did not fluoresce. Thus, higher levels of DNase corresponded to an increase in the amount of light output. Negative controls consisted of nuclease-free water (80 μl) in place of sample. DNAase activity can be detected and quantified in a rate dependent manner using the 903 or FTA filter papers as solid supports.
Ribonuclease (RNase)
Detection of RNase was carried out as follows using a cleavable fluorescent-labelled RNase substrate. Each punch was ejected into separate wells of 96-well plates. Lyophilized RNase Alert Substrate was dissolved in TE buffer (1 ml) and dispensed (10 μl) into the test wells of the 96-well plate. 10× RNase Alert Buffer (10 μl) and nuclease-free water (80 μl) was added and the test solution (100 μl) incubated for 60 minutes at 37° C. The RNase Alert QC System Substrate is a modified RNA oligonucleotide that emits a green fluorescence when cleaved by RNase. For this assay, fluorescence was measured on a Tecan Ultra (excitation/emission 485/535 nm using medium gain). Solutions containing RNase produced a green fluorescence, whereas solutions without RNase activity did not fluoresce. Thus, higher levels of RNase corresponded to an increase in the amount of light output. Negative controls consisted of nuclease-free water (80 μl) in place of sample.
Enzyme Assay for LDH
LDH is a cytosolic enzyme present in many different types of cells. When the plasma membrane is damaged, LDH is released into the bathing medium surrounding cells. The released LDH can be quantified by a coupled enzymatic reaction. First, LDH catalyzes the conversion of lactate to pyruvate via reduction of NAD+ to NADH. Second, diaphorase uses NADH to reduce a tetrazolium salt (INT) to a red formazan product. Therefore, the level of formazan formation is directly proportional to the amount of released LDH in the medium. The assay is performed by transferring a punch from with the addition of cells or LDH enzyme or into a microplate and adding the kit reagents (LDH Cytotoxicity Assay Kit; Thermo Scientific, Product Code 88953). After incubation at room temperature for 30 minutes, reactions are stopped and LDH activity is determined by spectrophotometric absorbance at 490 nm.
Immunoassay for LDH
An alternative more sensitive approach involves the use of immunoassay detection of LDH (LDHB human ELISA Kit (abcam product code 116693). This system involves the quantitative measurement of human LDHB protein in cell and tissue lysates using a punch in system as above. The assay employs an antibody specific for human LDHB coated on a 96-well plate. Samples are pipetted into the wells and LDHB present in the sample is bound to the wells by the immobilized antibody. The wells are washed and an anti-LDHB detector antibody is added. After washing away unbound detector antibody, HRP-conjugated label specific for the detector antibody is pipetted to the wells. The wells are again washed, a TMB substrate solution is added to the wells and colour develops in proportion to the amount of LDHB bound. The developing blue colour is measured at 600 nm. Optionally the reaction can be stopped by adding hydrochloric acid which changes the colour from blue to yellow and the intensity can be measured at 450 nm.
Thermo Scientific Phusion Blood Direct PCR Kit was demonstrated to support the amplification of DNA directly from blood samples stored on a range of solid supports including Whatman 903, FTA and FTA Elute cards (Chum and Andre 2013; Thermo Fisher Scientific). FTA and FTA elute cards are examples of chemically coated paper-based cards whilst 903 cards do not have any applied chemicals. In direct amplification workflows, no prior DNA extraction or purification steps are needed and excised portions of the cards are simply added to the PCR reaction mixture. Blood was chosen as the biological sample as this is considered to be the most challenging sample type from which to generate PCR amplicons. This is due to the presence of heam which is a potent PCR inhibitor (Akane et al 1994, J. Forensic Sci., 39, 362-372).
Sample preparation: Fresh blood or blood preserved with heparin (1.4 IU/ml), K2EDTA (1.8 mg/ml), or Na Citrate (109 mM) was applied to Whatman 903 Cards, FTA Elute Cards, or FTA Gene Cards and dried as per the manufacturer's instructions. For direct PCR, a 1 mm diameter disc was punched out of the sample and used in the following PCR reaction volumes: Whatman 903: 10-50 μl, FTA Elute Card: 25-50 μl and FTA Gene Card: 504 When larger punches or smaller reaction volumes were used, punches were washed with 20 μl of H2O at 50° C. for 3 minutes. After removing the H2O, PCR components were added directly to the rinsed punch. The parameters and reagents used are listed in tables II, III and IV, below.
The PCR study confirmed that DNA can be directly amplified from biological samples stored on various filter cards. Samples derived from the 903 Cards showed almost no inhibition, and a 1 mm punch could be used with reaction volumes as low as 10 μl. Whatman FTA and FTA Elute filter paper (a variant of the Whatman FTA treated filter paper) exhibited varying degrees of inhibition. FTA elute inhibited direct PCR reactions slightly; a 1 mm disc in a 25-50 μl reaction worked well, but when placed in a 10 μl reaction, the PCR was totally inhibited. FTA Gene Cards showed the greatest level of inhibition. Without any pre-treatments, a 1 mm punch of FTA Gene Card worked well only in a 50 μl reaction volume. For smaller reaction volumes, a very simple washing protocol was enough to remove inhibitors from both FTA Elute and FTA Gene Cards. After washing the card punch for 3 minutes with H2O, the sample was of sufficient purity for use in direct PCR reactions with Phusion Blood Direct PCR Kit at all reaction volumes tested.
Punches from 903 Cards and rinsed punches from FTA Elute and FTA Gene Cards (all 1 mm in diameter) were used in 50 μl reaction volumes with primers specific for 1 kb, 3.8 kb and 7.5 kb amplicons. In all cases, the PCR reaction generated the appropriately sized amplification product. The Phusion Blood Direct PCR Kit is compatible with blood from variety of species. A highly conserved 237 bp region upstream of the SOX21 gene (A. Woolfe, M. Goodson, PLoS Biol. 3, e7; 2004) was successfully amplified from blood of a number of vertebrate species dried onto 903 and FTA Gene Cards.
Although two embodiments have been described and illustrated, it will be apparent to the skilled addressee that additions, omissions and modifications are possible to those embodiments without departing from the scope of the invention claimed. For example,
Many cancers are associated with genetic rearrangements. The Ewing sarcoma breakpoint region 1 (EWSR1) is translocated in many sarcomas. Recently, its rearrangement has been described in salivary gland hyalinizing clear cell carcinomas (Shah A A et al 2013 Am J Surg Pathol. 37:571-8 EWSR1 genetic rearrangements in salivary gland tumors: a specific and very common feature of hyalinizing clear cell carcinoma). The study described below illustrates the potential of solid support material and the idea described in this document to potentially screen for such genetic rearrangements within a complex mammalian genome.
DNA Sample Collection, Storage and Detection
Murine tissues from c57BL/6 mice and NOS3 null mice (in a 129/B6 background) were applied to a range of different paper-based solid supports. The mice were euthanized and dissected to collect organs (blood, heart, brain, lung, liver, and kidney). The Organs were ‘sandwiched’ between two paper layers. Pressure was applied via a sterile pipette to imbed tissues in each of the cellulose matrices. For tissue homogenate, approximately 5 g of tissue was processed using a plastic dounce homogenizer in a 1.5 ml microfuge tube and then subsequently applied to the appropriate paper matrix. After application all the samples were allowed to air-dry for 2 hours prior to storage in a sealed pouch with desiccant. In some instances samples were stored up to 2 months before processing.
DNA Purification, Genotyping, and Quantitation
A Harris disposable micro punch (1.2 mm or 3 mm diameter) was used to excise the dried tissue samples from the paper cards respectively in the form of punched disks. The sample disk was excised from the centre of the dried sample and placed in a clean DNase free-1.5 ml micro-centrifuge tube. Null or gene knockout NOS3 mice were identified by PCR amplification of genomic DNA with endothelial Nitric Oxide Synthases (eNOS) exon 10-specific forward primer (see sequence listing 1), eNOS Neo-specific forward primer (sequence listing 2), and eNOS exon 12-specific reverse primer (see sequence listing 3). Target DNA's were amplified with an initial 10 min denaturation step followed by 36 cycles of 94° C. for 35 sec, 650 C for 1 min, and 72° C. for 1 min; followed by a final extension at 72° C. for 5 min. using a MJ Research thermo-cycler. The resultant PCR products were visualized with using an Experion capillary electrophoresis system. Mouse DNA quantification was achieved using the Primer Design genomic DNA quantification kit for mouse samples (gDNA-mo-q-DD) following manufacturer's instructions. Individual wild type (WT) and NOS null tissue samples were applied separately to different paper cards. In order to exemplify the ability to differentiate genotypic variants from DNA stored on the paper matrices, PCR amplification of a region was carried out on WT and transgenic (NOS3 null, gene knock-out) mice.
In
In Table V above the successful amplification of DNA isolated from tissues stored on various solid supports A,B,C and D is recorded. DNA was isolated from a 1.2 mm punch. ‘+’ signifies the presence of amplicons. ND=not determined.
Tissue samples were applied to solid support paper cards as described sample punches were excised and the RNA isolated using the GE Healthcare Illustra® RNA spin kit as described below. RNA quantitation was performed on an ABI 7900 real time PCR system utilizing the commercially-available mRNA quantification kits.
Using a Harris 3 mm disposable micro punch, a punch was excised from the center of the dried sample spot and place in a clean RNase-free 1.5 ml micro-centrifuge tube. The illustra buffer RA1 (350 μl) was combined with 3.5 μl β-mercaptoethanol and the solution was added to the disc. The disc was homogenized using a 20 gauge needle. The resultant homogenate was transferred to the RNAspin Mini filter column for subsequent removal of residual material. The column was centrifuged for 1 min at 11,000×g. and the RNAspin Mini Filter discarded. The homogenized lysate contains the RNA and this filtrate was transferred to a new RNase-free 1.5 ml micro-centrifuge tube.
Ethanol (70%; 350 μl) was added to the homogenized lysate and mixed by vortexing for 2×5 sec pulses. For each preparation, the lysate was pipette up-and-down 2-3 times, and applied to an RNA Mini-spin column placed in a 2 ml micro-centrifuge tube. The tubes were centrifuged for 30 sec at 8000×g and the flow through discarded. The RNA spin column was transferred to a new collection tube.
The illustra MDB buffer (350 μl) was added and the tube centrifuged at 11 000×g for 1 min. Once again the flow-through was discarded and the column returned to the collection tube. A DNase reaction mixture was prepared according to manufacturer's instructions and was added to the surface of the filter contained within the RNAspin column. This DNAse incubation was performed at room temperature for 15 min.
The wash buffer RA2 (200 μl) was applied to the RNA Mini-spin column and the column was centrifuged for 1 min at 11 000×g. Once again the flow-through was discarded and the column returned to the collection tube.
Buffer RA3 600 μl was applied to the RNA Mini-spin column and the column centrifuge for 1 min at 11 000×g the flow-through was discarded and the column returned to the collection tube. An addition column wash with buffer RA3 (250 μl) was also performed. In order to dry the membrane completely, the column was centrifuged for 2 min at 11 000×g and the column finally placed into a nuclease-free 1.5 ml micro-centrifuge tube.
RNase-free water (40 μl) was applied to the column and the column centrifuged at 11 000×g for 1 min. The purified RNA was either used immediately in downstream applications or stored at −80° C. until used.
To determine the integrity of RNA from multiple tissues after prolonged storage, real-time reverse transcription polymerase chain reaction (RT-PCR) was carried out on RNA isolated from mouse tissue samples stored on the paper cards. These were stored in the presence of a desiccant for 2 months. mRNA quantification was accomplished according to manufacturer's instructions using either i) the ABI Taqman rodent GAPDH control kit (part #4308313), ii) the Invitrogen real-time LUX mRNA primer sets for murine HPRT, GAPDH, and Beta-Actin genes (cat. 105M-02, 100M-02, and 101M-02 respectively) or iii) tissue specific gene primer sets from Applied Bio-systems.
Absolute quantitation of murine mRNA encoding HPRT, GAPDH and Beta-Actin was carried out with the appropriate Invitrogen real-time LUX primer sets. RNA levels derived from samples applied to paper support material A were determined by comparison to known values generated from a quantification titration curve from mouse RNA standard samples. Murine RNA recovery data associated with the isolation of RNA is described in
In summary the examples above demonstrate that it is possible to recover, from solid supports of differing constructions, a wide range of analytes which have the same or similar biological structure to the OSCC biomarkers of interest given in Table I.
A suitable swab device which will include a solid support collector is described in more detail below with reference to
In use the swab 10 is held and manipulated by means of the handle 22. The cover can be removed to reveal the solid support 30 or 31 ready for use. A saliva sample can be taken (which could be a self-sample), and the cover replaced by the sample taker, for sending to a laboratory for further processing. At the laboratory, the solid support can be removed from the remaining swab parts, and then a portion for the paper can be removed for testing, for example by using a punch. If the spine 21 is used, then the portion solid support can be removed without removing the solid support from the spine because a punch or similar can be made through the window 23.
Where multiple samples are taken, then a drying rack 50 can be used as illustrated in
Each solid support 30/31 is tested ex vivo for the presence of two or more of the biomarkers of interest according to any one of the techniques described above, indicative of oral cancerous activity.
Whilst numerous examples, techniques and embodiments are described above, it will be apparent to the skilled addressee that further additions, variants, and omissions are possible without departing from the scope of the invention set forth herein. For example a plain 903 paper solid support 30/31 is described, but other solid supports could be used. For example filter paper treated with preserving chemicals could be used, as sold under the brand name Whatman FTA or FTA Elute, each of which are pretreated. FTA is pretreated with a stabilising reagent mix comprising: a weak base, and a chelating agent, uric acid or a urate salt, and an anionic surfactant, such as odium dodecyl sulphate (SDS) and/or sodium lauryl sarcosinate (SLS). FTA Elute is pretreated with stabilising reagent mix comprising a chaotropic salt in the form of guanidinium thiocyanate. Where FTA or FTA Elute are used, the sapling technique may involve taking a saliva sample and then transferring it to the solid support to avoid direct contact between the oral cavity and the treated solid support. Where stabilising reagent are used, it has been found that the addition of cyclodextrin in the detection step acts as a sequesterant, and thereby improves the efficiency of direct PCR, qPCR and other nucleic acid amplification techniques.
Whilst a solid support formed from cellulose paper is preferred, other supports could be employed, for example: woven or non-woven fibrous materials, including man made, or naturally occurring polymer fibres, mineral fibre based materials such as glass fibre materials, surface treated solid materials for example, chemically of mechanically treated materials, including laser etched surfaces, all provided with a surface micro roughness of sufficient roughness to hold principally DNA RNA and protein molecules. Although this description refers to solid support, this term is intended to encompass also soft supports in the form of gels, having sufficient strength to accept a salivary sample, such as alginates
| Number | Date | Country | Kind |
|---|---|---|---|
| 1417281.1 | Sep 2014 | GB | national |
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/US15/51498 | 9/22/2015 | WO | 00 |
