WO2013158936A1

WO2013158936A1 - Monitoring immunoglobulin heavy chain evolution in b-cell acute lymphoblastic leukemia

Info

Publication number: WO2013158936A1
Application number: PCT/US2013/037258
Authority: WO
Inventors: Francois Pepin; Victoria CARLTON; Mark Klinger; Malek Faham
Original assignee: Sequenta, Inc
Priority date: 2012-04-20
Filing date: 2013-04-18
Publication date: 2013-10-24

Abstract

The invention is directed to methods of monitoring B-cell lymphoid proliferative disorders, such as B-cell acute lymphoblastic leukemias, by measuring the presence, absence and/or levels of correlating, or index, clonotypes and related clonotypes that have evolved therefrom, for example, as part of the disease condition. In one aspect, such methods are implemented by generating sequencing-based clonotype profiles and determining frequencies of correlating, or index, clonotypes present, including new clonotypes that have evolved therefrom, particularly, in the case of B-cell ALL, by VH substitution. The invention also includes use of such monitoring information to modify treatment status of a patient.

Description

MONITORING IMMUNOGLOBULIN HEAVY CHAIN EVOLUTION

IN B-CELL ACUTE LYMPHOBLASTIC LEUKEMIA

[0001] This application is a continuation-in-part of co-pending U.S. application Ser. No.

13/100,365 filed 4 May 2011, and claims priority from U.S. provisional applications Ser. No. 61/636,518 filed 20 April 2012; and Ser. No. 61/655,390 filed 4 June 2012, each of the foregoing applications being incorporated herein by reference in its entirety.

BACKGROUND OF THE INVENTION

[0002] A feature of certain acute lymphoblastic leukemis (ALLs) is the sequence "evolution" of clonotypes associated with the disease. Although treatment outcomes in childhood acute lymphoblastic leukemia (ALL) have improved dramatically over the past fifty years, 10 to 15% of patients will ultimately relapse, usually with disease that is highly refractory to additional therapy, e.g. Pui et al, Lancet Oncol, 2: 597-607 (2001); Pui et al, New Engl. J. Med., 350: 1535-1548 (2004); Tallen et al, J. Clin. Oncol, 28: 2339-2347 (2010). It is generally thought that these relapses are due to residual leukemic cells that are resistant to therapy and remain undetected during clinical remission. Several potential biological explanations for the persistence of leukemic populations have been proposed, including the presence of multiple clones at diagnosis with varying susceptibilities to cytotoxic drugs or the outgrowth of resistant clones during treatment, e.g. Rosenquist et al, Eur. J. Haematol, 63: 171-179 (1999).

[0003] Clonality of B-cell populations can be assessed by analysis of gene rearrangements that occur at the immunoglobulin heavy chain (IgH) gene locus. Early in B-cell development, somatic recombination at the IgH gene locus gives rise to unique rearrangements of the variable (VH), diversity (D), and joining (JH) gene segments, e.g. Tonegawa, Nature, 302: 575-581 (1983); Alt et al, Immunol. Today, 13: 306-314 (1992). In this two-step process, recombination signal sequences mediate D to JH joining, which is followed by VH to D-JH joining, e.g. Alt et al, EMBO J., 3: 1209-1219 (1984); Hiom et al, Cell, 88: 65-72 (1997); Hess et al, Genes Dev., 3: 1053-1061 (1989). During this recombination, non-templated nucleotides (N-bases) may be added at the junctions between gene segments, and other nucleotides may be deleted from the VH, D, and JH germline sequences, Alt et al, Proc. Natl. Acad. Sc , 79: 4118-4122 (1982). The resulting unique VHDJH rearrangements are used as clonotypic markers in precursor-B-cell ALL.

[0004] Precursor-B-cell ALL is generally thought to be a clonal disease resulting from malignant transformation and expansion of a single B-cell, e.g. Steenbergen et al, Leukemia, 11 : 1258-1265 (1997). PCR-based methods have, however, shown changes in clonal IgH rearrangements between initial diagnosis and relapse in a significant proportion of pre-B ALL cases, Beishuizen et al Blood, 83: 2238-2247 (1994); Li et al, Leukemia Research, 25: 1033-1045 (2001);

Szczepanski et al, Blood, 99: 2315-2323 (2002). These changes at the IgH locus could represent the persistence of ancestral clones that later expand, or continued evolution of a primary ancestral clone in the setting of genotoxic anti-neoplastic therapy.

[0005] Current methods of monitoring leukemia clonotypes are not well suited for detecting changes or evolution of the sequences of leukemic clonotypes. It would be highly advantageous for patients suffering from such diseases if there were available methods for detecting and monitoring sequence changes or evolution of leukemic clonotypes.

SUMMARY OF THE INVENTION

[0006] The present invention is drawn to methods for diagnosing and monitoring sequence evolution of IgH clonotypes in childhood ALL, particularly precursor B cell ALL. The invention is exemplified in a number of implementations and applications, some of which are summarized below and throughout the specification.

[0007] In one aspect the invention is directed to methods for monitoring and treating a patient suffering from a B cell proliferative disorder, such as, acute lymphoblastic leukemia using one or more patient-specific clonotypes correlated with the B cell disorder, wherein such methods comprise the following steps: (a) obtaining from the patient a sample comprising B-cells; (b) amplifying molecules of nucleic acid from the B-cells of the sample, the molecules of nucleic acid comprising or derived from recombined DNA sequences from immunoglobulin genes; (c) sequencing the amplified molecules of nucleic acid to form a clonotype profile; and (d) determining from the clonotype profile a presence, absence and/or level of the one or more patient-specific clonotypes correlated with the lymphoid proliferative disorder and previously unrecorded clonotype clonally evolved therefrom by V_H substitution. In some embodiments, methods of the invention further include a step of modifying a treatment regimen of a patient based on a presence, absence and/or level of the one or more patient-specific clonotypes and clonotypes related thereto by VH substitutions.

[0008] The invention provides sequencing-based methods for monitoring clonotypes correlated with B cell leukemias and their clonally evolved progeny. In any lymphoid proliferative disorders associated with clonal evolution of correlating or index clonotypes, the invention advantageously overcomes deficiencies in prior art methods which lack capability of detecting and measuring evolved clonotypes and thereby reduces the likelihood of patients inadvertently being harmed by false negative assessments of disease remission.

BRIEF DESCRIPTION OF THE DRAWINGS

[0009] The novel features of the invention are set forth with particularity in the appended claims. A better understanding of the features and advantages of the present invention is obtained by reference to the following detailed description that sets forth illustrative embodiments, in which the principles of the invention are utilized, and the accompanying drawings of which:

[0010] Fig. 1 A diagrammatically shows sequences of clonotypes evolved from an index clone of patient 23.

[0011] Fig. IB shows percentages of clonotypes that share ½ and NDN bases with index clones. The x-axis represents the number of shared bases. Data from ALL samples are shown as the black histogram (140), showing a sharp decline in shared based from 0 to 5, that can be explained by the matching random bases (as would be expected from unrelated sequences). There is an increase in frequency after 10 bases (142), which reflects a high rate of clonal evolution. For comparison, the line (144) indicates base sharing in CLL samples and lacks the increase in sharing after 10 bases.

[0012] Fig. 1C shows per patient frequency of evolved clones in ALL (160), CLL (162) and in patient-permuted ALL (164) samples (across ALL). Each solid dot or open circle represents a patient, with a solid dot representing a frequency with statistically significant value and an open circle representing a frequency without a statistically significant value.

[0013] FIGS. 2A-2C show a two-staged PCR scheme for amplifying and sequencing

immunoglobulin genes.

[0014] FIG. 3A illustrates details of one embodiment of determining a nucleotide sequence of the PCR product of Fig. 2C. FIG. 3B illustrates details of another embodiment of determining a nucleotide sequence of the PCR product of Fig. 2C.

[0015] FIG. 4A illustrates a PCR scheme for generating three sequencing templates from an IgH chain in a single reaction. FIGS. 4B-4C illustrates a PCR scheme for generating three sequencing templates from an IgH chain in three separate reactions after which the resulting amplicons are combined for a secondary PCR to add P5 and P7 primer binding sites. Fig. 4D illustrates the locations of sequence reads generated for an IgH chain. Fig. 4E illustrates the use of the codon structure of V and J regions to improve base calls in the NDN region. DETAILED DESCRIPTION OF THE INVENTION

[0016] The practice of the present invention may employ, unless otherwise indicated, conventional techniques and descriptions of molecular biology (including recombinant techniques), bioinformatics, cell biology, and biochemistry, which are within the skill of the art. Such conventional techniques include, but are not limited to, sampling and analysis of blood cells, nucleic acid sequencing and analysis, and the like. Specific illustrations of suitable techniques can be had by reference to the example herein below. However, other equivalent conventional procedures can, of course, also be used. Such conventional techniques and descriptions can be found in standard laboratory manuals such as Genome Analysis: A

Laboratory Manual Series (Vols. I-IV); PCR Primer: A Laboratory Manual; and Molecular Cloning: A Laboratory Manual (all from Cold Spring Harbor Laboratory Press); and the like.

[0017] The invention is directed to methods of monitoring B-cell lymphoid proliferative disorders by measuring the presence, absence and/or levels of correlating, or index, clonotypes and related clonotypes that have evolved therefrom, e.g as part of the disease condition. The invention also includes methods of using such monitoring information to make treatment decisions for patients suffering from such disorders. In one aspect, the invention provides methods for monitoring B cell leukemias, and more particularly, B cell acute lymphoblastic leukemias, or B cell ALLs. In some embodiments, methods of the invention are directed to monitoring and/or treating childhood B cell ALL, particularly childhood B precursor ALL. In another aspect, the invention provides a sequencing-based assay for detecting and measuring clonotypes, particularly previously unrecorded clonotypes, that have evolved from correlating or index clonotypes of a disease, e.g. determined in a diagnostic sample from a patient. In some embodiments, clonotypes being monitored comprise a VDJ region (or a portion thereof) encoding a heavy chain of an immunoglobulin (IgH) (or a portion thereof). In some

embodiments, evolution from correlating (or index) IgH clonotypes occurs by "VH substitution;" that is, evolved clonotypes differ from a correlating or index IgH clonotype by substitution of a V-encoding region (possibly along with other nucleotides in the NDN region, as described more fully below). Biological mechanisms responsible for VH substitution may vary, e.g. Gawad et al, Blood, 120(22): 4407-4417 (2012). The term "VH substitution" includes clonotypes formed by "VH replacement" (which refers to VH substitution by a particular mechanism) as well as those formed by VH changes by other mechanisms. In part, the invention is based on a recognition and appreciation of a variety of models or algorithms for determining clonotypes that are related to a correlating, or index, clonotype by VH substitution. Indentifying Clonotypes Evolved By VH Substitution

[0018] In some embodiments of the invention, a step of determining the presence, absence and/or level of evolved clonotypes includes comparing nucleotide sequences of clonotypes of a clonotype profile with the sequences of correlating (or index) clonotypes, and in some embodiments, sequences of previously recorded clonotypes evolved therefrom (collectively, "prior correlating clonotypes"). On the basis of such a sequence comparison, a clonotype in the profile is classified as clonally evolved from a prior correlating clonotypes by VH substitution. The manner in which such clonotype-clonotype comparisons are carried may vary widely with respect to which sequences are compared and how much extraneous data is employed, e.g. data regarding the likelihoods of the occurrences of particular sequences based on databases of clonotype sequences from populations of individuals. In some embodiments, such populations comprise individuals afflicted with a B cell ALL.

[0019] In some embodiments, the step of comparing includes determining whether the J segments of each prior correlating clonotype and each clonotype of a clonotype profile of a current sample ("sample clonotype") are the same. If they are not the same, then the next sample clonotype is selected and compared to the prior correlating clonotype. After every sample clonotype has been compared and classified, then the next prior correlating clonotype is selected and compared to each sample clonotype. Such a process leads to the formation of a first subset of sample clonotypes that each have a J segment identical to that of at least one prior correlating clonotype. Similar segment-to-segment comparisons may be carried out for Ni and D segments. Those sample clonotypes that have J, Ni, and D segments identical to those of at least one prior correlating clonotype, but which have a different V segment, may be classified as clonally evolved from a prior correlating clonotype by VH substitution. In other embodiments, the step of comparing may be implemented by comparing nucleotide sequences, or a combination of nucleotide sequences and segment identities.

[0020] In still other embodiments, a comparing step may be implemented as follows (referred to herein as the "6-base" algorithm): It is assumed that each base of the NDN sequences is independently distributed with each base having a 25% probability of occurring. The NDN region is ordered from the end of its ½ segment toward its V_H segment, and the number of consecutive matches from the J_H-NDN boundry is measured. Six consecutive identical bases in such a comparing step are required to reach a conclusion that a sample clonotype is evolved from a prior correlating clonotype, with significance of p=0.0001. The bases in the D segment come from a limited number of available alleles (so that the assumption of random nucleotides in such segments does not hold). Analysis of 8235 clonotypes from one of the CLL controls (described below) using the IMGT JunctionAnalysis tool showed a 6% probability of any two clonotypes sharing a D segment. This roughly corresponded to the probability of matching two consecutive bases (1/16 or 0.0625), so the D segments are represented as two effective NDN bases. Thus, in these embodiments, a sample clonotype and a prior correlating clonotype are classified as evolutionarily related by VH substitution if they have (i) identical J regions, (ii) at least six nucleotides beginning from the NDN-J boundary and extending to the VH direction that are identical, and (iii) identical D regions (as represented by a two-letter code).

[0021] In additional embodiments, a comparing step may make use of a probability model of the occurrences of the various components of the sample clonotypes and prior correlating clonotypes. In one such model, both information obtained directly from the sample clonotypes and prior correlating clonotypes and information about clonotypes obtained from databases is employed to classify sample clonotypes as evolved from prior correlating clonotypes or not. In one embodiment, the following direct information is used: (1) J segment identity and J segment deletions, (2) NDN sequence, and (3) V segment identity and V segment deletions. The following additional information about correlating clonotypes in the disease of interest may include (a) D segment identity, (b) position of the D segment (within the NDN region), and (c) deletions in the D segment from both the V direction ("V-side deletions") and the J direction ("J- side deletions"). In one embodiment, such information includes likelihoods of occurrence of the foregoing components from which sample clonotypes may be classified using a Bayesian model.

Monitoring Lymphoid Diseases And Treatment

[0022] Patients treated for many cancers often retain a minimal residual disease (MRD) related to the cancer. That is, even though a patient may have by a clinical measure a complete remission of the disease in response to treatment, a small fraction of the cancer cells may remain that have, for one reason or another, escaped destruction. The type and size of this residual population is an important prognostic factor for the patient's continued treatment, e.g. Campana, Hematol. Oncol. Clin. North Am., 23(5): 1083-1098 (2009); Buccisano et al, Blood, 119(2): 332-341 (2012).

[0023] In one aspect, the invention is directed to methods for monitoring minimal residual disease of a B-cell ALL after treatment, where the result of such monitoring is a key factor in determining whether to continue, discontinue or otherwise modify treatment. This aspect of the invention overcomes deficiencies in prior art methods because methods of the invention permit the detection and quantification of clones that have evolved from one or more originally identified disease-related clones (for example, identified at diagnosis by a variety of techniques, including but not limited to, analysis of a sequencing-based clonotype profile, an immunoscope profile confirmed by sequencing clonotypes, or by other methods, e.g. Pilarski et al, U.S. patent 6,416,948). The invention achieves the above objective in part by using sequencing-based clonotype profiles as the basic monitoring measurement.

[0024] In many malignant lymphoid and myeloid neoplasms, a diagnostic tissue sample, such as a peripheral blood sample or a bone marrow sample, is obtained before treatment from which a clonotype profile is generated (a "diagnostic clonotype profile"). One or more disease-correlated clonotypes (i.e. "correlating clonotypes" or "index clonotypes") are identified in the clonotype profile, usually as the clonotypes having the highest frequencies, e.g. >5 percent. After treatment, the presense, absence or frequency of such correlating clonotypes is assessed periodically to determine whether a remission is holding or whether the neoplasm is returning or relapsing, based on the presence of, or an increase in the frequency of, the correlating clonotypes (or related clonotypes) in a post-treatment clonotype profile. That is, after treatment, minimal residual disease of the cancer is assessed based on the presence, absence or frequency of the correlating clonotypes and/or related clonotypes, such as clonotypes evolved therefrom by VH substitution, or other mechanisms. In one aspect of the invention, a measure of MRD is taken as a frequency of the one or more clonotypes initially identified as being correlated with the cancer together with the clonotypes evolved therefrom after such initial identification.

[0025] Treatment of childhood ALL is typically done in the following phases: (1) Induction therapy: This is the first phase of treatment. The goal is to kill the leukemia cells in the blood and bone marrow. This puts the leukemia into remission. This is also called the remission induction phase. (2) Consolidation /intensification therapy: This is the second phase of therapy. It begins once the leukemia is in remission. The goal of consolidation/intensification therapy is to kill any remaining leukemia cells that may not be active but could begin to regrow and cause a relapse. (3) Maintenance therapy: This is the third phase of treatment. The goal is to kill any remaining leukemia cells that may regrow and cause a relapse. Often the cancer treatments are given in lower doses than those used for induction and consolidation intensification therapy. Usually induction therapy for ALL is carried out with chemotherapy with a combination of agents, such as vincristine, methotrexate, adrianmycin, daunorubicin, cytarabine, or the like, and a

glucocorticoid, and possibly additional agents, such as asparaginase, e.g. Graynon et al, Chapter 141a, in Cancer Medicine, vol. 2 (BC Dekker, London, 2003). In the course of the three phases, in some cases, radiation therapy and/or stem cell transplant therapty is also employed. Stem cell transplant is a method of giving high doses of chemotherapy and sometimes radiation therapy, and then replacing the blood-forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of a donor. After the patient receives treatment, the donor's stem cells are given to the patient through an infusion. These reinfused stem cells grow into (and restore) the patient's blood cells.

[0026] MRD measurements are used to assess the efficacy of the above treatment modalities. If increased numbers of leukemia cells are detected (e.g. between successive MRD measurements), then a relapse has taken place and the treatment regimen is modified to regain a remissive state. The modification may include use of a different chemotherapeutic combination, use of a different administration schedule, use of different amounts of drug, or a switch to a differ kind of therapy, e.g. from chemotherapy to bone marrow transplant therapy. A method for treating a patient having a B cell acute lymphoblastic leukemia (ALL) comprises administering to the patient a therapeutically effective amount of a anti-ALL agent. A therapeutically effective amount may vary depending on the nature of the anti-ALL agent. In one aspect, a

therapeutically effective amount may be alterred depending on the level of MRD, e.g. as determined by a sequencing-based clonotype profile.

[0027] Exemplary anti-ALL chemotherapeutic agents include, but are not limited to, cisplatin, carboplatin, oxalip latin, radiation, CPT-11, paclitaxel, 5-flourouracil, leucovorin, epothilone, gemcitabine, UFT, herceptin, Cytoxan, dacarbaxine, ifosfamide, mechlorethamine, melphalan, chlorambucil, anastrozole, exemstane, carmustine, lomustine, methotrexate, gemcitabine, cytarabine, fludarabine, bleomycin, dactinomycin, daunorubicin, doxorubicin, idarubicin, docetaxel, vinblastine, vincristin, vinorelbine, topotecan, lupron, megace, leucovorin, Iressa, flavopiridol, immunomotherapeutic agents, ZD6474, SU6668, and valspodar. Whenever the anti-ALL agent is a chemotherapeutic agent, it preferably is administered in a conventional pharmaceutical carrier. The pharmaceutical carrier may be solid or liquid. A solid carrier can include one or more substances which may also act as flavoring agent, lubricants, solubilizers, suspending agents, fillers, glidants, compression aids, binders or table-disintegrating agents; it can also be an encapsulating material. In powders, the carrier is a finely divided solid which is in admixture with the finely divided active ingredient. In tablets, the active ingredient is mixed with a carrier having the necessary compression properties in suitable proportions and compacted in the shape and size desired. The powders and tablets preferably contain up to 99% of the active ingredient. Suitable solid carriers include, for example, calcium phosphate, magnesium stearate, talc, sugars, lactose, dextrin, starch, gelatin, cellulose, methyl cellulose, sodium carboxymethyl cellulose, polyvinylpyrrolidine, low melting waxes and ion exchange resins. Liquid carriers are used in preparing solutions, suspensions, emulsions, syrups, elixirs and pressurized composition. The active ingredient can be dissolved or suspended in a pharmaceutically acceptable liquid carrier such as water, an organic solvent, a mixture of both or pharmaceutically acceptable oils or fats. The liquid carrier can contain other suitable pharmaceutical additives such as solubilizers, emulsifiers, buffers, preservatives, sweeteners, flavoring agents, suspending agents, thickening agent, colors, viscosity regulators, stabilizers or osmo -regulators. Suitable examples of liquid carriers for oral and parenteral administration include water (partially containing additives as above, e.g., cellulose derivatives, preferably sodium carboxymethyl cellulose solution), alcohols (including monohydric alcohols and polyhydric alcohols, e.g., glycols) and their derivatives, and oils (e.g., fractionated coconut oil and arachis oil). For parenteral administration, the carrier can also be an oily ester such as ethyl oleate and iopropyl myristate. Sterile liquid carriers are useful in sterile liquid form compositions for parenteral administration. The liquid carrier for pressurized compositions can be halogenated hydrocarbon or other pharmaceutically acceptable propellent. Liquid pharmaceutical compositions which are sterile solutions or suspensions can be utilized by, for example, intramuscular, intraperitoneal or subcutaneous injection. Sterile solutions can also be administered intravenously. The therapeutic agent can also be administered orally either in liquid or solid composition form.

Samples

[0028] Clonotype profiles for the method of the invention are generated from a sample of nucleic acids extracted from a sample containing B cells. B-cells include, for example, plasma B cells, memory B cells, Bl cells, B2 cells, marginal-zone B cells, and follicular B cells. B-cells can express immunoglobulins (antibodies, B cell receptor). In one aspect a sample of B cells includes at least 1,000 B cells; but more typically, a sample includes at least 10,000 B cells, and more typically, at least 100,000 B cells. In another aspect, a sample includes a number of B cells in the range of from 1000 to 1,000,000 B cells. Adequate sampling of the cells is an important aspect of interpreting the repertoire data, as described further below in the definitions of

"clonotype" and "repertoire." The number of cells in a sample sets a limit on the sensitivity of a measurement. For example, in a sample containing 1,000 B cells, the lowest frequency of clonotype detectable is 1/1000 or .001, regardless of how many sequencing reads are obtained when the DNA of such cells is analyzed by sequencing.

[0029] The sample can include nucleic acid, for example, DNA (e.g., genomic DNA or mitochondrial DNA) or RNA (e.g., messenger RNA or microRNA). The nucleic acid can be cell- free DNA or RNA, e.g. extracted from the circulatory system, Vlassov et al, Curr. Mol.

Med., 10: 142-165 (2010); Swarup et al, FEBS Lett., 581 : 795-799 (2007). In the methods of the provided invention, the amount of RNA or DNA from a subject that can be analyzed includes, for example, as low as a single cell in some applications (e.g., a calibration test) and as many as 10 million of cells or more translating to a range of DNA of 6pg-60ug, and RNA of

approximately lpg-lOug.

[0030] As discussed more fully below (Definitions), a sample of lymphocytes is sufficiently large so that substantially every B cell with a distinct clonotype is represented therein, thereby forming a repertoire (as the term is used herein). In one embodiment, a sample is taken that contains with a probability of ninety-nine percent every clonotype of a population present at a frequency of .001 percent or greater. In another embodiment, a sample is taken that contains with a probability of ninety-nine percent every clonotype of a population present at a frequency of .0001 percent or greater. In one embodiment, a sample of B cells includes at least a half million cells, and in another embodiment such sample includes at least one million cells.

[0031] Whenever a source of material from which a sample is taken is scarce, such as, clinical study samples, or the like, DNA from the material may be amplified by a non-biasing technique prior to specific amplification of BCR encoding sequences, such as whole genome amplification (WGA), multiple displacement amplification (MDA); or like technique, e.g. Hawkins et al, Curr. Opin. Biotech., 13: 65-67 (2002); Dean et al, Genome Research, 11 : 1095-1099 (2001); Wang et al, Nucleic Acids Research, 32: e76 (2004); Hosono et al, Genome Research, 13: 954-964 (2003); and the like.

[0032] Blood samples are of particular interest and may be obtained using conventional techniques, e.g. Innis et al, editors, PCR Protocols (Academic Press, 1990); or the like. For example, white blood cells may be separated from blood samples using convention techniques, e.g. RosetteSep kit (Stem Cell Technologies, Vancouver, Canada). Blood samples may range in volume from 100 to 10 mL; in one aspect, blood sample volumes are in the range of from 100 μΐ_^ to 2 mL. DNA and/or RNA may then be extracted from such blood sample using

conventional techniques for use in methods of the invention, e.g. DNeasy Blood & Tissue Kit (Qiagen, Valencia, CA). Optionally, subsets of white blood cells, e.g. lymphocytes, may be further isolated using conventional techniques, e.g. fluorescently activated cell sorting

(FACS)(Becton Dickinson, San Jose, CA), magnetically activated cell sorting (MACS)(Miltenyi Biotec, Auburn, CA), or the like. For example, memory B cells may be isolated by way of surface markers CD 19 and CD27.

[0033] Since the identifying recombinations are present in the DNA of each individual's adaptive immunity cell as well as their associated RNA transcripts, either RNA or DNA can be sequenced in the methods of the provided invention. A recombined sequence from a B-cell encoding an immunoglobulin molecule, or a portion thereof, is referred to as a clonotype. The DNA or R A can correspond to sequences from immunoglobulin (Ig) genes that encode antibodies.

[0034] The DNA and RNA analyzed in the methods of the invention correspond to sequences encoding heavy chain immunoglobulins (IgH). Each chain is composed of a constant (C) and a variable region. For the heavy chain, the variable region is composed of a variable (V), diversity (D), and joining (J) segments. Several distinct sequences coding for each type of these segments are present in the genome. A specific VDJ recombination event occurs during the development of a B-cell, marking that cell to generate a specific heavy chain. Somatic mutation often occurs close to the site of the recombination, causing the addition or deletion of several nucleotides, further increasing the diversity of heavy chains generated by B-cells. The possible diversity of the antibodies generated by a B-cell is then the product of the different heavy and light chains. The variable regions of the heavy and light chains contribute to form the antigen recognition (or binding) region or site. Added to this diversity is a process of somatic hypermutation which can occur after a specific response is mounted against some epitope.

[0035] In accordance with the invention, primers may be selected to generate amplicons of recombined nucleic acids extracted from B lymphocytes. Such sequences may be referred to herein as "somatically rearranged regions," or "somatically recombined regions," or

"recombined sequences." Somatically rearranged regions may comprise nucleic acids from developing or from fully developed lymphocytes, where developing lymphocytes are cells in which rearrangement of immune genes has not been completed to form molecules having full V(D)J regions. Exemplary incomplete somatically rearranged regions include incomplete IgH molecules (such as, molecules containing only D-J regions).

Amplification of Nucleic Acid Populations

[0036] As noted below, amplicons of target populations of nucleic acids may be generated by a variety of amplification techniques. In one aspect of the invention, multiplex PCR is used to amplify members of a mixture of nucleic acids, particularly mixtures comprising recombined immune molecules such as T cell receptors, B cell receptors, or portions thereof. Guidance for carrying out multiplex PCRs of such immune molecules is found in the following references, which are incorporated by reference: Faham et al, U.S. patent publication 2011/0207134; Lim et al, U.S. patent publication 2008/0166718; and the like. As described more fully below, in one aspect, the step of spatially isolating individual nucleic acid molecules is achieved by carrying out a primary multiplex amplification of a preselected somatically rearranged region or portion thereof (i.e. target sequences) using forward and reverse primers that each have tails non- complementary to the target sequences to produce a first amplicon whose member sequences have common sequences at each end that allow further manipulation. For example, such common ends may include primer binding sites for continued amplification using just a single forward primer and a single reverse primer instead of multiples of each, or for bridge

amplification of individual molecules on a solid surface, or the like. Such common ends may be added in a single amplification as described above, or they may be added in a two-step procedure to avoid difficulties associated with manufacturing and exercising quality control over mixtures of long primers (e.g. 50-70 bases or more). In such a two-step process (described more fully below), the primary amplification is carried out as described above, except that the primer tails are limited in length to provide only forward and reverse primer binding sites at the ends of the sequences of the first amplicon. A secondary amplification is then carried out using secondary amplification primers specific to these primer binding sites to add further sequences to the ends of a second amplicon. The secondary amplification primers have tails non-complementary to the target sequences, which form the ends of the second amplicon and which may be used in connection with sequencing the clonotypes of the second amplicon. In one embodiment, such added sequences may include primer binding sites for generating sequence reads and primer binding sites for carrying out bridge PCR on a solid surface to generate clonal populations of spatially isolated individual molecules, for example, when Solexa-based sequencing is used. In this latter approach, a sample of sequences from the second amplicon are disposed on a solid surface that has attached complementary oligonucleotides capable of annealing to sequences of the sample, after which cycles of primer extension, denaturation, annealing are implemented until clonal populations of templates are formed. Preferably, the size of the sample is selected so that (i) it includes an effective representation of clonotypes in the original sample, and (ii) the density of clonal populations on the solid surface is in a range that permits unambiguous sequence determination of clonotypes.

[0037] The region to be amplified can include the full clonal sequence or a subset of the clonal sequence, including the V-D junction, D-J junction of an immunoglobulin gene, the full variable region of an immunoglobulin, the antigen recognition region, or a CDR, e.g., complementarity determining region 3 (CDR3).

[0038] After amplification of DNA from the genome (or amplification of nucleic acid in the form of cDNA by reverse transcribing RNA), the individual nucleic acid molecules can be isolated, optionally re-amplified, and then sequenced individually. Exemplary amplification protocols may be found in van Dongen et al, Leukemia, 17: 2257-2317 (2003) or van Dongen et al, U.S. patent publication 2006/0234234, which is incorporated by reference. Briefly, an exemplary protocol is as follows: Reaction buffer: ABI Buffer II or ABI Gold Buffer (Life Technologies, San Diego, CA); 50 μΐ, final reaction volume; 100 ng sample DNA; 10 pmol of each primer (subject to adjustments to balance amplification as described below); dNTPs at 200 μΜ final concentration; MgCl₂ at 1.5 mM final concentration (subject to optimization depending on target sequences and polymerase); Taq polymerase (1-2 U/tube); cycling conditions:

preactivation 7 min at 95oC; annealing at 60oC; cycling times: 30s denaturation; 30s annealing; 30s extension. Polymerases that can be used for amplification in the methods of the invention are commercially available and include, for example, Taq polymerase, AccuPrime polymerase, or Pfu. The choice of polymerase to use can be based on whether fidelity or efficiency is preferred.

[0039] Methods for isolation of nucleic acids from a pool include subcloning nucleic acid into DNA vectors and transforming bacteria (bacterial cloning), spatial separation of the molecules in two dimensions on a solid substrate (e.g., glass slide), spatial separation of the molecules in three dimensions in a solution within micelles (such as can be achieved using oil emulsions with or without immobilizing the molecules on a solid surface such as beads), or using microreaction chambers in, for example, microfiuidic or nano-fluidic chips. Dilution can be used to ensure that on average a single molecule is present in a given volume, spatial region, bead, or reaction chamber. Guidance for such methods of isolating individual nucleic acid molecules is found in the following references: Sambrook, Molecular Cloning: A Laboratory Manual (Cold Spring Harbor Laboratory Press, 2001s); Shendure et al, Science, 309: 1728-1732 (including supplemental material)(2005); U.S. patent 6,300,070; Bentley et al, Nature, 456: 53-59

(including supplemental material)(2008); U.S. patent 7,323,305; Matsubara et al, Biosensors & Bioelectronics, 20: 1482-1490 (2005): U.S. patent 6,753,147; and the like.

[0040] Real time PCR, picogreen staining, nanofluidic electrophoresis (e.g. LabChip) or UV absorption measurements can be used in an initial step to judge the functional amount of amplifiable material.

[0041] In one aspect, multiplex amplifications are carried out so that relative amounts of sequences in a starting population are substantially the same as those in the amplified population, or amplicon. That is, multiplex amplifications are carried out with minimal amplification bias among member sequences of a sample population. In one embodiment, such relative amounts are substantially the same if each relative amount in an amplicon is within five fold of its value in the starting sample. In another embodiment, such relative amounts are substantially the same if each relative amount in an amplicon is within two fold of its value in the starting sample. As discussed more fully below, amplification bias in PCR may be detected and corrected using conventional techniques so that a set of PCR primers may be selected for a predetermined repertoire that provide unbiased amplification of any sample.

[0042] In one embodiment, amplification bias may be avoided by carrying out a two-stage amplification (as described above) wherein a small number of amplification cycles are implemented in a first, or primary, stage using primers having tails non-complementary with the target sequences. The tails include primer binding sites that are added to the ends of the sequences of the primary amplicon so that such sites are used in a second stage amplification using only a single forward primer and a single reverse primer, thereby eliminating a primary cause of amplification bias. Preferably, the primary PCR will have a small enough number of cycles (e.g. 5-10) to minimize the differential amplification by the different primers. The secondary amplification is done with one pair of primers and hence the issue of differential amplification is minimal. One percent of the primary PCR is taken directly to the secondary PCR. Thirty- five cycles (equivalent to -28 cycles without the 100 fold dilution step) used between the two amplifications were sufficient to show a robust amplification irrespective of whether the breakdown of cycles were: one cycle primary and 34 secondary or 25 primary and 10 secondary. Even though ideally doing only 1 cycle in the primary PCR may decrease the amplification bias, there are other considerations. One aspect of this is representation. This plays a role when the starting input amount is not in excess to the number of reads ultimately obtained. For example, if 1,000,000 reads are obtained and starting with 1,000,000 input molecules then taking only representation from 100,000 molecules to the secondary

amplification would degrade the precision of estimating the relative abundance of the different species in the original sample. The 100 fold dilution between the 2 steps means that the representation is reduced unless the primary PCR amplification generated significantly more than 100 molecules. This indicates that a minimum 8 cycles (256 fold), but more comfortably 10 cycle (-1,000 fold), may be used. The alternative to that is to take more than 1% of the primary PCR into the secondary but because of the high concentration of primer used in the primary PCR, a big dilution factor can be used to ensure these primers do not interfere in the

amplification and worsen the amplification bias between sequences. Another alternative is to add a purification or enzymatic step to eliminate the primers from the primary PCR to allow a smaller dilution of it. In this example, the primary PCR was 10 cycles and the second 25 cycles.

[0043] Briefly, the scheme of Faham and Willis (cited above) for amplifying IgH-encoding nucleic acids (RNA) is illustrated in Figs. 2A-2C. Nucleic acids (200) are extracted from lymphocytes in a sample and combined in a PCR with a primer (202) specific for C region (203) and primers (212) specific for the various V regions (206) of the immunoglobulin genes.

Primers (212) each have an identical tail (214) that provides a primer binding site for a second stage of amplification. As mentioned above, primer (202) is positioned adjacent to junction (204) between the C region (203) and J region (210). In the PCR, amplicon (216) is generated that contains a portion of C-encoding region (203), J-encoding region (210), D-encoding region (208), and a portion of V-encoding region (206). Amplicon (216) is further amplified in a second stage using primer P5 (222) and primer P7 (220), which each have tails (225 and

221/223, respectively) designed for use in an Illumina DNA sequencer. Tail (221/223) of primer P7 (220) optionally incorporates tag (221) for labeling separate samples in the sequencing process. Second stage amplification produces amplicon (230) which may be used in an Illumina DNA sequencer.

Generating Sequence Reads for Clonotypes

[0044] Any high-throughput technique for sequencing nucleic acids can be used in the method of the invention. Preferably, such technique has a capability of generating in a cost-effective manner a volume of sequence data from which at least 1000 clonotypes can be determined, and preferably, from which at least 10,000 to 1,000,000 clonotypes can be determined. DNA sequencing techniques include classic dideoxy sequencing reactions (Sanger method) using labeled terminators or primers and gel separation in slab or capillary, sequencing by synthesis using reversibly terminated labeled nucleotides, pyrosequencing, 454 sequencing, allele specific hybridization to a library of labeled oligonucleotide probes, sequencing by synthesis using allele specific hybridization to a library of labeled clones that is followed by ligation, real time monitoring of the incorporation of labeled nucleotides during a polymerization step, polony sequencing, and SOLiD sequencing. Sequencing of the separated molecules has more recently been demonstrated by sequential or single extension reactions using polymerases or ligases as well as by single or sequential differential hybridizations with libraries of probes. These reactions have been performed on many clonal sequences in parallel including demonstrations in current commercial applications of over 100 million sequences in parallel. In one aspect of the invention, high-throughput methods of sequencing are employed that comprise a step of spatially isolating individual molecules on a solid surface where they are sequenced in parallel. Such solid surfaces may include nonporous surfaces (such as in Solexa sequencing, e.g. Bentley et al, Nature,456: 53-59 (2008) or Complete Genomics sequencing, e.g. Drmanac et al, Science, 327: 78-81 (2010)), arrays of wells, which may include bead- or particle-bound templates (such as with 454, e.g. Margulies et al, Nature, 437: 376-380 (2005) or Ion Torrent sequencing, U.S. patent publication 2010/0137143 or 2010/0304982), micromachined membranes (such as with SMRT sequencing, e.g. Eid et al, Science, 323: 133-138 (2009)), or bead arrays (as with SOLiD sequencing or polony sequencing, e.g. Kim et al, Science, 316: 1481-1414 (2007)). In another aspect, such methods comprise amplifying the isolated molecules either before or after they are spatially isolated on a solid surface. Prior amplification may comprise emulsion-based amplification, such as emulsion PCR, or rolling circle amplification. Of particular interest is Solexa-based sequencing where individual template molecules are spatially isolated on a solid surface, after which they are amplified in parallel by bridge PCR to form separate clonal populations, or clusters, and then sequenced, as described in Bentley et al (cited above) and in manufacturer's instructions (e.g. TruSeq™ Sample Preparation Kit and Data Sheet, Illumina, Inc., San Diego, CA, 2010); and further in the following references: U.S. patents 6,090,592; 6,300,070; 7,115,400; and EP0972081B1; which are incorporated by reference. In one embodiment, individual molecules disposed and amplified on a solid surface form clusters in a density of at least 10⁵ clusters per cm²; or in a density of at least 5x10⁵ per cm²; or in a density of at least 10⁶ clusters per cm². In one embodiment, sequencing chemistries are employed having relatively high error rates. In such embodiments, the average quality scores produced by such chemistries are monotonically declining functions of sequence read lengths. In one embodiment, such decline corresponds to 0.5 percent of sequence reads have at least one error in positions 1- 75; 1 percent of sequence reads have at least one error in positions 76-100; and 2 percent of sequence reads have at least one error in positions 101-125.

[0045] In one aspect, a sequence-based clonotype profile of an individual is obtained using the following steps: (a) obtaining a nucleic acid sample from B-cells of the individual; (b) spatially isolating individual molecules derived from such nucleic acid sample, the individual molecules comprising at least one template generated from a nucleic acid in the sample, which template comprises a somatically rearranged region or a portion thereof, each individual molecule being capable of producing at least one sequence read; (c) sequencing said spatially isolated individual molecules; and (d) determining abundances of different sequences of the nucleic acid molecules from the nucleic acid sample to generate the clonotype profile. In one embodiment, each of the somatically rearranged regions comprise a V region and a J region. In another embodiment, the step of sequencing comprises bidirectionally sequencing each of the spatially isolated individual molecules to produce at least one forward sequence read and at least one reverse sequence read. Further to the latter embodiment, at least one of the forward sequence reads and at least one of the reverse sequence reads have an overlap region such that bases of such overlap region are determined by a reverse complementary relationship between such sequence reads. In still another embodiment, each of the somatically rearranged regions comprise a V region and a J region and the step of sequencing further includes determining a sequence of each of the individual nucleic acid molecules from one or more of its forward sequence reads and at least one reverse sequence read starting from a position in a J region and extending in the direction of its associated V region. In another embodiment, individual molecules comprise nucleic acids selected from the group consisting of complete IgH molecules, incomplete IgH molecules. In another embodiment, the step of sequencing comprises generating the sequence reads having monotonically decreasing quality scores. Further to the latter embodiment, monotonically decreasing quality scores are such that the sequence reads have error rates no better than the following: 0.2 percent of sequence reads contain at least one error in base positions 1 to 50, 0.2 to 1.0 percent of sequence reads contain at least one error in positions 51-75, 0.5 to 1.5 percent of sequence reads contain at least one error in positions 76-100. In another embodiment, the above method comprises the following steps: (a) obtaining a nucleic acid sample from T-cells and/or B-cells of the individual; (b) spatially isolating individual molecules derived from such nucleic acid sample, the individual molecules comprising nested sets of templates each generated from a nucleic acid in the sample and each containing a somatically rearranged region or a portion thereof, each nested set being capable of producing a plurality of sequence reads each extending in the same direction and each starting from a different position on the nucleic acid from which the nested set was generated; (c) sequencing said spatially isolated individual molecules; and (d) determining abundances of different sequences of the nucleic acid molecules from the nucleic acid sample to generate the clonotype profile. In one embodiment, the step of sequencing includes producing a plurality of sequence reads for each of the nested sets. In another embodiment, each of the somatically rearranged regions comprise a V region and a J region, and each of the plurality of sequence reads starts from a different position in the V region and extends in the direction of its associated J region.

[0046] In one aspect, for each sample from an individual, the sequencing technique used in the methods of the invention generates sequences of least 1000 clonotypes per run; in another aspect, such technique generates sequences of at least 10,000 clonotypes per run; in another aspect, such technique generates sequences of at least 100,000 clonotypes per run; in another aspect, such technique generates sequences of at least 500,000 clonotypes per run; and in another aspect, such technique generates sequences of at least 1,000,000 clonotypes per run. In still another aspect, such technique generates sequences of between 100,000 to 1,000,000 clonotypes per run per individual sample. [0047] The sequencing technique used in the methods of the provided invention can generate about 30 bp, about 40 bp, about 50 bp, about 60 bp, about 70 bp, about 80 bp, about 90 bp, about 100 bp, about 110, about 120 bp per read, about 150 bp, about 200 bp, about 250 bp, about 300 bp, about 350 bp, about 400 bp, about 450 bp, about 500 bp, about 550 bp, or about 600 bp per read.

Clonotype Determination from Sequence Data

[0048] Constructing clo no types from sequence read data is disclosed in Faham and Willis (cited above), which is incorporated herein by reference. Briefly, constructing clonotypes from sequence read data depends in part on the sequencing method used to generate such data, as the different methods have different expected read lengths and data quality. In one approach, a Solexa sequencer is employed to generate sequence read data for analysis. In one embodiment, a sample is obtained that provides at least 0.5-1.0x10⁶ lymphocytes to produce at least 1 million template molecules, which after optional amplification may produce a corresponding one million or more clonal populations of template molecules (or clusters). For most high throughput sequencing approaches, including the Solexa approach, such over sampling at the cluster level is desirable so that each template sequence is determined with a large degree of redundancy to increase the accuracy of sequence determination. For Solexa-based implementations, preferably the sequence of each independent template is determined 10 times or more. For other sequencing approaches with different expected read lengths and data quality, different levels of redundancy may be used for comparable accuracy of sequence determination. Those of ordinary skill in the art recognize that the above parameters, e.g. sample size, redundancy, and the like, are design choices related to particular applications.

[0049] In one aspect, clonotypes of IgH chains (illustrated in Fig. 3 A) are determined by at least one sequence read starting in its C region and extending in the direction of its associated V region (referred to herein as a "C read" (304)) and at least one sequence read starting in its V region and extending in the direction of its associated J region (referred to herein as a "V read" (306)). Such reads may or may not have an overlap region (308) and such overlap may or may not encompass the NDN region (315) as shown in Fig. 3 A. Overlap region (308) may be entirely in the J region, entirely in the NDN region, entirely in the V region, or it may encompass a J region-NDN region boundary or a V region-NDN region boundary, or both such boundaries (as illustrated in Fig. 3A). Typically, such sequence reads are generated by extending sequencing primers, e.g. (302) and (310) in Fig. 3 A, with a polymerase in a sequencing-by- synthesis reaction, e.g. Metzger, Nature Reviews Genetics, 11 : 31-46 (2010); Fuller et al, Nature Biotechnology, 27: 1013-1023 (2009). The binding sites for primers (302) and (310) are predetermined, so that they can provide a starting point or anchoring point for initial alignment and analysis of the sequence reads. In one embodiment, a C read is positioned so that it encompasses the D and/or NDN region of the IgH chain and includes a portion of the adjacent V region, e.g. as illustrated in Figs. 3A and 3B. In one aspect, the overlap of the V read and the C read in the V region is used to align the reads with one another. In other embodiments, such alignment of sequence reads is not necessary, so that a V read may only be long enough to identify the particular V region of a clonotype. This latter aspect is illustrated in Fig. 3B.

Sequence read (330) is used to identify a V region, with or without overlapping another sequence read, and another sequence read (332) traverses the NDN region and is used to determine the sequence thereof. Portion (334) of sequence read (332) that extends into the V region is used to associate the sequence information of sequence read (332) with that of sequence read (330) to determine a clonotype. For some sequencing methods, such as base-by-base approaches like the Solexa sequencing method, sequencing run time and reagent costs are reduced by minimizing the number of sequencing cycles in an analysis. Optionally, as illustrated in Fig. 3 A, amplicon (300) is produced with sample tag (312) to distinguish between clonotypes originating from different biological samples, e.g. different patients. Sample tag (312) may be identified by annealing a primer to primer binding region (316) and extending it (314) to produce a sequence read across tag (312), from which sample tag (312) is decoded.

[0050] In one aspect of the invention, sequences of clonotypes may be determined by combining information from one or more sequence reads, for example, along the V(D)J regions of the selected chains. In another aspect, sequences of clonotypes are determined by combining information from a plurality of sequence reads. Such pluralities of sequence reads may include one or more sequence reads along a sense strand (i.e. "forward" sequence reads) and one or more sequence reads along its complementary strand (i.e. "reverse" sequence reads). When multiple sequence reads are generated along the same strand, separate templates are first generated by amplifying sample molecules with primers selected for the different positions of the sequence reads. This concept is illustrated in Fig. 4A where primers (404, 406 and 408) are employed to generate amplicons (410, 412, and 414, respectively) in a single reaction. Such amplifications may be carried out in the same reaction or in separate reactions. In one aspect, whenever PCR is employed, separate amplification reactions are used for generating the separate templates which, in turn, are combined and used to generate multiple sequence reads along the same strand. This latter approach is preferable for avoiding the need to balance primer concentrations (and/or other reaction parameters) to ensure equal amplification of the multiple templates (sometimes referred to herein as "balanced amplification" or "unbias amplification"). The generation of templates in separate reactions is illustrated in Figs. 4B-4C. There a sample containing IgH (400) is divided into three portions (472, 474, and 476) which are added to separate PCRs using J region primers (401) and V region primers (404, 406, and 408, respectively) to produce amplicons (420, 422 and 424, respectively). The latter amplicons are then combined (478) in secondary PCR (480) using P5 and P7 primers to prepare the templates (482) for bridge PCR and sequencing on an Illumina GA sequencer, or like instrument.

[0051] Sequence reads of the invention may have a wide variety of lengths, depending in part on the sequencing technique being employed. For example, for some techniques, several trade-offs may arise in its implementation, for example, (i) the number and lengths of sequence reads per template and (ii) the cost and duration of a sequencing operation. In one embodiment, sequence reads are in the range of from 20 to 400 nucleotides; in another embodiment, sequence reads are in a range of from 30 to 200 nucleotides; in still another embodiment, sequence reads are in the range of from 30 to 120 nucleotides. In one embodiment, 1 to 4 sequence reads are generated for determining the sequence of each clonotype; in another embodiment, 2 to 4 sequence reads are generated for determining the sequence of each clonotype; and in another embodiment, 2 to 3 sequence reads are generated for determining the sequence of each clonotype. In the foregoing embodiments, the numbers given are exclusive of sequence reads used to identify samples from different individuals. The lengths of the various sequence reads used in the embodiments described below may also vary based on the information that is sought to be captured by the read; for example, the starting location and length of a sequence read may be designed to provide the length of an NDN region as well as its nucleotide sequence; thus, sequence reads spanning the entire NDN region are selected. In other aspects, one or more sequence reads that in combination (but not separately) encompass a D and /or NDN region are sufficient.

[0052] In another aspect of the invention, sequences of clonotypes are determined in part by aligning sequence reads to one or more V region reference sequences and one or more J region reference sequences, and in part by base determination without alignment to reference sequences, such as in the highly variable NDN region. A variety of alignment algorithms may be applied to the sequence reads and reference sequences. For example, guidance for selecting alignment methods is available in Batzoglou, Briefings in Bio informatics, 6: 6-22 (2005), which is incorporated by reference. In one aspect, whenever V reads or C reads (as mentioned above) are aligned to V and J region reference sequences, a tree search algorithm is employed, e.g. as described generally in Gusfield (cited above) and Cormen et al, Introduction to Algorithms, Third Edition (The MIT Press, 2009). [0053] The construction of IgH clonotypes from sequence reads is characterized by at least two factors: i) the presence of somatic mutations which makes alignment more difficult, and ii) the NDN region is larger so that it is often not possible to map a portion of the V segment to the C read. In one aspect of the invention, this problem is overcome by using a plurality of primer sets for generating V reads, which are located at different locations along the V region, preferably so that the primer binding sites are nonoverlapping and spaced apart, and with at least one primer binding site adjacent to the NDN region, e.g. in one embodiment from 5 to 50 bases from the V- NDN junction, or in another embodiment from 10 to 50 bases from the V-NDN junction. The redundancy of a plurality of primer sets minimizes the risk of failing to detect a clonotype due to a failure of one or two primers having binding sites affected by somatic mutations. In addition, the presence of at least one primer binding site adjacent to the NDN region makes it more likely that a V read will overlap with the C read and hence effectively extend the length of the C read. This allows for the generation of a continuous sequence that spans all sizes of NDN regions and that can also map substantially the entire V and J regions on both sides of the NDN region.

Embodiments for carrying out such a scheme are illustrated in Figs. 4 A and 4D. In Fig. 4 A, a sample comprising IgH chains (400) are sequenced by generating a plurality amplicons for each chain by amplifying the chains with a single set of J region primers (401) and a plurality (three shown) of sets of V region (402) primers (404, 406, 408) to produce a plurality of nested amplicons (e.g., 410, 412, 414) all comprising the same NDN region and having different lengths encompassing successively larger portions (411, 413, 415) of V region (402). Members of a nested set may be grouped together after sequencing by noting the identify (or substantial identity) of their respective NDN, J and/or C regions, thereby allowing reconstruction of a longer V(D)J segment than would be the case otherwise for a sequencing platform with limited read length and/or sequence quality. In one embodiment, the plurality of primer sets may be a number in the range of from 2 to 5. In another embodiment the plurality is 2-3; and still another embodiment the plurality is 3. The concentrations and positions of the primers in a plurality may vary widely. Concentrations of the V region primers may or may not be the same. In one embodiment, the primer closest to the NDN region has a higher concentration than the other primers of the plurality, e.g. to insure that amplicons containing the NDN region are represented in the resulting amplicon. In a particular embodiment where a plurality of three primers is employed, a concentration ratio of 60:20:20 is used. One or more primers (e.g. 435 and 437 in Fig. 4D) adjacent to the NDN region (444) may be used to generate one or more sequence reads (e.g. 434 and 436) that overlap the sequence read (442) generated by J region primer (432), thereby improving the quality of base calls in overlap region (440). Sequence reads from the plurality of primers may or may not overlap the adjacent downstream primer binding site and/or adjacent downstream sequence read. In one embodiment, sequence reads proximal to the NDN region (e.g. 436 and 438) may be used to identify the particular V region associated with the clonotype. Such a plurality of primers reduces the likelihood of incomplete or failed

amplification in case one of the primer binding sites is hypermutated during immunoglobulin development. It also increases the likelihood that diversity introduced by hypermutation of the V region will be capture in a clonotype sequence. A secondary PCR may be performed to prepare the nested amplicons for sequencing, e.g. by amplifying with the P5 (401) and P7 (404, 406, 408) primers as illustrated to produce amplicons (420, 422, and 424), which may be distributed as single molecules on a solid surface, where they are further amplified by bridge PCR, or like technique.

[0054] Base calling in NDN regions (particularly of IgH chains) can be improved by using the codon structure of the flanking J and V regions, as illustrated in Fig. 4E. (As used herein, "codon structure" means the codons of the natural reading frame of segments of TCR or BCR transcripts or genes outside of the NDN regions, e.g. the V region, J region, or the like.) There amplicon (450), which is an enlarged view of the amplicon of Fig. 4B, is shown along with the relative positions of C read (442) and adjacent V read (434) above and the codon structures (452 and 454) of V region (430) and J region (446), respectively, below. In accordance with this aspect of the invention, after the codon structures (452 and 454) are identified by conventional alignment to the V and J reference sequences, bases in NDN region (456) are called (or identified) one base at a time moving from J region (446) toward V region (430) and in the opposite direction from V region (430) toward J region (446) using sequence reads (434) and (442). Under normal biological conditions, only the recombined TCR or IgH sequences that have in frame codons from the V region through the NDN region and to the J region are expressed as proteins. That is, of the variants generated somatically only ones expressed are those whose J region and V region codon frames are in- frame with one another and remain in- frame through the NDN region. (Here the correct frames of the V and J regions are determined from reference sequences). If an out-of- frame sequence is identified based one or more low quality base calls, the corresponding clonotype is flagged for re-evaluation or as a potential disease-related anomaly. If the sequence identified is in- frame and based on high quality base calls, then there is greater confidence that the corresponding clonotype has been correctly called. Accordingly, in one aspect, the invention includes a method of determining V(D)J-based clonotypes from bidirectional sequence reads comprising the steps of: (a) generating at least one J region sequence read that begins in a J region and extends into an NDN region and at least one V region sequence read that begins in the V regions and extends toward the NDN region such that the J region sequence read and the V region sequence read are overlapping in an overlap region, and the J region and the V region each have a codon structure; (b) determining whether the codon structure of the J region extended into the NDN region is in frame with the codon structure of the V region extended toward the NDN region. In a further embodiment, the step of generating includes generating at least one V region sequence read that begins in the V region and extends through the NDN region to the J region, such that the J region sequence read and the

V region sequence read are overlapping in an overlap region.

[0055] Somatic Hypermutations. In one embodiment, IgH-based clonotypes that have undergone somatic hypermutation are determined as follows. A somatic mutation is defined as a sequenced base that is different from the corresponding base of a reference sequence (of the relevant segment, usually V, J or C) and that is present in a statistically significant number of reads. In one embodiment, C reads may be used to find somatic mutations with respect to the mapped J segment and likewise V reads for the V segment. Only pieces of the C and V reads are used that are either directly mapped to J or V segments or that are inside the clonotype extension up to the NDN boundary. In this way, the NDN region is avoided and the same 'sequence information' is not used for mutation finding that was previously used for clonotype

determination (to avoid erroneously classifying as mutations nucleotides that are really just different recombined NDN regions). For each segment type, the mapped segment (major allele) is used as a scaffold and all reads are considered which have mapped to this allele during the read mapping phase. Each position of the reference sequences where at least one read has mapped is analyzed for somatic mutations. In one embodiment, the criteria for accepting a non- reference base as a valid mutation include the following: 1) at least N reads with the given mutation base, 2) at least a given fraction N/M reads (where M is the total number of mapped reads at this base position) and 3) a statistical cut based on the binomial distribution, the average Q score of the N reads at the mutation base as well as the number (M-N) of reads with a non- mutation base. Preferably, the above parameters are selected so that the false discovery rate of mutations per clonotype is less than 1 in 1000, and more preferably, less than 1 in 10000.

[0056] Phylogenic Clonotypes (Clans). In cancers, such as lymphoid neoplasms, a single lymphocyte progenitor may give rise to many related lymphocyte progeny, each possessing and/or expressing a slightly different TCR or BCR, and therefore a different clonotype, due to cancer-related somatic mutation(s), such as base substitutions, aberrant rearrangements, or the like. Cells producing such clonotypes are referred to herein as phylogenic clones, and a set of such related clones are referred to herein as a "clan." Likewise, clonotypes of phylogenic clones are referred to as phylogenic clonotypes and a set of phylogenic clonotypes may be referred to as a clan of clonotypes. In one aspect, methods of the invention comprise monitoring the frequency of a clan of clonotypes (i.e., the sum of frequencies of the constituent phylogenic clonotypes of the clan), rather than a frequency of an individual clonotype. Phylogenic clonotypes may be identified by one or more measures of relatedness to a parent clonotype. In one embodiment, phylogenic clonotypes may be grouped into the same clan by percent homology, as described more fully below. In another embodiment, phylogenic clonotypes are identified by common usage of V regions, J regions, and/or NDN regions. For example, a clan may be defined by clonotypes having common J and ND regions but different V regions; or it may be defined by clonotypes having the same V and J regions (including identical base substitutions mutations) but with different NDN regions; or it may be defined by a clonotype that has undergone one or more insertions and/or deletions of from 1-10 bases, or from 1-5 bases, or from 1-3 bases, to generate clan members. In another embodiment, members of a clan are determined as follows. Clonotypes are assigned to the same clan if they satisfy the following criteria: i) they are mapped to the same V and J reference segments, with the mappings occurring at the same relative positions in the clonotype sequence, and ii) their NDN regions are substantially identical.

"Substantial" in reference to clan membership means that some small differences in the NDN region are allowed because somatic mutations may have occurred in this region. Preferably, in one embodiment, to avoid falsely calling a mutation in the NDN region, whether a base substitution is accepted as a cancer-related mutation depends directly on the size of the NDN region of the clan. For example, a method may accept a clonotype as a clan member if it has a one-base difference from clan NDN sequence(s) as a cancer-related mutation if the length of the clan NDN sequence(s) is m nucleotides or greater, e.g. 9 nucleotides or greater, otherwise it is not accepted, or if it has a two-base difference from clan NDN sequence(s) as cancer-related mutations if the length of the clan NDN sequence(s) is n nucleotides or greater, e.g. 20 nucleotides or greater, otherwise it is not accepted. In another embodiment, members of a clan are determined using the following criteria: (a) V read maps to the same V region, (b) C read maps to the same J region, (c) NDN region substantially identical (as described above), and (d) position of NDN region between V-NDN boundary and J-NDN boundary is the same (or equivalently, the number of downstream base additions to D and the number of upstream base additions to D are the same). Clonotypes of a single sample may be grouped into clans and clans from successive samples acquired at different times may be compared with one another. In particular, in one aspect of the invention, clans containing clonotypes correlated with a disease, such as a lymphoid neoplasm, are identified from clonotypes of each sample and compared with that of the immediately previous sample to determine disease status, such as, continued remission, incipient relapse, evidence of further clonal evolution, or the like.

[0057] It is expected that PCR error is concentrated in some bases that were mutated in the early cycles of PCR. Sequencing error is expected to be distributed in many bases even though it is totally random as the error is likely to have some systematic biases. It is assumed that some bases will have sequencing error at a higher rate, say 5% (5 fold the average). Given these assumptions, sequencing error becomes the dominant type of error. Distinguishing PCR errors from the occurrence of highly related clonotypes will play a role in analysis. Given the biological significance to determining that there are two or more highly related clonotypes, a conservative approach to making such calls is taken. The detection of enough of the minor clonotypes so as to be sure with high confidence (say 99.9%) that there are more than one clonotype is considered. For example of clonotypes that are present at 100 copies/1,000,000, the minor variant is detected 14 or more times for it to be designated as an independent clonotype. Similarly, for clonotypes present at 1,000 copies/1,000,000 the minor variant can be detected 74 or more times to be designated as an independent clonotype. This algorithm can be enhanced by using the base quality score that is obtained with each sequenced base. If the relationship between quality score and error rate is validated above, then instead of employing the conservative 5% error rate for all bases, the quality score can be used to decide the number of reads that need to be present to call an independent clonotype. The median quality score of the specific base in all the reads can be used, or more rigorously, the likelihood of being an error can be computed given the quality score of the specific base in each read, and then the probabilities can be combined (assuming independence) to estimate the likely number of sequencing error for that base. As a result, there are different thresholds of rejecting the sequencing error hypothesis for different bases with different quality scores. For example for a clonotype present at 1,000 copies/1,000,000 the minor variant is designated independent when it is detected 22 and 74 times if the probability of error were 0.01 and 0.05, respectively.

[0058] In the presence of sequencing errors, each genuine clonotype is surrounded by a 'cloud' of reads with varying numbers of errors with respect to the its sequence. The "cloud" of sequencing errors drops off in density as the distance increases from the clonotype in sequence space. A variety of algorithms are available for converting sequence reads into clonotypes. In one aspect, coalescing of sequence reads (that is, merging candidate clonotypes determined to have one or more sequencing errors) depends on at least three factors: the number of sequences obtained for each of the clonotypes being compared; the number of bases at which they differ; and the sequencing quality score at the positions at which they are discordant. A likelihood ratio may be constructed and assessed that is based on the expected error rates and binomial distribution of errors. For example, two clonotypes, one with 150 reads and the other with 2 reads with one difference between them in an area of poor sequencing quality will likely be coalesced as they are likely to be generated by sequencing error. On the other hand two clonotypes, one with 100 reads and the other with 50 reads with two differences between them are not coalesced as they are considered to be unlikely to be generated by sequencing error. In one embodiment of the invention, the algorithm described below may be used for determining clonotypes from sequence reads. In one aspect of the invention, sequence reads are first converted into candidate clonotypes. Such a conversion depends on the sequencing platform employed. For platforms that generate high Q score long sequence reads, the sequence read or a portion thereof may be taken directly as a candidate clonotype. For platforms that generate lower Q score shorter sequence reads, some alignment and assembly steps may be required for converting a set of related sequence reads into a candidate clonotype. For example, for Solexa- based platforms, in some embodiments, candidate clonotypes are generated from collections of paired reads from multiple clusters, e.g. 10 or more, as mentioned above

[0059] The cloud of sequence reads surrounding each candidate clonotype can be modeled using the binomial distribution and a simple model for the probability of a single base error. This latter error model can be inferred from mapping V and J segments or from the clonotype finding algorithm itself, via self-consistency and convergence. A model is constructed for the probability of a given 'cloud' sequence Y with read count C2 and E errors (with respect to sequence X) being part of a true clonotype sequence X with perfect read count CI under the null model that X is the only true clonotype in this region of sequence space. A decision is made whether or not to coalesce sequence Y into the clonotype X according the parameters CI, C2, and E. For any given CI and E a max value C2 is pre-calculated for deciding to coalesce the sequence Y. The max values for C2 are chosen so that the probability of failing to coalesce Y under the null hypothesis that Y is part of clonotype X is less than some value P after integrating over all possible sequences Y with error E in the neighborhood of sequence X. The value P is controls the behavior of the algorithm and makes the coalescing more or less permissive.

[0060] If a sequence Y is not coalesced into clonotype X because its read count is above the threshold C2 for coalescing into clonotype X then it becomes a candidate for seeding separate clonotypes. An algorithm implementing such principles makes sure that any other sequences Y2, Y3, etc. which are 'nearer' to this sequence Y (that had been deemed independent of X) are not aggregated into X. This concept of 'nearness' includes both error counts with respect to Y and X and the absolute read count of X and Y, i.e. it is modeled in the same fashion as the above model for the cloud of error sequences around clonotype X. In this way 'cloud' sequences can be properly attributed to their correct clonotype if they happen to be 'near' more than one clonotype.

[0061] In one embodiment, an algorithm proceeds in a top down fashion by starting with the sequence X with the highest read count. This sequence seeds the first clonotype. Neighboring sequences are either coalesced into this clonotype if their counts are below the precalculated thresholds (see above), or left alone if they are above the threshold or 'closer' to another sequence that was not coalesced. After searching all neighboring sequences within a maximum error count, the process of coalescing reads into clonotype X is finished. Its reads and all reads that have been coalesced into it are accounted for and removed from the list of reads available for making other clonotypes. The next sequence is then moved on to with the highest read count. Neighboring reads are coalesced into this clonotype as above and this process is continued until there are no more sequences with read counts above a given threshold, e.g. until all sequences with more than 1 count have been used as seeds for clonotypes.

[0062] As mentioned above, in another embodiment of the above algorithm, a further test may be added for determining whether to coalesce a candidate sequence Y into an existing clonotype X, which takes into account quality score of the relevant sequence reads. The average quality score(s) are determined for sequence(s) Y (averaged across all reads with sequence Y) were sequences Y and X differ. If the average score is above a predetermined value then it is more likely that the difference indicates a truly different clonotype that should not be coalesced and if the average score is below such predetermined value then it is more likely that sequence Y is caused by sequencing errors and therefore should be coalesced into X.

[0063] While the present invention has been described with reference to several particular example embodiments, those skilled in the art will recognize that many changes may be made thereto without departing from the spirit and scope of the present invention. The present invention is applicable to a variety of sensor implementations and other subject matter, in addition to those discussed above.

Example 1

Na^'ive Bayesian Classifier of Evolution in ALL

[0064] In this example, construction of a na^'ive Bayesian classifier model of V_H substitution is outlined. "IMGT" referes to immunology databases maintained by the international

ImMunoGeneTics information system (httpi ywww.iragt.org), described in Robinson et al, Nucleic Acids Research (1 January 2013) 41(D1): D1222-D1227. The model below may be implemented in various computer programming languages, including but not limited to, C++, Ruby, Java, Python, or the like.

[0065] Elements of IgH V(D)J generation used in model:

Different pieces of data about each test ciones:

»^■ J allele & J deletion

HDH sequence

V allele & V deletion

Additional information from iMGT about disease ciones:

D allele

*^■ position of D region

*^> D deletions (J & V side)

[0066] Bayes' Theorem combines the following quantities:

P( data \ evolution) P( evolution )

P( evoiutionldata)

Pi da ta)

** If data can be described as d , «¾, .... d„ and we assume

Independence between components, then we have:

P(data) = P(d_{l :} d₂- .-, _m) = P(di)P(<¼)...P(</_B) = Π?=ι ?W

[0067] Probabilities needed for the na^'ive Bayes classifier:

posterior probability, our goal.

P(evolution): prior probability, set to 0.0001, but could

improved

P(data\ evoiu tion ) : conditions I probability olution) and

)

[0068] Data elements used: NDN decomposed as N-_t DN:_;

» Matching J allele &: J deletion.

Matching N_\ bases, if any.

Matching D bases, D allele & J- side D-deletion, if any.

** Matching Λ½ bases, if any.

[0069] Matching J allele and J deletions:

P( Jallele . .jdehtioni evolution} = 1

V-replacement mode! of evolution requires that the J allele &>

deletion matches.

P( Ja/te/e,

normal }

»» Based on 116k normal BM clones from 4 samples annotated

through I GT.

- J allele & J deletion not dependent on each other.

[0070] Matching N bases (Ni and N₂):

** Count how marry sequential bases are matched (out of m_n

bases total)

i bases

*^■ 1/ {m_ni ÷ 1) represents a non-informative prior: all possibilities

are equally likely.

*· This is incorrect for Ni (generally match everything) but this is

reasonable for A½.

»· Geometric distribution: each base has 25% of occuring.

[0071] Matching D regions:

D atch: D allele & J-side D deletion match

s*- P{ Dmatchl evolution) = high

* high is set arbitrarily to 0.95

^ P{ Dmatchl noEvofution) =

D regions are not matched directly; the number of matching bases is known (out of η¾).

evolution) +

P(D\ DnotMaich) P{DnotMatch\ evolution)

* P(DlD atch) = l/(m_d ÷ 1)

*^■

= 0.25^rf * 0.75 V-side deletions are ignored in the model.

[0072] Results from data of Example 2: 492 evolved clonotypes identified: hadQyaiity evoS fewMol noEvol unee rtainV bad Quality 132 0 0 0 0

few ol 0 0 5232 0 0

uncertainV 0 0 0 0 25253

unrelated 0 0 0 46856 0

unrefatedButC ⁾ 0 492 0 38 0

Example 2

Evolution of the Heavy Chain Locus in Children with B Precusor ALL

[0073] In this example, clonal evolution in ALL was determined by performing IgH repertoire sequencing on diagnostic samples from 51 children with pre-B ALL. Using this approach, high frequency leukemic "index" clonotypes, or correlating clonotypes, were identified and distinct but related "evolved" clonotypes were found in most of the pre-B ALL patients.

[0074] Clinical samples. 51 diagnostic bone marrow samples from children with acute lymphoblastic leukemia diagnosed at Lucile Packard Children's Hospital were collected on a protocol approved by the Stanford Institution Review Board as described in Salzman et al, PLoS One 7, e30733 (2012). Informed consent was obtained prior to specimen collection and samples were de-identified prior to use in studies. Peripheral blood mononuclear cells were obtained from 35 patients with chronic lymphocytic leukemia diagnosed at Stanford University Medical Center. All CLL patient samples were obtained with explicit authorization and monitoring by the Stanford University School of Medicine Institutional Review Board. Patient and sample characteristics are summarized in Table 1. The patients were a random sampling of children diagnosed with ALL at Lucile Packard Children's Hospital over the previous 7 years. Data were collected on prognostic variables currently used for disease stratification, such as age, initial white blood cell count, cytogenetics, central nervous system (CNS) stage, and end of induction minimal residual disease. Samples that had less than 500 starting cells as measured by flow cytometry (6 normal B-cell sorts) were not analyzed further. One patient had only 1 malignant cell sort (patient 13).

[0075] Sequencing the IgH locus in pre-B ALL diagnostic bone marrow samples. Clonal evolution in pre-B ALL bone marrow samples at diagnosis was characterized by amplification and sequencing of IgH loci. DNA from bone marrow mononuclear cells (BMMC) (which were isolated from each of the 51 patients at diagnosis and cryopreserved) was isolated, and IgH encoding DNA was amplified, sequenced and analyzed to identify index clones and clones evolved therefrom using the "6-base" clonal evolution algorithm described above.

[0076] IgH amplification and sequencing. The procedure disclosed by Faham and Willis (cited above) was followed. Genomic DNA was amplified using locus specific primer sets for IgH. The goal of this amplification reaction was to reproducibly amplify all possible rearranged IgH sequences in a sample while appending the necessary sequences for cluster formation and sample indexing. Briefly, steps of the Faham and Willis procedure were applied as follows: DNA was isolated using AllPrep DNA mini and/or micro kits, according to manufacturer's instructions (Qiagen). First stage primers were designed so as to allow for the amplification of all known alleles of the germline IgH sequences. To minimize the risk of not amplifying a specific clonotype sequence because of a somatic hypermutation at the primer hybridization site, three sets of primers were designed in the V_H segments. Therefore each V_H segment is amplified by 3 primers ameliorating the problem of somatic hypermutations interfering with amplification. Primers were optimized such that each possible V_H and ½ segment was amplified at a similar rate so as to minimally skew the repertoire frequency distribution during the amplification process. Specificity of the primers was, in contrast, not optimized as the primer sequences could be mapped and removed from the eventual sequence read. Thus a given sequence may have been amplified by multiple primers. This methodology led to slightly different primer designs than have been published previously for similar IgH amplification approaches , e.g. van Dongen et al, Leukemia (cited above). The numbers of primers and the positions of these primers are shown in Faham and Willis, U.S. patent publication 2011/0207134. At the 5' ends of V_H segment primers a universal sequence was appended. These sequences are complementary to a set of second stage PCR primers. Similarly the primers on the ½ side had a 5' tail with a universal sequence that is complementary to second stage PCR primers. The second stage PCR primers contained the sequence primer and the P5 sequence used for cluster formation in the Illumina Genome Analyzer sequencer. The primers on the V_H side of the amplification constituted one of a set of primers, each of which had a 3' region that annealed to the overhang sequence appended in the first reaction but which further contained one of multiple 6 base pair indices that allowed for sample multiplexing on the sequencer. Each of these primers further contained a 5' tail with the P7 sequence used for cluster formation in the Illumina Genome Analyzer sequencer. First stage PCR was carried out using a high fidelity polymerase

(AccuPrime, Life Technologies) for 16 cycles. 1/100 of this amplification reaction was then used as the template for a second PCR reaction using the second stage primers including the primer containing a sample index that was unique to a particular sample. A second stage PCR was carried out for 22 cycles. Different samples were pooled to be sequenced in the same sequencing Illumina Genome Analyzer sequencing lane. The pool was then purified using the QIAquick PCR purification kit (Qiagen). Cluster formation and sequencing was carried out per the manufacturer protocol (Illumina, Inc., La Jolla, CA). Specifically, three sequencing reactions were performed. First 115 bp were sequenced from the ½ side sufficient to sequence through the junctional sequence from J_H to VH- At this point, the synthesized strand was denatured and washed off. A second sequencing primer was annealed that allowed the sample index to be sequenced for 6 cycles to identify the sample. At this point the reverse complement strand was generated per the Illumina protocol. A final sequencing read of 95 bp was obtained from the VH- ίο-½ direction providing ample sequence to map the VH segment accurately.

[0077] Clonotype determination. After exclusion of low quality reads, sequence data were then analyzed to determine the clonotype sequences including mapping to germline VH and ½ consensus sequences. First, the sample index sequences were used to identify which of the sequences originate from which of the pooled samples. Sequences whose index were not a perfect match to one of the indices used in a specific run were excluded. Next the forward read was used to map the ½ segment. Since all the sequences started from the same position of the ½ segments, all the ½ segments started at a predefined sequencing position. The first 25 bp of the JH segments were used to map the ½ segment. Any read with more than 5 high quality mismatches to the known ½ segments was excluded from further analysis. After ½ segment identification, VH segments were mapped. The reverse read was used for this purpose. First, the VH primer was mapped and excluded. Thereafter, the next 70 bases of the reverse read were mapped to the known VH segments. Reads that did not map to ½ and VH segments were excluded. The next step in mapping involved identifying the frame that related the forward and reverse reads and this allowed a continuous sequence from J_H to VH to be constructed. This was done using the last 15 bases of the forward read which were reliably within the VH segment regardless of NDN length. While these bases could be of relatively lower sequence quality as they were at the terminal end of a long read, they could be used to map within a single identified VH segment in order to identify the position at which the two reads could be joined. Finally, the known VH and ½ sequences to which the reads map were used to identify the point in the forward read at which the sequences at the junctions diverged from these mapped segments. To generate a clonotype, at least two identical sequences needed to be identified. Given sequencing and PCR errors, many different but highly related clonotypes might originate from one clonotype. Therefore coalescence of highly related clonotypes was allowed. For example two sequences with one base difference but present at vastly different frequencies were consistent with sequencing or PCR error. On the other hand two sequences with two base differences and present at similar magnitudes were not likely to arise from sequencing error. The number of molecules associated with each clonotype was estimated based the frequency of spikes added in known quantities. Clonotypes with less than one molecule were discarded. The frequency of all the clonotypes in each sample was determined by calculating the number of sequencing reads for each clonotype and dividing by the total number of passed sequencing reads in the sample. Individual clonotypes with at least at 5% frequency were designated index clonotypes.

[0078] Leukemic index clonotypes identified in ALL diagnostic samples. A frequency threshold of 5% was set to designate a clonotype as an "index" leukemic clone; that is, a clonotype correlated with the leukemia. Using this threshold, 86 leukemic index clonotypes were identified in the diagnostic bone marrow samples (Table 2). 16 patients had one index clonotype, 16 patients had 2 index clonotypes, and 11 had greater than two index clonotypes (Table 2). For patients with one or more index clonotypes, a significant majority of the IgH reads were generated by the index clonotypes (mean 87%) (Table 2).

[0079] Extent of NDN sharing required for identification of evolved clonotypes. Visual comparison of index and non-index clonotype sequences within individual patients revealed that many clonotypes shared the same JH segments and a portion of the NDN region adjacent to the JH segment, but differed in their VH segment and the NDN region immediately adjacent to the VH segment. Fig. 1 A schematically illustrates how clonotype coding segments (100) of an index clone (106) relate to several evolved clonotypes in patient 23. Index clonotype (106) and evolved clonotypes (clone 1 (101), clone 2 (102), clone 3 (103), clone 4 (104) and clone 5 (105)) share nucleotides (shown in capital letters) of JH (110) and a large portion of the NiDN₂ regions (112, 114 and 116, respectively) but differ in their VH segments (118) (only partially shown as lower case letters). Within each ALL sample, index clones sharing the same JH segment were compared to other clones in its clonotype profile and analyzed with respect to the number of consecutive NDN bases shared in the JH-to-VH direction (as exemplified by the clonotypes shown in Fig. 1 A). In addition to the expected exponential decline in sharing of sequential NDN nucleotides, there were a large number of clones that shared over 15 bases (Fig. IB). Based on these observations, the "6-base" algorithm described above was developed to identify evolved clones based on shared NDN bases. Because D segment lengths vary, yet bases in each D segment are not independent of each other (i.e. they are not random sequence regions), identical D segments are represented as two effective NDN bases. This modification maintained separation between the level of sharing observed in the ALL and CLL samples. Very few CLL clones (0.03%) with the same J segment as the index clone shared more than 6 effective NDN bases with the index clone, while 37% of ALL clones with the same J segment shared 6 or more effective NDN bases with an index clone, which suggests that a threshold of 6 shared effective NDN bases can be used to define evolved clonotypes (equivalent to p<10^~4 with a geometric distribution).

[0080] Evolution criteria. Potentially related clonotypes for further analysis were identified using three criteria: (1) Identical JH segment sequence to index clonotype, (2) greater than 1 molecule and (3) different VH allele from the index clonotype. The potentially related clonotypes were then analyzed for the extent of NDN sharing as described above. The NDN sequence was determined by identifying the location where the consensus sequence does not match the VH and JH segment sequences. In the case of index clones, the JunctionAnalysis tool from IMGT (38) was used to increase accuracy and identify which bases belong to the D segment. The location of the VH allele was obtained from the Ensembl database.

[0081] Evolved clonotypes identified in ALL diagnostic samples. With the 6-base algorithm, almost 14,000 evolved clonotypes were identified in the diagnostic ALL bone marrow samples (Table 2). The number of evolved clonotypes per ALL patient varied widely from 0 to 4,024 clonotypes, with 37 of 43 patients having evolved clonotypes (Table 2). Forty-two percent of clonotypes with a frequency above 0.1 % were comprised of clonotypes evolved from the ancestral ALL clone.

[0082] Validation of evolved clonotype selection criteria. When the clonal evolution selection criteria (using the 6-base algorithm) were applied to the ALL patient samples, the vast majority of samples (37 of 43 patients, 86%>) showed the presence of evolved clonotypes.

[0083] Variation in clonal evolution patterns at the patient level. The clonal evolution pattern in each patient was characterized. The percent of evolved clonotypes ranged dramatically from 0% to 86% across the ALL patients, with the majority of patients having evolved clonotypes (Table 2). The 43 ALL patients who had index clonotypes could be categorized into three distinct bins based on the percent of clonal evolution present in their diagnostic sample. Specifically, 6 patients had no evolution (0%), 23 patients had some evolution (0-10%) and 14 patients had a high degree of evolution (>10%>) (Table 2). This wide variation underscores the differences in clonal evolution between patients, and may serve as the basis for further exploration of the prognostic significance of such clonal evolution in ALL.

[0084] Striking differences in number of evolved clonotypes between independent index clonotypes in the same patients. The distribution of evolved clonotypes within samples that contained multiple index clonotypes was assessed. Twenty-seven ALL patients had multiple index clonotypes in their diagnostic bone marrow samples (Table 2). The definition of index clones is based on a frequency threshold and therefore there were several cases where index clones were related to each other by evolution. Similarly, as part of normal B cell development and in pre-B ALL, IgH can rearrange in one or both chromosomes potentially leading to more than one independent index clonotype (i.e., not related to each other by evolution). Altogether, there were 15 samples with more than one independent index clone.

[0085] Low-frequency evolved clonotypes that were identified in this example would be undetectable by routine methods due to the limited sensitivity of flow cytometry-based MRD quantification. Moreover, evolved clonotypes at relapse would be undetectable by standard allele-specific PCR techniques because primers are designed for the specific detection of high- frequency index clonotypes. This example demonstrates that a sequencing-based approach, which enables quantitative analysis of clonal evolution in diagnostic and follow-up ALL samples, provides improved MRD monitoring.

Table 1

Summary of patient characteristics

Number Percent

Age (years)

0-1 1 2

1-10 38 75

>10 12 24

Initial WBC Count

<50K 38 75

>50K 13 25

NCI Risk Group

Standard Risk 33 65

High Risk 15 29

Very High Risk 2 4

Infant Leukemia 1 2

Cytogenetics

TEL-AML 15* 29

Hyperdiploid w/o trisomy 4, 10, 17 10 20

Hyperdiploid w/ trisomy 4, 10, 17 7* 14

MLL-rearranged 1 2

Philadelphia Chromomsome 2 4

Other 10 20

Normal 6 12

Not Done 1 2

CNS Stage

1 38 75

2 12 24

3 1 2

End of Induction

MRD

<0.1% 36 71

>0.1% <1% 4 8

>1% 4 8

Not Done 7 14

Current Disease

Status

Relapse 4 8

Continuous Remission 47 92

^sample 8 had both TEL-AML and Hyperdiploid w/ trisomy 4, 10, 17 Table 2

Per patient summary of malignant clones in ALL samples and sample sorts

*NA indicates that a particular sort was not available for a patient.

Definitions

[0086] Unless otherwise specifically defined herein, terms and symbols of nucleic acid chemistry, biochemistry, genetics, and molecular biology used herein follow those of standard treatises and texts in the field, e.g. Kornberg and Baker, DNA Replication, Second Edition (W.H. Freeman, New York, 1992); Lehninger, Biochemistry, Second Edition (Worth Publishers, New York, 1975); Strachan and Read, Human Molecular Genetics, Second Edition (Wiley-Liss, New York, 1999); Abbas et al, Cellular and Molecular Immunology, 6^th edition (Saunders, 2007).

[0087] "Aligning" means a method of comparing a test sequence, such as a sequence read, to one or more reference sequences to determine which reference sequence or which portion of a reference sequence is closest based on some sequence distance measure. An exemplary method of aligning nucleotide sequences is the Smith Waterman algorithm. Distance measures may include Hamming distance, Levenshtein distance, or the like. Distance measures may include a component related to the quality values of nucleotides of the sequences being compared.

[0088] "Amplicon" means the product of a polynucleotide amplification reaction; that is, a clonal population of polynucleotides, which may be single stranded or double stranded, which are replicated from one or more starting sequences. The one or more starting sequences may be one or more copies of the same sequence, or they may be a mixture of different sequences.

Preferably, amplicons are formed by the amplification of a single starting sequence. Amplicons may be produced by a variety of amplification reactions whose products comprise replicates of the one or more starting, or target, nucleic acids. In one aspect, amplification reactions producing amplicons are "template-driven" in that base pairing of reactants, either nucleotides or oligonucleotides, have complements in a template polynucleotide that are required for the creation of reaction products. In one aspect, template-driven reactions are primer extensions with a nucleic acid polymerase or oligonucleotide ligations with a nucleic acid ligase. Such reactions include, but are not limited to, polymerase chain reactions (PCRs), linear polymerase reactions, nucleic acid sequence-based amplification (NASBAs), rolling circle amplifications, and the like, disclosed in the following references that are incorporated herein by reference: Mullis et al, U.S. patents 4,683,195; 4,965,188; 4,683,202; 4,800,159 (PCR); Gelfand et al, U.S. patent 5,210,015 (real-time PCR with "taqman" probes); Wittwer et al, U.S. patent 6,174,670; Kacian et al, U.S. patent 5,399,491 ("NASBA"); Lizardi, U.S. patent 5,854,033; Aono et al, Japanese patent publ. JP 4-262799 (rolling circle amplification); and the like. In one aspect, amplicons of the invention are produced by PCRs. An amplification reaction may be a "realtime" amplification if a detection chemistry is available that permits a reaction product to be measured as the amplification reaction progresses, e.g. "real-time PCR" described below, or "real-time NASBA" as described in Leone et al, Nucleic Acids Research, 26: 2150-2155 (1998), and like references. As used herein, the term "amplifying" means performing an amplification reaction. A "reaction mixture" means a solution containing all the necessary reactants for performing a reaction, which may include, but not be limited to, buffering agents to maintain pH at a selected level during a reaction, salts, co-factors, scavengers, and the like.

[0089] "Clonality" as used herein means a measure of the degree to which the distribution of clonotype abundances among clo no types of a repertoire is skewed to a single or a few

clonotypes. Roughly, clonality is an inverse measure of clonotype diversity. Many measures or statistics are available from ecology describing species-abundance relationships that may be used for clonality measures in accordance with the invention, e.g. Chapters 17 & 18, in Pielou, An Introduction to Mathematical Ecology, (Wiley-Interscience, 1969). In one aspect, a clonality measure used with the invention is a function of a clonotype profile (that is, the number of distinct clonotypes detected and their abundances), so that after a clonotype profile is measured, clonality may be computed from it to give a single number. One clonality measure is Simpson's measure, which is simply the probability that two randomly drawn clonotypes will be the same. Other clonality measures include information-based measures and Mcintosh's diversity index, disclosed in Pielou (cited above).

[0090] "Clonotype" means a recombined nucleotide sequence of a lymphocyte which encodes an immune receptor or a portion thereof. More particularly, clonotype means a recombined nucleotide sequence of a T cell or B cell which encodes a T cell receptor (TCR) or B cell receptor (BCR), or a portion thereof. In various embodiments, clonotypes may encode all or a portion of a VDJ rearrangement of IgH, a DJ rearrangement of IgH, a VJ rearrangement of IgK, a VJ rearrangement of IgL, a VDJ rearrangement of TCR β, a DJ rearrangement of TCR β, a VJ rearrangement of TCR a, a VJ rearrangement of TCR γ, a VDJ rearrangement of TCR δ, a VD rearrangement of TCR δ, a Kde-V rearrangement, or the like. As used herein, "VDJ" or equivalently "V(D)J" represent recombined sequences that have undergone P and/or N nucleotide additions or subtractions, e.g. Janeway et al, Immunobiology, Sixth Edition (Garland Science, New York, 2005). Thus, in a VDJ segment, the D portion is sometimes represented as "NDN" to reflect such additional processing. In some case, the nomenclature will further distinguish the N regions as Ni (between D and J) and N₂ (between D and V), so that a VDJ region may be equivalently represented as "VN₂DNi J". Clonotypes may also encode

translocation breakpoint regions involving immune receptor genes, such as Bell -IgH or Bcll- IgH. In one aspect, clonotypes have sequences that are sufficiently long to represent or reflect the diversity of the immune molecules that they are derived from; consequently, clonotypes may vary widely in length. In some embodiments, clonotypes have lengths in the range of from 25 to 400 nucleotides; in other embodiments, clonotypes have lengths in the range of from 25 to 200 nucleotides. Clonotypes associated with a disease are referred to herein interchangeably as "correlating clonotypes" or "index clonotypes".

[0091] "Clonotype profile" means a listing of distinct clonotypes and their relative abundances that are derived from a population of lymphocytes. Typically, the population of lymphocytes are obtained from a tissue sample. The term "clonotype profile" is related to, but more general than, the immunology concept of immune "repertoire" as described in references, such as the following: Arstila et al, Science, 286: 958-961 (1999); Yassai et al, Immunogenetics, 61 : 493- 502 (2009); Kedzierska et al, Mol. Immunol, 45(3): 607-618 (2008); and the like. The term "clonotype profile" includes a wide variety of lists and abundances of rearranged immune receptor-encoding nucleic acids, which may be derived from selected subsets of lymphocytes (e.g. tissue-infiltrating lymphocytes, immunophenotypic subsets, or the like), or which may encode portions of immune receptors that have reduced diversity as compared to full immune receptors. In some embodiments, clonotype profiles may comprise at least 10³ distinct clonotypes; in other embodiments, clonotype profiles may comprise at least 10⁴ distinct clonotypes; in other embodiments, clonotype profiles may comprise at least 10⁵ distinct clonotypes; in other embodiments, clonotype profiles may comprise at least 10⁶ distinct clonotypes. In such embodiments, such clonotype profiles may further comprise abundances or relative frequencies of each of the distinct clonotypes. In one aspect, a clonotype profile is a set of distinct recombined nucleotide sequences (with their abundances) that encode T cell receptors (TCRs) or B cell receptors (BCRs), or fragments thereof, respectively, in a population of lymphocytes of an individual, wherein the nucleotide sequences of the set have a one-to-one correspondence with distinct lymphocytes or their clonal subpopulations for substantially all of the lymphocytes of the population. In one aspect, nucleic acid segments defining clonotypes are selected so that their diversity (i.e. the number of distinct nucleic acid sequences in the set) is large enough so that substantially every T cell or B cell or clone thereof in an individual carries a unique nucleic acid sequence of such repertoire. That is, preferably each different clone of a sample has different clonotype. In other aspects of the invention, the population of lymphocytes corresponding to a repertoire may be circulating B cells, or may be circulating T cells, or may be subpopulations of either of the foregoing populations, including but not limited to, CD4+ T cells, or CD8+ T cells, or other subpopulations defined by cell surface markers, or the like. Such subpopulations may be acquired by taking samples from particular tissues, e.g. bone marrow, or lymph nodes, or the like, or by sorting or enriching cells from a sample (such as peripheral blood) based on one or more cell surface markers, size, morphology, or the like. In still other aspects, the population of lymphocytes corresponding to a repertoire may be derived from disease tissues, such as a tumor tissue, an infected tissue, or the like. In one embodiment, a clonotype profile comprising human TCR β chains or fragments thereof comprises a number of distinct nucleotide sequences in the range of from 0.1 x 10⁶to 1.8 x 10⁶, or in the range of from 0.5 x 10⁶to 1.5 x 10⁶, or in the range of from 0.8 x 10⁶ to 1.2 x 10⁶. In another embodiment, a clonotype profile comprising human IgH chains or fragments thereof comprises a number of distinct nucleotide sequences in the range of from 0.1 x 10⁶to 1.8 x 10⁶, or in the range of from 0.5 x 10⁶to 1.5 x 10⁶, or in the range of from 0.8 x 10⁶ to 1.2 x 10⁶. In a particular

embodiment, a clonotype profile of the invention comprises a set of nucleotide sequences encoding substantially all segments of the V(D)J region of an IgH chain. In one aspect, "substantially all" as used herein means every segment having a relative abundance of .001 percent or higher; or in another aspect, "substantially all" as used herein means every segment having a relative abundance of .0001 percent or higher. In another particular embodiment, a clonotype profile of the invention comprises a set of nucleotide sequences that encodes substantially all segments of the V(D)J region of a TCR β chain. In another embodiment, a clonotype profile of the invention comprises a set of nucleotide sequences having lengths in the range of from 25-200 nucleotides and including segments of the V, D, and J regions of a TCR β chain. In another embodiment, a clonotype profile of the invention comprises a set of nucleotide sequences having lengths in the range of from 25-200 nucleotides and including segments of the V, D, and J regions of an IgH chain. In another embodiment, a clonotype profile of the invention comprises a number of distinct nucleotide sequences that is substantially equivalent to the number of lymphocytes expressing a distinct IgH chain. In another embodiment, a clonotype profile of the invention comprises a number of distinct nucleotide sequences that is substantially equivalent to the number of lymphocytes expressing a distinct TCR β chain. In still another embodiment, "substantially equivalent" means that with ninety- nine percent probability a clonotype profile will include a nucleotide sequence encoding an IgH or TCR β or portion thereof carried or expressed by every lymphocyte of a population of an individual at a frequency of .001 percent or greater. In still another embodiment, "substantially equivalent" means that with ninety-nine percent probability a repertoire of nucleotide sequences will include a nucleotide sequence encoding an IgH or TCR β or portion thereof carried or expressed by every lymphocyte present at a frequency of .0001 percent or greater. In some embodiments, clonotype profiles are derived from samples comprising from 10⁵ to 10⁷ lymphocytes. Such numbers of lymphocytes may be obtained from peripheral blood samples of from 1-10 mL.

[0092] "Coalescing" means treating two candidate clonotypes with sequence differences as the same by determining that such differences are due to experimental or measurement error and not due to genuine biological differences. In one aspect, a sequence of a higher frequency candidate clonotype is compared to that of a lower frequency candidate clonotype and if predetermined criteria are satisfied then the number of lower frequency candidate clonotypes is added to that of the higher frequency candidate clonotype and the lower frequency candidate clonotype is thereafter disregarded. That is, the read counts associated with the lower frequency candidate clonotype are added to those of the higher frequency candidate clonotype.

[0093] "Complementarity determining regions" (CDRs) mean regions of an immunoglobulin (i.e., antibody) or T cell receptor where the molecule complements an antigen's conformation, thereby determining the molecule's specificity and contact with a specific antigen. T cell receptors and immunoglobulins each have three CDRs: CDR1 and CDR2 are found in the variable (V) domain, and CDR3 includes some of V, all of diverse (D) (heavy chains only) and joint (J), and some of the constant (C) domains.

[0094] "Lymphoid neoplasm" means an abnormal proliferation of lymphocytes that may be malignant or non-malignant. A lymphoid cancer is a malignant lymphoid neoplasm. Lymphoid neoplasms are the result of, or are associated with, lymphoproliferative disorders, including but not limited to, follicular lymphoma, chronic lymphocytic leukemia (CLL), acute lymphocytic leukemia (ALL), hairy cell leukemia, lymphomas, multiple myeloma, post-transplant lymphoproliferative disorder, mantle cell lymphoma (MCL), diffuse large B cell lymphoma (DLBCL), T cell lymphoma, or the like, e.g. Jaffe et al, Blood, 112: 4384-4399 (2008);

Swerdlow et al, WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues (e. 4^th) (IARC Press, 2008).

[0095] "Minimal residual disease" means remaining cancer cells after treatment. The term is most frequently used in connection with treatment of lymphomas and leukemias.

[0096] "Pecent homologous," "percent identical," or like terms used in reference to the comparison of a reference sequence and another sequence ("comparison sequence") mean that in an optimal alignment between the two sequences, the comparison sequence is identical to the reference sequence in a number of subunit positions equivalent to the indicated percentage, the subunits being nucleotides for polynucleotide comparisons or amino acids for polypeptide comparisons. As used herein, an "optimal alignment" of sequences being compared is one that maximizes matches between subunits and minimizes the number of gaps employed in constructing an alignment. Percent identities may be determined with commercially available implementations of algorithms, such as that described by Needleman and Wunsch, J. Mol. Biol, 48: 443-453 (1970)("GAP" program of Wisconsin Sequence Analysis Package, Genetics Computer Group, Madison, WI), or the like. Other software packages in the art for constructing alignments and calculating percentage identity or other measures of similarity include the "BestFit" program, based on the algorithm of Smith and Waterman, Advances in Applied Mathematics, 2: 482-489 (1981) (Wisconsin Sequence Analysis Package, Genetics Computer Group, Madison, WI). In other words, for example, to obtain a polynucleotide having a nucleotide sequence at least 95 percent identical to a reference nucleotide sequence, up to five percent of the nucleotides in the reference sequence may be deleted or substituted with another nucleotide, or a number of nucleotides up to five percent of the total number of nucleotides in the reference sequence may be inserted into the reference sequence.

[0097] "Polymerase chain reaction," or "PCR," means a reaction for the in vitro amplification of specific DNA sequences by the simultaneous primer extension of complementary strands of DNA. In other words, PCR is a reaction for making multiple copies or replicates of a target nucleic acid flanked by primer binding sites, such reaction comprising one or more repetitions of the following steps: (i) denaturing the target nucleic acid, (ii) annealing primers to the primer binding sites, and (iii) extending the primers by a nucleic acid polymerase in the presence of nucleoside triphosphates. Usually, the reaction is cycled through different temperatures optimized for each step in a thermal cycler instrument. Particular temperatures, durations at each step, and rates of change between steps depend on many factors well-known to those of ordinary skill in the art, e.g. exemplified by the references: McPherson et al, editors, PCR: A Practical Approach and PCR2: A Practical Approach (IRL Press, Oxford, 1991 and 1995, respectively). For example, in a conventional PCR using Taq DNA polymerase, a double stranded target nucleic acid may be denatured at a temperature >90°C, primers annealed at a temperature in the range 50-75°C, and primers extended at a temperature in the range 72-78°C. The term "PCR" encompasses derivative forms of the reaction, including but not limited to, RT-PCR, real-time PCR, nested PCR, quantitative PCR, multiplexed PCR, and the like. Reaction volumes range from a few hundred nanoliters, e.g. 200 nL, to a few hundred μί, e.g. 200 μΐ,. "Reverse transcription PCR," or "RT-PCR," means a PCR that is preceded by a reverse transcription reaction that converts a target RNA to a complementary single stranded DNA, which is then amplified, e.g. Tecott et al, U.S. patent 5,168,038, which patent is incorporated herein by reference. "Real-time PCR" means a PCR for which the amount of reaction product, i.e. amplicon, is monitored as the reaction proceeds. There are many forms of real-time PCR that differ mainly in the detection chemistries used for monitoring the reaction product, e.g. Gelfand et al, U.S. patent 5,210,015 ("taqman"); Wittwer et al, U.S. patents 6,174,670 and 6,569,627 (intercalating dyes); Tyagi et al, U.S. patent 5,925,517 (molecular beacons); which patents are incorporated herein by reference. Detection chemistries for real-time PCR are reviewed in Mackay et al, Nucleic Acids Research, 30: 1292-1305 (2002), which is also incorporated herein by reference. "Nested PCR" means a two-stage PCR wherein the amplicon of a first PCR becomes the sample for a second PCR using a new set of primers, at least one of which binds to an interior location of the first amplicon. As used herein, "initial primers" in reference to a nested amplification reaction mean the primers used to generate a first amplicon, and "secondary primers" mean the one or more primers used to generate a second, or nested, amplicon.

"Multiplexed PCR" means a PCR wherein multiple target sequences (or a single target sequence and one or more reference sequences) are simultaneously carried out in the same reaction mixture, e.g. Bernard et al, Anal. Biochem., 273: 221-228 (1999)(two-color real-time PCR). Usually, distinct sets of primers are employed for each sequence being amplified. Typically, the number of target sequences in a multiplex PCR is in the range of from 2 to 50, or from 2 to 40, or from 2 to 30. "Quantitative PCR" means a PCR designed to measure the abundance of one or more specific target sequences in a sample or specimen. Quantitative PCR includes both absolute quantitation and relative quantitation of such target sequences. Quantitative measurements are made using one or more reference sequences or internal standards that may be assayed separately or together with a target sequence. The reference sequence may be endogenous or exogenous to a sample or specimen, and in the latter case, may comprise one or more competitor templates. Typical endogenous reference sequences include segments of transcripts of the following genes: β-actin, GAPDH, p₂-microglobulin, ribosomal RNA, and the like. Techniques for quantitative PCR are well-known to those of ordinary skill in the art, as exemplified in the following references that are incorporated by reference: Freeman et al, Biotechniques, 26: 112-126 (1999); Becker-Andre et al, Nucleic Acids Research, 17: 9437-9447 (1989); Zimmerman et al, Biotechniques, 21 : 268-279 (1996); Diviacco et al, Gene, 122: 3013- 3020 (1992); Becker-Andre et al, Nucleic Acids Research, 17: 9437-9446 (1989); and the like.

[0098] "Polynucleotide" refers to a linear polymer of nucleotide monomers and may be DNA or RNA. Monomers making up polynucleotides are capable of specifically binding to a natural polynucleotide by way of a regular pattern of monomer-to-monomer interactions, such as Watson-Crick type of base pairing, base stacking, Hoogsteen or reverse Hoogsteen types of base pairing, or the like. Such monomers and their internucleosidic linkages may be naturally occurring or may be analogs thereof, e.g., naturally occurring or non-naturally occurring analogs. Non-naturally occurring analogs may include PNAs, phosphorothioate internucleosidic linkages, bases containing linking groups permitting the attachment of labels, such as fluorophores, or haptens, and the like. Polynucleotides may comprise the four natural nucleosides (e.g.

deoxyadenosine, deoxycytidine, deoxyguanosine, deoxythymidine for DNA or their ribose counterparts for RNA) linked by phosphodiester linkages. However, they may also comprise non-natural nucleotide analogs, e.g. including modified bases, sugars, or internucleosidic linkages. It is clear to those skilled in the art that where an enzyme has specific oligonucleotide or polynucleotide substrate requirements for activity (e.g. single stranded DNA, RNA/DNA duplex, or the like), then selection of an appropriate composition for the oligonucleotide or polynucleotide substrates is well within the knowledge of one of ordinary skill, especially with guidance from treatises such as Sambrook et al, MOLECULAR CLONING, 2nd ed. (Cold Spring Harbor Laboratory, New York, 1989), and like references. As used herein, the term "oligonucleotide" refers to smaller polynucleotides, for example, having 3-60 monomeric units, or in some embodiments having from 12 to 60 monomeric units. In various embodiments, a polynucleotide or oligonucleotides may be represented by a sequence of letters (upper or lower case), such as "ATGCCTG," and it will be understood that the nucleotides are in 5'→3' order from left to right and that "A" denotes deoxyadenosine, "C" denotes deoxycytidine, "G" denotes deoxyguanosine, and "T" denotes thymidine, "I" denotes deoxyinosine, "U" denotes uridine, unless otherwise indicated or obvious from context.

[0099] "Primer" means an oligonucleotide, either natural or synthetic that is capable, upon forming a duplex with a polynucleotide template, of acting as a point of initiation of nucleic acid synthesis and being extended from its 3' end along the template so that an extended duplex is formed. Extension of a primer is usually carried out with a nucleic acid polymerase, such as a DNA or RNA polymerase. The sequence of nucleotides added in the extension process is determined by the sequence of the template polynucleotide. Usually primers are extended by a DNA polymerase. Primers usually have a length in the range of from 14 to 40 nucleotides, or in the range of from 18 to 36 nucleotides. Primers are employed in a variety of nucleic

amplification reactions, for example, linear amplification reactions using a single primer, or polymerase chain reactions, employing two or more primers. Guidance for selecting the lengths and sequences of primers for particular applications is well known to those of ordinary skill in the art, as evidenced by the following references that are incorporated by reference:

Dieffenbach, editor, PCR Primer: A Laboratory Manual, 2^nd Edition (Cold Spring Harbor Press, New York, 2003). [00100] "Quality score" means a measure of the probability that a base assignment at a particular sequence location is correct. A variety methods are well known to those of ordinary skill for calculating quality scores for particular circumstances, such as, for bases called as a result of different sequencing chemistries, detection systems, base-calling algorithms, and so on. Generally, quality score values are monotonically related to probabilities of correct base calling. For example, a quality score, or Q, of 10 may mean that there is a 90 percent chance that a base is called correctly, a Q of 20 may mean that there is a 99 percent chance that a base is called correctly, and so on. For some sequencing platforms, particularly those using sequencing-by- synthesis chemistries, average quality scores decrease as a function of sequence read length, so that quality scores at the beginning of a sequence read are higher than those at the end of a sequence read, such declines being due to phenomena such as incomplete extensions, carry forward extensions, loss of template, loss of polymerase, capping failures, deprotection failures, and the like.

[00101] "Sequence read" means a sequence of nucleotides determined from a sequence or stream of data generated by a sequencing technique, which determination is made, for example, by means of base-calling software associated with the technique, e.g. base-calling software from a commercial provider of a DNA sequencing platform. A sequence read usually includes quality scores for each nucleotide in the sequence. Typically, sequence reads are made by extending a primer along a template nucleic acid, e.g. with a DNA polymerase or a DNA ligase. Data is generated by recording signals, such as optical, chemical (e.g. pH change), or electrical signals, associated with such extension. Such initial data is converted into a sequence read.

Claims

What is claimed is:

1. A method of monitoring minimal residual disease of a B cell acute lymphoblastic leukemia patient by one or more patient-specific clonotypes correlated with the B cell acute lymphoblastic leukemia, the method comprising the steps of:

(a) obtaining from the patient a sample comprising B-cells;

(b) amplifying molecules of nucleic acid from the B-cells of the sample, the molecules of nucleic acid comprising or derived from recombined DNA sequences from immunoglobulin genes;

(c) sequencing the amplified molecules of nucleic acid to form a clonotype profile; and

(d) determining from the clonotype profile a presence, absence and/or level of the one or more patient-specific clonotypes correlated with the B cell acute lymphoblastic leukemia and previously unrecorded clonotypes evolved therefrom by V_H substitution.

2. The method of claim 1 further including the step of repeating said steps (a) through (d) on a successive sample from said patient to monitor said B cell acute lymphoblastic leukemia.

3. The method of claim 1 wherein each said molecules of nucleic acid comprise at least a portion of a VDJ region.

4. The method of claim 1 wherein each of said clonotype profiles includes every clonotype present at a frequency of .001 percent or greater with a probability of ninety-nine percent.

5. The method of claim 1 wherein each of said clonotype profiles includes at least 10⁴ clonotypes.

6. The method of claim 1 wherein said sample is a sample of bone marrow or a sample of peripheral blood.

7. The method of claim 1 wherein said V_H substitution is a V_H replacement.

8. The method of claim 1 further including a step of modifying a treatment of said patient based on said presence, absence and/or level of said one or more patient-specific clonotypes and said previously unrecorded clonotypes evolved therefrom by V_H substitution.

9. The method of claim 8 wherein (a) said B cell acute lymphoblastic leukemia is a childhood acute lymphoblastic leukemia, (b) said level of said one or more patient-specific clonotypes and said previously unrecorded clonotypes evolved therefrom increases in a successive sample, and (c) said step of modifying includes administering an anti-ALL agent different from that administered in an induction therapy.

10. The method of claim 8 wherein (a) said B cell acute lymphoblastic leukemia is a childhood acute lymphoblastic leukemia, (b) said level of said one or more patient-specific clonotypes and said previously unrecorded clonotypes evolved therefrom increases in a successive sample, and (c) said step of modifying includes performing a bone marrow transplant on said patient.

11. The method of claim 1 wherein said step of determining includes a step of comparing each clonotype from said clonotype profile with each of said one or more patient-specific clonotypes and previously recorded clonotypes clonally evolved therefrom by V_H substitution.

12. The method of claim 11 wherein said step of comparing includes classifying a sample clonotype as evolved from a prior correlating clonotype based on identity of at least six nucleotides extending in a V_H direction from a J-NDN boundry.

13. The method of claim 11 wherein said step of comparing includes classifying a sample clonotype as evolved from a prior correlating clonotype based on likelihoods of occurrence of J segments, J deletions, NDN segments, V segments, and V deletions.

14. The method of claim 13 wherein said step of comparing is further based on likelihoods of occurrence in B cell acute lymphoblastic leukemia of D segments, positions of D segments in NDN segments, J-side deletions of D segments, and V-side deletions of D segments.

15. The method of claim 14 wherein said step of comparing relates said likelihoods to a classification of a sample clonotype using a na^'ive Bayesian classifier model.