Patent Application
20160017434
The present invention relates to methods for establishing the presence, or absence, of a bladder tumour and/or establishing the prediction of prognosis and disease outcome for a human individual suffering from bladder cancer. The present invention further relates to the use of expression analysis of the indicated genes, or molecular markers, for establishing the presence, or absence, of a bladder tumour and/or establishing the prediction of prognosis and disease outcome for a human individual suffering from bladder cancer and to kit of parts for establishing the presence, or absence, of a bladder tumour and/or establishing the prediction of prognosis and disease outcome for a human individual suffering from bladder cancer.
Urinary bladder (or bladder) cancer is one of the most common cancers worldwide, with the highest incidence in industrialized countries. In the Western world, the chances of developing this type of cancer is 1 in 26, for women the chance is 1 in 90. Bladder cancer is the 4th most common cancer in men.
Two main histological types of bladder cancer are the urothelial cell carcinomas (UCC) and the squamous cell carcinomas (SCC). The UCCs are the most prevalent in Western and industrialized countries and are related to cigarette smoking and occupational exposure. The squamous cell carcinomas (SCC) are more frequently seen in some Middle Eastern and African countries where the schistosoma haematobium parasite is endemic.
In the Western world, 90% of the bladder tumours are UCCs, 3 to 5% are SCCs, and 1 to 2% are adenocarcinomas. Two third of the patients with UCC can be categorized into non-muscle invasive bladder cancer (NMIBC) and one third in muscle invasive bladder cancer (MIBC).
In NMIBC, the disease is generally confined to the bladder mucosa (stage Ta, carcinoma in situ (CIS)) or bladder submucosa (stage T1). In MIBC, the patient has a tumour initially invading the detrusor muscle (stage T2), followed by the perivesical fat (stage T3) and the organs surrounding the bladder (stage T4). The management of these two types of UCC differs significantly. The management of NMIBC consists of transurethral resection of the bladder tumour (TURBT). However, after TURBT, 30% to 85% of patients develop recurrences. This high risk of recurrence makes bladder cancer one of the most prevalent human tumours.
Patients with NMIBC can be divided into 3 groups. 20% to 30% of patients have a relatively benign type of UCC, with a low recurrence rate. These low risk tumours do not exhibit progression. 40% to 50% of patients have so-called intermediate risk tumours. These patients often develop a superficial recurrence, but seldom progression. A small group of patients (20% to 30%) has a relatively aggressive superficial tumour at presentation and despite maximum treatment and 70% to 80% of these patients will have recurrent disease. 50% of these patients will develop muscle invasive disease associated with a poor prognosis. Therefore, there is a need to identify the patient group at risk for progression.
The primary treatment for MIBC is cystectomy. Despite this radical treatment, 50% of patients with primary MIBC develop metastases within 2 years after cystectomy and subsequently die of the disease. The 5-year tumour-specific survival of these patients is 55%. In comparison, patients with NMIBC have a 5-year tumour-specific survival of 88-90%. However, patients with MIBC who have a history of NMIBC, the 5-year tumour-specific survival drops to only 28%. These percentages emphasize the need for the identification of patients with a high risk of progression of their NMIBC.
The risk for progression and cancer related death is associated with tumour stage and grade. Currently, staging and grading of the tumour is used for making treatment decisions. Unfortunately, this procedure has led to overtreatment (e.g. cystectomy in patients who would have survived without this treatment) or undertreatment (i.e. patients with progressive disease dying after TURBT and who would have survived if they underwent cystectomy at an earlier stage). At present no reliable methods are available to accurately predict prognosis of individual patients with bladder cancer. The limited value of the established prognostic markers requires the analysis of new molecular parameters in predicting the prognosis and treatment of bladder cancer patients.
Bladder cancer is a genetic disorder driven by the progressive accumulation of multiple genetic and epigenetic changes. At the molecular level, these genetic changes result in uncontrolled cell proliferation, decreased cell death, invasion, and metastasis. The specific alterations in gene expression that occur as a result of interactions between various cellular pathways determine the biological behavior of the tumor, including growth, recurrence, progression, and metastasis, and may influence patient survival. To detect and monitor cancer and determine the likely prognosis, it is necessary to identify molecular markers of the disease that can be used in the clinic.
Considering the above, there is a need in the art for molecular markers capable of establishing the presence, or absence, of a bladder tumour and/or establishing the prediction of prognosis and disease outcome for a human individual suffering from bladder cancer. A suitable molecular marker preferably fulfils the following criteria:
1) it must be reproducible (intra- and inter-institutional); and
2) it must have an impact on clinical management.
It is an object of the present invention, amongst other objects, to meet at least partially, if not completely, the above stated needs of the art.
According to the present invention, the above object, amongst other objects, is met by bladder tumour markers and methods as outlined in the appended claims.
Specifically, the above object, amongst other objects, is met by an (in vitro) method for establishing the presence, or absence, of a bladder tumour in a human individual; or classification of the tumours according to aggressiveness, prediction of prognosis and/or disease outcome for a human individual suffering from bladder cancer comprising:
According to the present invention, establishing the presence, or absence, of bladder cancer in a human individual preferably includes diagnosis, prognosis and/or prediction of disease survival.
It should be noted that the present method, when taken alone, does not suffice to diagnose an individual as suffering from bladder cancer. For this, a trained physician is required capable of taking into account factors not related to the present invention such as disease symptoms, history, pathology, general condition, age, sex, and/or other indicators. The present methods and molecular markers provide the trained physician with additional tools, or aids, to arrive at a reliable diagnosis.
According to the present invention, expression analysis comprises establishing an increased, or decreased, expression of a gene as compared to expression of this gene in non-bladder cancer tissue, i.e., under non-disease conditions.
For example, establishing an increased expression of ADAMTS12, ASPN, CDC20, COL10A1, CTHRC1, FAP, SFRP4, FOXM1, KRT6A, ANLN, CHI3L1, TPX2, CCNB2, IGF2BP2, INHBA, PDCD1LG2, transcript cluster 2526893, or transcript cluster 2526896, as compared to expression of these genes under non-bladder cancer conditions, allows establishing the presence, or absence, of a bladder tumour in a human individual suspected of suffering from bladder cancer and allows establishing the prediction of prognosis and disease outcome for an individual patient suffering from bladder cancer.
INHBA: Inhibin βA is a ligand in the TGF-β superfamily. INHBA forms a disulphide-linked homodimer known as activin A. In cancer a biological mechanism is suggested that is centered on activin A induced TGF-β signalling.
CTHRC1: collagen triple helix repeat containing-1 is a 30 kDa secreted protein that has the ability to inhibit collagen matrix synthesis. It is typically expressed at epithelial-mesenchymal interfaces. CTHRC1 is a cell-type-specific inhibitor TGF-β. Increased CTHRC1 expression results in morphological cell changes, increased cell proliferation, and decreased apoptosis.
CHI3L1: Chitinase 3-like 1 is a member of the mammalian chitinase family. It has been suggested that CHI3L1 is associated with cancer cell proliferation, differentiation, metastatic potential, and extracellular tissue remodelling, but in vivo proofs are yet to be obtained.
COL10A1: controls growth and maturation of endochondral bone. Overexpression of COL10A1 was also found in advanced breast cancer tissue specimen. COL10A1 was identified as a gene with restricted expression in most normal tissues and elevated expression in many diverse tumour types.
FAP: Human fibroblast activation protein alpha is a 97-kDa membrane bound serine protease. FAP was found to be selectively expressed on fibroblasts within the tumour stroma or on tumour-associated fibroblasts in epithelial cancers (e.g. colon cancer, myeloma, esophageal cancer, gastric cancer, breast cancer).
ASPN: asporin is an extracellular matrix protein that belongs to the small leucine-rich repeat proteoglycan family of proteins. Its biological role is unknown, but there is an association between ASPN and various bone and joint diseases, including rheumatoid arthritis. ASPN binds to various growth factors, including TGFβ and BMP2. ASPN was found to be upregulated in invasive ductal and lobular carcinomas.
ADAMTS12 is a desintegrin and metalloprotease with thrombospondin motif ADAMTS12 transcripts were only detected at significant levels in fetal lung, but not in any other analysed normal tissue. ADAMTS12 could be detected in gastric, colorectal, renal, and pancreatic carcinomas. ADAMTS12 may play roles in pulmonary cells during fetal development or in tumour processes through its proteolytic activity or as a molecule potentially involved in regulation of cell adhesion. In colon carcinomas, the expression of ADAMTS12 in fibroblasts is linked with an anti-proliferative effect on tumour cells. It seems that ADAMTS12 is a novel anti-tumour proteinase that plays an important role in inhibiting tumour development in colorectal cancer.
IGF2BP2: Insulin-like growth factor-II mRNA-binding protein 2 (IMP2) belongs to a family of RNA-binding proteins implicated in mRNA localization, turnover and translational control. Translational control and mRNA localization are important mechanisms for control of gene expression in germ cells and during early embryogenesis. Although the fetal expression is prominent, data indicating that the proteins are also present in mature tissues have been accumulating. In colon cancer, IGF2BP2 transcripts were shown to exist in sense:antisense pairs, which may have a direct regulatory function.
PDCD1LG2: Programmed cell death 1 (PD-1) and its ligands, Programmed death ligand 1 (PD-L1) and PD-L2, have an important inhibitory function to play in the regulation of immune homeostasis and in the maintenance of peripheral tolerance. The selective blockade of these inhibitory molecules is an attractive approach to cancer immunotherapy. PD-L1 is upregulated by many human cancers. On the other hand, the role of PD-L2 in modulating immune responses is less clear, and its expression is more restricted compared to PD-L1, thus making it a less obvious target in cancer immunotherapy.
SFRP4: Secreted frizzled-related protein 4 (SFRP4) is a secreted protein with putative inhibitory activity of the Wnt-signaling cascade. Membranous SFRP4 expression predicted for biochemical relapse. In colorectal carcinoma, SFRP4 is upregulated, which is in contrast to other SFRP family members. In ovarian cancers, there is supporting evidence that SFRP4 acts as a tumour suppressor gene via the inhibition of the Wnt signalling pathway. Although the risk of invasive bladder cancer increases with the number of methylated SFRP genes, methylation of sFRP-4 is not an independent predictor of bladder cancer and therefore an exception.
KRT6A: The keratin 6 (K6 or Krt6) gene family is comprised of three members, K6a, K6b, and K6hf (or Krt75). Only KRT6A is expressed in the mammary gland, and only in a very small fraction of mammary luminal epithelial cells.
TPX2: The microtubule-associated protein TPX2 (Xklp2) has been reported to be crucial for mitotic spindle which can bind to tubulin and induce microtubule polymerization. TPX2 mRNA is closely linked to increased or abnormal cell proliferation in malignant salivary gland tumours, breast cancer, endometrioid adenocarcinoma, neuroblastoma, pancreatic cancer, ovarian cancer and cervical cancer. An increased expression of TPX2 might reflect an advanced loss of cell cycle inhibitory mechanisms resulting in more aggressive tumours.
CCNB2: Cyclin B2 is a member of the cyclin protein family. Cyclins B1 and B2 are particularly critical for the maintenance of the mitotic state. Cyclin B2 has been found to be up-regulated in human tumors, such as colorectal cancer, lung cancer, pituitary cancer. Recently it was shown that circulating CCNB2 in serum was significantly higher in cancer patients than in normal controls. The CCNB2 mRNA level was correlated with cancer stage and metastases status of patients with lung cancer and digestive tract cancer.
ANLN: Anillin is a gene highly expressed in the brain and ubiquitously present in various tissues. ANLN is overexpressed in breast cancer, endometrial carcinomas and gastric cancer. A tumor-progression-related pattern of ANLN expression was found in breast, ovarian, kidney, colorectal, hepatic, lung, endometrial and pancreatic cancer.
FOXM1: The human cell cycle transcription factor Forkhead box M1 is known to play a key role in regulating timely mitotic progression and accurate chromosomal segregation during cell division. Deregulation of FOXM1 has been linked to a majority of human cancers. Up-regulation of FOXM1 precedes malignancy in a number of solid cancers including oral, oesophagus, lung, breast, kidney bladder and uterus cancer. It is an early molecular signal required for aberrant cell cycle and cancer initiation.
CDC20: cell division cycle 20 homolog is a component of the mammalian cell cycle mechanism that activates the anaphase-promoting complex (APC). Its expression is essential for cell division. P53 was found to inhibit tumor cell growth through the indirect regulation of CDC20. CDC20 was found to be upregulated in many types of malignancies like ovarian cancer, bladder cancer, glioblastomas, pancreatic ductal carcinomas. In ovarian cancer and non-small cell lung cancer CDC20 appears to be associated with a poor prognosis. It has been suggested that CDC20 may function as an oncoprotein that promotes the development and progression of human cancers.
According to the present invention, the method as described above is preferably an ex vivo or in vitro method. In this embodiment, expression analysis of the indicated genes is performed on a sample derived, originating or obtained from an individual suspected of suffering from bladder cancer. Such sample can be a body fluid such as saliva, lymph, blood or urine, or a tissue sample such as a transurethral resection of a bladder tumour (TURBT). Samples of, derived or originating from blood, such as plasma or cells, and urine, such as urine sediments, are preferably contemplated within the context of the present invention as are samples of, derived or originating from TURBT specimens.
According to another preferred embodiment of the present method, determining the expression comprises determining mRNA expression of the said one or more genes.
Expression analysis based on mRNA is generally known in the art and routinely practiced in diagnostic labs world-wide. For example, suitable techniques for mRNA analysis are Northern blot hybridisation and amplification based techniques such as PCR, and especially real time PCR, and NASBA.
According to a particularly preferred embodiment, expression analysis comprises high-throughput DNA array chip analysis not only allowing the simultaneous analysis of multiple samples but also an automatic processing of the data obtained.
According to another preferred embodiment of the present method, determining the expression comprises determining protein levels of the said genes. Suitable techniques are, for example, matrix-assisted laser desorption-ionization time-of-flight mass spectrometer (MALDI-TOF).
According to the present invention, the present method is preferably provided by expression analysis of a number of the present genes selected from the group consisting of two or more, three or more, four or more, five or more, six or more, seven or more, eight or more, nine or more, ten or more, eleven or more, twelve or more, thirteen or more, fourteen or more, fifteen or more, sixteen or more, seventeen or more or eighteen of the genes chosen from the group consisting of ADAMTS12, ASPN, CDC20, COL10A1, CTHRC1, FAP, SFRP4, FOXM1, KRT6A, ANLN, CHI3L1, TPX2, CCNB2, IGF2BP2, INHBA, PDCD1LG2, transcript cluster 2526893, and/or transcript cluster 2526896.
Preferred combinations within the context of the present invention are CCNB2 in combination with one or more selected from the consisting of ADAMTS12, ASPN, CDC20, COL10A1, CTHRC1, FAP, SFRP4, FOXM1, KRT6A, ANLN, CHI3L1, TPX2, CCNB2, IGF2BP2, INHBA, PDCD1LG2, transcript cluster 2526893, and/or transcript cluster 2526896, such as in combination with CDC20 and, preferably further in combination with PDCD1LG2, more preferably further in combination with INHBA, i.e. the combination at least comprising CCNB2, CDC20, PDCD1LG2 and INHBA. The latter panel of four markers provides a prediction of 0.991 (95% CI: 0.977-1.000). Within the present group of combinations with CCNB2, the preferred samples are urine or urine derived samples such as urine sediments.
Other preferred combinations within the context of the present invention are FAP in combination with one or more selected from the consisting of ADAMTS12, ASPN, CDC20, COL10A1, CTHRC1, FAP, SFRP4, FOXM1, KRT6A, ANLN, CHI3L1, TPX2, CCNB2, IGF2BP2, INHBA, PDCD1LG2, transcript cluster 2526893, and/or transcript cluster 2526896 such as in combination with CDC20 and, preferably, further in combination with INHBA, more preferably further in combination with IGF2BP2, i.e. the combination at least comprising FAP, CDC20, INHBA and IGF2BP2. Within the present group of combinations with FAP, the preferred samples are tissue or tissue derived samples such as biopses. The Area Under the Curve (AUC) for the combination of IGF2BP2+FAP+CHI3L1+CDC20 expression is 0.955 (95% CI: 0.929-0.980).
According to a most preferred embodiment of the above methods, the present invention relates to methods, wherein establishing the presence, or absence, of a tumour further comprises establishing suspected metastasis or no metastasis. Establishing whether the bladder tumour identified is capable to metastasize, is likely to metastasize, or has metastasized, is inherently a valuable tool for a trained physician to develop an individualised treatment protocol.
In case of metastasis, the survival rate of a patient is generally directly correlated with the point in time on which the metastasis is identified, detected or established. The earlier in time the treatment commences, the higher the survival rates. Additionally, if a tumour is not capable of metastasis, is not likely to metastasize, or has not metastasized, the patient needs not to be subjected to, or can be spared of, treatments severely affecting the quality of life.
Establishing the presence, or absence, of a tumour, according to another preferred embodiment, can further comprise establishing whether a NMIBC will, or is likely to, progress into MIBC.
Considering the diagnostic- and/or prognostic value of the present markers, the present invention also relates to the use of expression analysis of one or more genes selected from the group consisting of ADAMTS12, ASPN, CDC20, COL10A1, CTHRC1, FAP, SFRP4, FOXM1, KRT6A, ANLN, CHI3L1, TPX2, CCNB2, IGF2BP2, INHBA, PDCD1LG2, transcript cluster 2526893, and transcript cluster 2526896 for establishing the presence, or absence, of a bladder tumour or establishing the prediction of prognosis and disease outcome for an individual patient suffering from bladder cancer.
The present use, for reasons indicated above, is preferably an ex vivo or in vitro use and, preferably, involves the use of two or more, three or more, four or more, five or more, six or more, seven or more, eight or more, nine or more, ten or more, eleven or more, twelve or more, thirteen or more, fourteen or more, fifteen or more, sixteen or more, seventeen or more and eighteen of the present markers for establishing the presence, or absence of a bladder tumour, and establishing the prediction of prognosis and disease outcome for an individual patient suffering from bladder cancer.
Preferred combinations within the context of the present use are CCNB2 in combination with one or more selected from the consisting of ADAMTS12, ASPN, CDC20, COL10A1, CTHRC1, FAP, SFRP4, FOXM1, KRT6A, ANLN, CHI3L1, TPX2, CCNB2, IGF2BP2, INHBA, PDCD1LG2, transcript cluster 2526893, and/or transcript cluster 2526896, such as in combination with CDC20 and, preferably further in combination with PDCD1LG2, more preferably further in combination with INHBA, i.e. the combination at least comprising CCNB2, CDC20, PDCD1LG2 and INHBA. The latter panel of four markers provides a prediction of 0.991 (95% CI: 0.977-1.000). Within the present group of combinations with CCNB2, the preferred samples are urine or urine derived samples such as urine sediments.
Other preferred combinations within the context of the present use are FAP in combination with one or more selected from the consisting of ADAMTS12, ASPN, CDC20, COL10A1, CTHRC1, FAP, SFRP4, FOXM1, KRT6A, ANLN, CHI3L1, TPX2, CCNB2, IGF2BP2, INHBA, PDCD1LG2, transcript cluster 2526893, and/or transcript cluster 2526896 such as in combination with CDC20 and, preferably, further in combination with INHBA, more preferably further in combination with IGF2BP2, i.e. the combination at least comprising FAP, CDC20, INHBA and IGF2BP2. Within the present group of combinations with FAP, the preferred samples are tissue or tissue derived samples such as biopses. The Area Under the Curve (AUC) for the combination of IGF2BP2+FAP+CHI3L1+CDC20 expression is 0.955 (95% CI: 0.929-0.980).
Considering the diagnostic and/or prognostic value of the present genes as biomarkers for bladder cancer, the present invention also relates to a kit of parts for establishing the presence, or absence, of a bladder tumour and establishing the prediction of prognosis and disease outcome for an individual patient suffering from bladder cancer said kit of parts comprises:
Preferred combinations included in the present kits are CCNB2 in combination with one or more selected from the consisting of ADAMTS12, ASPN, CDC20, COL10A1, CTHRC1, FAP, SFRP4, FOXM1, KRT6A, ANLN, CHI3L1, TPX2, CCNB2, IGF2BP2, INHBA, PDCD1LG2, transcript cluster 2526893, and/or transcript cluster 2526896, such as in combination with CDC20 and, preferably further in combination with PDCD1LG2, more preferably further in combination with INHBA, i.e. the combination at least comprising CCNB2, CDC20, PDCD1LG2 and INHBA.
Other preferred combinations included in the present kits are FAP in combination with one or more selected from the consisting of ADAMTS12, ASPN, CDC20, COL10A1, CTHRC1, FAP, SFRP4, FOXM1, KRT6A, ANLN, CHI3L1, TPX2, CCNB2, IGF2BP2, INHBA, PDCD1LG2, transcript cluster 2526893, and/or transcript cluster 2526896 such as in combination with CDC20 and, preferably, further in combination with INHBA, more preferably further in combination with IGF2BP2, i.e. the combination at least comprising FAP, CDC20, INHBA and IGF2BP2.
According to a preferred embodiment, the present kit of parts comprises mRNA expression analysis means, preferably for PCR, rtPCR or NASBA.
According to a particularly preferred embodiment, the present kit of parts comprises means for expression analysis of two or more, three or more, four or more, five or more, six or more, seven or more, eight or more, nine or more, ten or more, eleven or more, twelve or more, thirteen or more, fourteen or more, fifteen or more, sixteen or more, seventeen or more or eighteen of the present genes.
In the present description, reference is made to genes suitable as biomarkers for bladder cancer by referring to their arbitrarily assigned names. Although the skilled person is readily capable of identifying and using the present genes as biomarkers based on the indicated names, the appended
Such analysis techniques can, for example, be based on the genomic sequence of the gene or the provided cDNA or amino acid sequences. This sequence information can either be derived from the provided sequences, or can be readily obtained from public databases, for example by using the provided accession numbers.
The present invention will be further elucidated in the following examples of preferred embodiments of the invention. In the examples, reference is made to figures, wherein:
Below the present invention will be further illustrated by examples of preferred embodiments of the present invention.
To identify markers for bladder cancer, the gene expression profile (GeneChip® Human Exon 1.0 ST arrays, Affymetrix) of samples from patients with and without bladder cancer were used. The expression analysis was performed according to standard protocols.
Briefly, tissue was obtained after radical cystectomy from patients with bladder cancer. The tissues were snap frozen and cryostat sections were hematoxylin-eosin (H.E.) stained for classification by a pathologist.
Malignant- and non-malignant areas were dissected and total RNA was extracted with TRIpure® (Roche, Indianapolis, Ind., CA, USA) following manufacturer's instructions. Total RNA was purified with the Qiagen RNeasy mini kit (Qiagen, Valencia, Calif., USA). The integrity of the RNA was checked by electrophoresis using the Agilent 2100 Bioanalyzer.
From the purified total RNA, 1 μg was used for the GeneChip® Whole Transcript (WT) Sense Target Labeling Assay. (Affymetrix, Santa Clara, Calif., USA). Using a random hexamer incorporating a T7 promoter, double-stranded cDNA was synthesized.
Then, cRNA was generated from the double-stranded cDNA template through an in vitro transcription reaction and purified using the Affymetrix sample clean-up module. Single-stranded cDNA was regenerated through a random-primed reverse transcription using a dNTP mix containing dUTP. The RNA was hydrolyzed with RNaseH and the cDNA was purified. Subsequently, the cDNA was fragmented by incubation with a mixture of UDG (uracil DNA glycosylase) and APE 1 (apurinic/apyrimidinic endonuclease 1) restriction endonucleases and, finally, end-labeled via a terminal transferase reaction incorporating a biotinylated dideoxynucleotide. Of the fragmented, biotinylated cDNA, 5.5 μg was added to a hybridization mixture, loaded on a GeneChip® Human Exon 1.0 ST array and hybridized for 16 hours at 45° C. and 60 rpm.
Using the GeneChip® Human Exon 1.0 ST array, genes are indirectly measured by exon analysis which measurements can be combined into transcript clusters measurements. There are more than 300,000 transcript clusters on the array, of which 90,000 contain more than one exon. Of these 90,000 there are more than 17,000 high confidence (CORE) genes which are used in the default analysis. In total there are more than 5.5 million features per array.
Following hybridization, the array was washed and stained according to the Affymetrix protocol. The stained array was scanned at 532 nm using a GeneChip® Scanner 3000, generating CEL files for each array.
Exon-level and gene level expression values were derived from the CEL file probe-level hybridization intensities using Partek Genomics Suite 6.2, (Partek Incorporated, Saint Louis, Mo., USA). Data analysis with this software was performed with the GeneChip® array core meta probe sets as well as the extended meta probe sets.
Differentially expressed genes between conditions, e.g. NMIBC versus MIBC and MIBC versus NBl, are calculated using Anova (ANalysis Of Variance), a T-test for more than two groups. The target identification is biased since clinically well-defined risk groups were analyzed. The markers are categorized based on their role in cancer biology. For the identification of markers the non-muscle invasive bladder cancer (NMIBC) group (N=48), the muscle invasive bladder cancer (MIBC) group (N=49), the bladder cancer metastasis (BC-Meta) group (N=5) and the normal bladder (NBl) group (N=12) were compared.
Based on the GeneChip® microarrays expression analysis data, the most differentially expressed genes between NBl and NMIBC/MIBC (diagnostic genes) and also the most differentially expressed genes between the NMIBC and MIBC (prognostic genes) were selected.
In total, a group of 46 genes of interest were selected which will be further elucidated in example 2 and listed in Table 2. Based on the selected 18 genes in example 2, the GeneChip® expression data for these genes are shown in Table 1.
GeneChip® Microarray data showing the expression characteristics of 18 targets characterizing bladder cancer tissue, based on the analysis of 12 well annotated NBl, 48 NMIBC, 49 MIBC and 5 BC-Meta tissue specimens.
As can be clearly seen in Table IA an up regulation of expression of INHBA (
As can be clearly seen in Table 1B an up regulation of expression of TPX2 (
Using the gene expression profile (GeneChip® Human Exon 1.0 ST Array, Affymetrix) on 114 tissue specimens of normal bladder (NBl), non-muscle invasive bladder cancer (NMIBC), muscle invasive bladder cancer (MIBC) and bladder cancer metastasis (BC-Meta) several genes were found to be differentially expressed. The expression levels of 46 of these differentially expressed genes, together with the expression level of a housekeeping gene (GAPDH) and reference gene (TBP) were validated using the TaqMan® Low Density arrays (TLDA, Applied Biosystems). In Table 2 an overview of the validated genes is shown.
The validation with TLDA analysis was performed with 66 bladder tissue samples. Among these, 64 samples were newly selected and isolated, 2 normal bladder samples had been used before in the identification step with the GeneChip® Human Exon 1.0 ST Array.
Bladder cancer specimens in the following categories were used: Normal bladder (NBl, n=7), non-muscle invasive bladder cancer (NMIBC, n=29), muscle invasive bladder cancer (MIBC, n=27) and bladder cancer metastasis (BC-Meta, n=3).
To determine whether the identified biomarkers for bladder cancer could be used in a kit for specific detection in urine, 16 urinary sediments from patients suffering from bladder cancer (8 NMIBC and 8 MIBC) were included in the TLDA analysis and validation.
All tissue samples were snap frozen and cryostat sections were stained with hematoxylin and eosin (H.E.). These H.E.-stained sections were classified by a pathologist. Tumor areas were dissected. RNA was extracted from 10 μm thick serial sections that were collected from each tissue specimen at several levels. Tissue was evaluated by HE-staining of sections at each level and verified microscopically. Total RNA was extracted with TRIpure® (Roche, Indianapolis, Ind., CA, USA) according to the manufacturer's instructions. Total RNA was purified using the RNeasy mini kit (Qiagen, Valencia, Calif., USA).
The 16 urine samples of patients with bladder cancer were immediately cooled to 4° C. and were processed within 48 h after collection to guarantee good sample quality. The urine, EDTA stabilized, was centrifuged at 4° C. and 1.800×g for 10 minutes. The obtained urinary sediment were washed twice with icecold buffered sodium chloride solution. On centrifugation at 4° C. and 1.000×g for 10 minutes, the sediments were snap frozen in liquid nitrogen and stored at −70° C. RNA was extracted from the urinary sediments using a modified TriPure reagent protocol. After the chloroform extraction, GlycoBlue was added to the aquous phase to precipitate the RNA using isopropanol. Total RNA from the sediments was used to generate amplified sense-strand cDNA using the Whole Transcriptome Expression kit according to the manufacturers protocol.
RNA quantity and quality were assessed on a NanoDrop 1000 spectrophotometer (NanoDrop Technologies, Wilmington, Del., USA) and on an Agilent 2100 Bioanalyzer (Agilent Technologies Inc., Santa Clara, Calif., USA).
Two μg total RNA was eliminated from genomic DNA and reverse transcribed using the Quantitect® Reverse Transcription Kit Qiagen gMBH, Hilden, D) according to the manufacturer's instructions. Gene expression levels were measured using the TaqMan® Low Density Arrays (TLDA; Applied Biosystems).
A list of assays used in this study is given in Table 2. Of the individual cDNAs, 3 μl is added to 50 μl Taqman® Universal Probe Master Mix (Applied Biosystems) and 47 μl milliQ. One hundred μl of each sample was loaded into 1 sample reservoir of a TaqMan® Array (384-Well Micro Fluidic Card) (Applied Biosystems). The TaqMan® Array was centrifuged twice for 1 minute at 280 g and sealed to prevent well-to-well contamination. The cards were placed in the micro-fluid card sample block of an 7900 HT Fast Real-Time PCR System (Applied Biosystems). The thermal cycle conditions were: 2 minutes 50° C., 10 minutes at 94.5° C., followed by 40 cycles for 30 seconds at 97° C. and 1 minute at 59.7° C.
Raw data were recorded with the Sequence detection System (SDS) software of the instruments. Micro Fluidic Cards were analyzed with RQ documents and the RQ Manager Software for automated data analysis. Delta cycle threshold (Ct) values were determined as the difference between the Ct of each test gene and the Ct of glyceraldehyde 3-phosphate dehydrogenase (GAPDH) (endogenous control gene).
Furthermore, gene expression values were calculated based on the comparative threshold cycle (Ct) method, in which a normal bladder RNA sample was designated as a calibrator to which the other samples were compared.
For the validation of the differentially expressed genes found by the GeneChip® Human Exon 1.0 ST array, 66 bladder tissue specimens and 16 urinary sediments from bladder cancer patients were used in Taqman Low Density Arrays (TLDAs). In these TLDAs, expression levels were determined for the 48 genes of interest. The bladder tissue specimens were put in order from normal bladder, bladder cancer with low to high T-stage and finally bladder cancer metastasis.
Both GeneChip® Human Exon 1.0 ST array and TLDA data were analyzed using scatter- and box plots.
After analysis of the data a list of genes, shown in Table 3, was derived the expression of which is indicative for establishing the presence, or absence, of bladder tumour in a human individual suspected of suffering from bladder cancer comprising and, accordingly, indicative for bladder cancer and prognosis thereof
Below detailed GeneChip® Human Exon 1.0 ST array data and TLDA validation data is presented for the 16 genes and only GeneChip® array data for the two transcript clusters, based on the groups normal bladder (NBl), non-muscle invasive bladder cancer (NMIBC), muscle invasive bladder cancer (MIBC) and bladder cancer metastasis (BC-Meta). For the identification of markers the non-muscle invasive bladder cancer (NMIBC) group, the muscle invasive bladder cancer (MIBC) group, the bladder cancer metastasis (BC-Meta) group and the normal bladder (NBl) group were compared.
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2log
2log
The identified genes mentioned in example 2 and listed in Table 3 were used for further validation and selection in a larger cohort of patient samples. For 17 of the 18 identified genes and for the control gene TBP used for normalization, fluorescence based real-time qPCR assays were designed and established according the MIQE guidelines. The performance of transcript clusters 2526896 and 2526893 were very similar. Therefore, no qPCR assay was established for transcript cluster 2526893. PCR products were cloned in either the pCR2.1-TOPO cloning vector (Invitrogen). Calibration curves with a wide linear dynamic range (10-1,000,000 copies) were generated using serial dilutions of the plasmids. The amplification efficiency of the primer pair was determined using the calibration curve and was >1.85. Control samples with known template concentrations were used as a reference. Two μl of each cDNA sample were amplified in a 20 μl PCR reaction containing optimized amounts of forward primer and reverse primer, 2 pmol of hydrolysis probe and 1× Probes Master mix (Roche, Cat No. 04902343001). The following amplification conditions were used: 95° C. for 10 minutes followed by 50 cycles at 95° C. for 10 seconds, 60° C. for 30 seconds and a final cooling step at 40° C. for 55 seconds (LightCycler LC480, Roche). The crossing point (Cp) values were determined using the Lightcycler 480 SW 1.5 software (Roche). The Cp values of the samples were converted to concentrations by interpolation in the generated calibration curve. The assay performance of the real-time PCR experiments was evaluated during in-study validation. The reference control samples had an inter- and intra-assay variation<30%.
Total RNA was extracted from bladder tissue and urinary sediments and used for reverse transcription to generate cDNA. In total 211 bladder tissue specimen and 100 urinary sediments were used. The group of 206 bladder tissue specimen consisted of 10 normal bladders, 124 NMIBC, 72 MIBC. The group of 100 urinary sediments consisted of urinary sediments from 15 healthy controls (defined as normal), and from 65 patients with NMIBC, and 18 patients with MIBC.
Statistical analyses were performed with SPSS® version 20.0. All data were log-transformed prior to statistical analysis as a transformation to a normal distribution. Two-tailed P values of 0.05 or less were considered to indicate statistical significance. The nonparametric Mann Whitney test (for continuous variables) was used to test if biomarker levels were significantly correlated with the presence of BCa and/or BCa prognosis (muscle invasiveness, metastasis).
The assay results for the 17 selected biomarkers are shown in Tables 4-7.
In Table 4 the expression data of the 17 selected biomarkers in tissue are shown for the groups NBl and BCa total (NMIBC+MIBC). The difference (Fold-Change) between the groups and P-value provide information about/deter mine the diagnostic performance of the markers. In Table 5 the data in tissue are shown for the groups NMIBC and MIBC and thereby provide information about the prognostic performance of the biomarkers. In Tables 6 and 7 the data in the urine samples are shown.
INHBA (
CTHRC1 (
CHI3L1 (
COL10A1 (
FAP (
Transcript cluster 2526896 (
ASPN (
Transcript cluster 2526893 (
ADAMTS12 (
IGF2BP2 (
PDCD1LG2 (
SFRP4 (
KRT6A (
TPX2 (
CCNB2 (
ANLN (
FOXM1 (
CDC20 (
Based on the highest up-regulation in BCa vs NBl and MIBC vs. NMIBC, lowest P-value and high copy numbers the best performing diagnostic and prognostic individual biomarkers in tissue and urine were identified. The five best performing individual biomarkers for the detection of BCa in tissue were identified and are shown in boxplots in
The five best performing individual biomarkers that could distinguish MIBC tissue from NMIBC tissue were identified and are shown in boxplots in
The six best performing individual biomarkers for the detection of BCa in urine were identified and are shown in a boxplot in
Given that the nature of these tumors is very heterogeneous, it is likely that combination of markers can identify different patients and have additional diagnostic and/or prognostic value to each other. For the identification of the best combinations of biomarkers for the diagnosis of BCa in urine and/or tissue and for the best combinations of markers that had prognostic value by distinguishing MIBC from NMIBC in tissue and/or urine the method of binary logistic regression analysis was performed. All data were log-transformed prior to statistical analysis as a transformation to a normal distribution. Binary logistic regression analysis (stepwise forward) was performed with the 17 biomarkers in order to find regression models and marker combinations for predicting the presence of bladder cancer (NMIBC and MIBC) in urine or for predicting whether BCa is muscle invasive or not. The statistical significant level for all tests was set at P=0.05.
As example two possible identified combinations of biomarkers are described, one for predicting the occurrence of BCa based on the expression of the markers in urine and one for predicting the occurrence of muscle invasive disease based on the expression of the markers in tissue.
In urine, CCNB2 is a key predictor and predicts that 66.7% of healthy controls have no cancer and that 96.5% from the cancer patients do have cancer. With the addition of CDC20 and PDCD1LG2 the new model predicts that 80% of the healthy controls have no cancer and 96.5% of the cancer patients are correctly classified. When INHBA is added to this model the model model predicts that 93.3% of the healthy controls have no cancer and that 98.8% of the cancer patients are correctly classified. This four biomarker model is highly significant (P=1.9E-13) showing that the biomarkers can predict the presence of bladder cancer in urine well. To visualize the performance of the biomarker combinations a ROC curve is shown (
In a ROC curve, the true positive rate to detect BCa or MIBC (sensitivity) is plotted in function of the false positive rate (i.e. positives in the control group, 1-specificity) for different cut-off points. Each point on the curve represents a sensitivity/specificity pair corresponding to a particular decision threshold. The Area Under the Curve (AUC) of the ROC curve is a measure how well a parameter can distinguish between two groups and is maximum 1.0 (all samples correctly classified). The AUC for the combination of CCNB2, CDC20, PDCD1LG2 and INHBA expression is 0.991 (95% CI: 0.977-1.000).
In tissue, FAP is a key predictor and predicts that 87% of the NMIBC are NMIBC and that 80.3% of the MIBC specimen are correctly classified. When CDC20 and CHI3L1 are added 89.3 of the NMIBC are correctly classified and 83.1% of the MIBC are correctly classified. The addition of IGF2BP2 leads to the correct classification of 90.2% of the NMIBC and 83.1% of the MIBC. This four marker model is higly significant (P=4.9×10-32) showing that the biomarkers can predict the occurrence of muscle invasive disease well. The Area Under the Curve (AUC) for the combination of IGF2BP2+FAP+CHI3Li+CDC20 expression is 0.955 (95% CI: 0.929-0.980). See
Based on the binary logistic regression model the following genes and combinations were identified. For predicting the occurrence of BCa (diagnosis) based on the detection and quantification expression of the markers in tissue: at least ANLN combined with one or more markers from the list: IGF2BP2, FAP, CTHRC1, CCNB2, COL10A1 and/or TPX2.
For predicting the occurrence of muscle invasive disease (prognosis) based on the expression of the markers in tissue: at least FAP, combined with one or more markers from the list: CDC20, CHI3L1, IGF2BP2, INHBA, ADAMTS12, CCNB2 and/or ANLN or at least CHI3L1, combined with one or more markers from the list: CDC20, FAP, IGF2BP2, INHBA, ADAMTS12, CCNB2 and/or ANLN.
For predicting the occurrence of BCa based on the expression of the markers in urine at least CCNB2, combined with one or more markers from the list: CDC20, PDCD1LG2, TPX2, SFRP4, COL10A1, INHBA and/or TC2526896 or at least PDCD1LG2, combined with one or more markers from the list: CCNB2, CDC20, TPX2, SFRP4, COL10A1, INHBA and/or CTHRC1
For predicting the occurrence of muscle invasive disease based on the expression of the markers in urine at least FAP, combined with one or more from the list FOXM1, CCNB2, CDC20 and/or TC2526896
The present invention relates to biomarkers and their diagnostic and prognostic uses for bladder cancer. The biomarkers can be used alone or in combination. The invention provides methods for diagnosing bladder cancer in a subject, comprising measuring the levels of a single or a plurality of biomarkers in a biological sample derived from a subject suspected of having bladder cancer. Differential expression of one or more biomarkers in the biological sample is compared to one or more biomarkers in a healthy control sample indicates that a subject has cancer. Furthermore, the invention provides methods for determining classification of tumors according to the aggressiveness or establishing the prediction of prognosis and disease outcome for a human individual suffering from bladder cancer, comprising measuring the levels of a single or a plurality of biomarkers in a biological sample derived from a subject having bladder cancer. Differential expression of one or more biomarkers in the biological sample is compared to one or more biomarkers in a NMIBC control sample that indicates that a subject has an aggressive type of bladder cancer.
Based on the results obtained and described in examples 1, 2, 3 and 4, the following observations can be made:
| Number | Date | Country | Kind |
|---|---|---|---|
| PCT/EP2013/054777 | Mar 2013 | EP | regional |
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/EP2014/054501 | 3/7/2014 | WO | 00 |
