NZ795437A - Epigenetic markers and related methods and means for the detection and management of ovarian cancer - Google Patents
Epigenetic markers and related methods and means for the detection and management of ovarian cancerInfo
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- NZ795437A NZ795437A NZ795437A NZ79543717A NZ795437A NZ 795437 A NZ795437 A NZ 795437A NZ 795437 A NZ795437 A NZ 795437A NZ 79543717 A NZ79543717 A NZ 79543717A NZ 795437 A NZ795437 A NZ 795437A
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- methylation
- cst
- methylated
- ovarian cancer
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Abstract
The present invention relates to methods of determining the presence or absence of an ovarian cancer in a woman, as well as to related methods to determine the response to therapy against ovarian cancer in a woman. Such methods are based on the detection – from cell-free DNA of said woman – of one or more methylated (or un-methylated) CpGs being associated with differentially methylated regions (DMRs) of the present invention; such as methylation (or un-methylation) at one or more or all of certain CpGs being associated with such DMRs. Accordingly, such methods have diagnostic, prognostic and/or predictive utility for detecting or managing ovarian cancer in women. The present invention further relates to nucleic acids comprising certain sequences that may be detected during the method, or nucleic acids (such as probes and/or primers) that are useful to detect such sequences, as wells as compositions, kits, computer program products and other aspects that are useful for or related to the practice or application of such methods. or more methylated (or un-methylated) CpGs being associated with differentially methylated regions (DMRs) of the present invention; such as methylation (or un-methylation) at one or more or all of certain CpGs being associated with such DMRs. Accordingly, such methods have diagnostic, prognostic and/or predictive utility for detecting or managing ovarian cancer in women. The present invention further relates to nucleic acids comprising certain sequences that may be detected during the method, or nucleic acids (such as probes and/or primers) that are useful to detect such sequences, as wells as compositions, kits, computer program products and other aspects that are useful for or related to the practice or application of such methods.
Description
The present invention relates to methods of determining the ce or absence of an ovarian
cancer in a woman, as well as to related methods to determine the se to therapy against
ovarian cancer in a woman. Such methods are based on the detection – from ree DNA of said
woman – of one or more methylated (or un-methylated) CpGs being associated with entially
methylated regions (DMRs) of the present invention; such as methylation (or un-methylation) at
one or more or all of n CpGs being associated with such DMRs. Accordingly, such methods
have diagnostic, prognostic and/or predictive utility for detecting or managing ovarian cancer in
women. The present ion further relates to nucleic acids comprising certain sequences that
may be detected during the method, or nucleic acids (such as probes and/or primers) that are
useful to detect such sequences, as wells as compositions, kits, computer program products and
other aspects that are useful for or related to the practice or application of such methods.
NZ 795437
ETIC MARKERS AND D METHODS AND MEANS FOR THE DETECTION AND MANAGEMENT
OF N CANCER
DESCRIPTION
The present invention relates to methods of determining the presence or absence of an ovarian cancer in a
woman, as well as to related methods to determine the se to therapy against ovarian cancer in a woman.
Such methods are based on the detection — from cell-free DNA of said woman — of one or more ated (or un-
methylated) Cst being associated with differentially methylated regions (DMRs) of the present invention; such as
ation (or hylation) at one or more or all of certain Cst being associated with such DMRs. Accordingly,
such methods have diagnostic, prognostic and/or predictive y for detecting or managing ovarian cancer in
women. The present invention further relates to nucleic acids comprising certain sequences that may be detected
during the method, or nucleic acids (such as probes and/or primers) that are useful to detect such sequences, as
wells as compositions, kits, computer program ts and other aspects that are useful for or related to the
practice or application of such methods.
Three quarters of ovarian cancers are diagnosed once the tumour has spread into the abdomen and long-
term survival rates of these women are low (10-30%) (Ref. 1). High-grade serous (HGS) ovarian cancer (OC)
accounts for 70—80% of OC deaths and the survival s have not changed significantly over the past few decades
(Ref. 2). Early diagnosis and personalised treatment still remain the t unmet needs in combating this
devastating disease (Ref. 2).
A number of ovarian cancer biomarkers have been studied in the past. Amongst those, CA125, which was
discovered more than 30 years ago (Ref. 3), is still the ‘gold standard’ despite the relatively low sensitivity for early
epithelial ovarian cancer and the modest positive tive value (Ref. 4). The 35 most promising ovarian cancer
biomarkers were evaluated in samples taken up to 6 months prior to OC diagnosis from 118 women and 951 age-
matched controls from the Prostate, Lung, ctal, and n (PLCO) Cancer Screening Trial. At a fixed
specificity of 95%, CA125 had the best sensitivity (Ref. 5). The performance of CA125 dropped dramatically when
samples taken > 6 months prior to diagnosis were evaluated (Ref. 5). Recently it was trated that the
performance of the Risk of Ovarian Cancer Algorithm (ROCA) demonstrates superior performance characteristics
during screening, but this requires serial blood samples that are not available in patients presenting clinically (Refs. 6,
7). In addition, the dynamics of CA125 in women undergoing neoadjuvant chemotherapy (NACT) are of limited use
in predicting disease response and outcome (Ref. 8).
The vast majority of protein-based tumour markers are produced not only by cancerous but also non-
neoplastic normal cells; CA125 is produced by mesothelial cells (i.e. peritoneum and pleura) and hence benign or
inflammatory ses can result in aberrant ions of serum CA125.
[5] Recently, markers based on DNA shed from tumour cells, have shown great promise in monitoring
treatment response and ting prognosis (Refs. 9-13). But efforts to characterise the cancer genome have shown
that only a few genes are frequently mutated in most s with the gene mutation site differing across individuals
for similar tumours. Hence, the detection of somatic mutations is limited to patients that harbour a predefined set of
mutations. The necessity of prior knowledge regarding specific genomic composition of tumour tissues is one of the
40 limiting factors when using these ‘liquid ’ approaches for early detection or differential diagnosis of a pelvic
mass. Current technology allows for the detection of a mutant allele fraction of 0.1% (which is one mutant molecule
in a background of 1000 wild-type molecules) (Refs. 9, 14).
The development of cell-free DNA based early cancer detection tests poses two major challenges: (1) a very
low abundance of cancer-DNA in the blood and (2) an extremely high level of “background DNA" (shed from white
blood cells (Ref. 15)) in all population based cohorts which allow for the validation of potential screening markers
years in advance of current sis.
Alteration of DNA methylation (DNAme) is (i) an early event in cancer development, (ii) more ntly
observed than somatic mutations and (iii) centred around specific regions, i.e. CpG islands (Ref. 17). Together with
its chemical and biological ity, the detection of aberrant DNA methylation patterns in serum or plasma provide a
novel strategy for cancer diagnosis as evidenced by several proof of principle studies in the past (Refs. 9, 10, 13, 15,
18-20). The fact that technologies to detect DNA methylation allow for the detection of specific methylation patterns
(for example, full methylation or un-methylation) of all of (for example, between 7 and 16) certain linked Cst in a
region of 0 base-pairs as opposed to single point mutations (e.g. in the TP53 gene) is likely to improve both
the performance characteristics of the test and the detection limit of the assay. Plasma SEPT9 methylation analyses —
currently the only cell-free DNA which is available for cancer screening in the clinical setting — demonstrates a
specificity of 79% and a sensitivity of 68% for detection of colon cancers (Ref. 21). Maternal plasma cell-free DNA
testing for foetal trisomy has already become al ce as it has a higher sensitivity and a lower false positive
rate compared to imaging-based techniques (Ref. 22).
[8] The inventors have ed two different epigenome-wide approaches to identify the most ing
DNAme-based markers, developed serum tests and validated their performance benchmarking against serum ovarian
cancer marker CA125.
It has been ted that DNA methylation s have promise (and challenges) for early detection of
s cancers such as ovarian cancer (Ref. 20). Indeed, there are a number of publications that disclose various
epigenetic biomarkers and their association with various cancers, including women’s cancers such as ovarian cancer,
and the use of such biomarkers (including in certain combinations) for the detection and/or management of one or
more of such cancers: W02002/018631A2; /018632A2; W02007/019670A1; EP1862555A1;
W02009/153667A2; W02012/104642A1; W02012/138609A2; W02012/143481A2; U52013/0041047A1;
W02013/09661A1). In particular, single-CpG-resolution methylation analysis (including patterns/signatures) in certain
specific markers or genes (such as DNA hypermethylation of the CpG sites on the A, GRM6, ZNF540, ZFP42,
EOMES HOXA9, POU4F2, TWIST1, VIM, , RIMS4, PCDHAC1, Z, ASCL2, KCNQ1, C2CD4D, PRAC,
WNT3A, TRH, FAM78A, , SLC13A5, NKX6-2, GP5 and HOTAIR genes) has identified cancers, or aggressive
types thereof, such as renal cell carcinomas (Arai et al, 2012; Carcinogenesis 33:1487), bladder cancer (Reinert et al,
2012; PLos ONE 10:e46297), other cancers including breast cancer (Refs. 30, 31. re et al, 2015; Clinical
Epigenomics , ovarian cancer (Teschendorff et al, 2009; PLos ONE 4: e8274) and/or association with
chemotherapeutic response in ovarian cancer (Ref. 25).
Hence, there is still a need, from one or more of the above or perspectives, for improved methods to
determine the presence or absence of ovarian cancer in a woman, ably in a non-invasive ; such as by
the use of ree DNA of said woman (eg isolated from a sample of a circulatory fluid). Preferably, such methods
will have ed ability to discriminate ovarian cancer from benign pelvic mass, and/or high-grade serious (HGS)
ovarian cancer from less severe or aggressive forms of ovarian cancer; such as by having improved specificity and/or
sensitivity for the phenotype/disease to be detected. Such methods would provide a significant shift in the clinical
paradigm for early-detection, diagnosis (eg by an in-vitro method) and/or management of ovarian cancer; in
particular of HGS ovarian cancer and or chemotherapy-responsive ovarian cancer; and in particular providing the
40 potential for dualisation of treatment for women suffering from ovarian cancer.
ingly, it is an object of the present invention to provide alternative, improved, simpler; cheaper and/or
integrated methods, means, compounds, compositions, kits and other aspects that address one or more of these or
other problems (such as those set forth elsewhere herein). Such an object underlying the present invention is solved
by the subject matter as disclosed or defined anywhere , for example by the subject matter of itemised
embodiments or the claimed embodiments.
Generally, and by way of brief description, the main aspects of the present invention can be bed as
follows:
In a first aspect, and as may be further described, defined, d or othenNise disclosed herein, the
ion relates to a method of determining the presence or absence of, or response to therapy against, an
ovarian cancer in a woman, said method comprising the steps:
0 Providing a biological sample from said woman, said sample comprising cell-free DNA of said woman; fl
0 Determining, in at least one molecule of said cell-free DNA, the methylation status at one or more Cst located
within one or more of the nucleotide ces comprised in one or more of the respective DMRs of the
present invention independently selected from the group consisting of DMR#: #141, #204, #228, #144, #123,
#129, #137, #148, #150, #154, #158, #164, #176, #178, #180, #186, #188, #190, #192, #200, #202,
#208,#210, #213, #214, #219, #222, #223, #224, #225 and #226, or a nucleotide sequence present within
about 2,000bp (such as within about 200bp) 5’ or 3’ thereof, or an a||e|ic variant and/or complementary
sequence of any of said nucleotide sequences,
m, the presence in at least one of said cell-free DNA molecules of one or more: (i) ated Cst associated
with one or more of the hyper-methylated DMRs of the present invention; and/or (ii) un-methylated Cst associated
with one or more of the hypo-methylated DMRs of the present invention, indicates the presence of, or a reduced
response to therapy against, an ovarian cancer in said woman.
[14] In a second aspect, and as may be further described, defined, claimed or othenNise disclosed herein, the
invention relates to a chemotherapeutic agent, such as one selected from the group consisting of: carboplatin,
paclitaxel, docetaxel, cisplatin, liposomal doxorubicin, gemcitabine, tedin, etoposide, hosphamide, an
angiogenesis inhibitor (such as bevacizumab) and a PARP inhibitor (such as olaparib), for use in a method of therapy
of ovarian cancer in a woman, wherein said chemotherapeutic agent is administered to a woman within about 3
months of said woman having been predicted and/or determined, using a method of the first aspect, to n_ot respond
to a therapy against ovarian cancer.
In a third aspect, and as may be further described, defined, d or otherwise disclosed herein, the
invention s to a c acid comprising a nucleic acid ce consisting of at least about 10 contiguous
bases (preferably at least about 15 contiguous bases for any DMR other than DMR #222) comprised in a sequence
producible by bisulphite conversion of a sequence comprised within a DMR selected from the group consisting of
DMR#: #141, #204, #228, #144, #123, #129, #137, #148, #150, #154, #158, #164, #176, #178, #180, #186,
#188, #190, #192, #200, #202, #208,#210, #213, #214, #219, #222, #223, #224, #225 and #226, or an c
variant and/or complementary ce of any of said nucleotide sequences.
In other aspects, the invention also relates to a nucleic acid probe, a nucleic acid PCR primer pair, a
tion of nucleic acids of the invention, a kit and a computer m product, in each case as may be
described, defined, claimed or otherwise disclosed herein, and in each case related to use within or in connection
with a method of the ion and/or to detect one or more a nucleic acid of the invention.
The figures show:
40 [18] FIGURE 1 depicts the study design. Using two different epigenome-wide technologies, 711 human tissue
samples have been analysed to fy a total of 31 regions whose ation status has been analysed in two sets
consisting of 151 serum samples. Three markers have been validated in two ndent settings: (1) Serum Set 3
which consisted of 250 serum samples from women with various benign and malignant conditions of the female
genital tract; and (2) NACT (NeoAdjuvant ChemoTherapy) Set consisting of serial samples from women with
advanced stage ovarian cancer before and during chemotherapy. Samples obtainable from the UKCTOCS (United
Kingdom Collaborative Trial of Ovarian Cancer Screening) sample collection may be included in a third tion set
to include serum samples from those women in the l arm who developed n cancer within 2 years; for
each case, a number of (such as three) control women who did not develop ovarian cancer within 5 years of sample
donation can been matched to those women who did so develop ovarian cancer.
FIGURE 2 depicts the principles of methylation pattern discovery in tissue and analyses in serum. Reduced
Representation Bisulfite Sequencing (RRBS) was used in tissue s in order to fy those CpG regions for
which methylation patterns discriminate ovarian cancer from other s, in ular blood cells which were
deemed to be the most abundant source of cell-free DNA. An example of region #141 is provided which is a 136
base-pair long region ning 7 linked Cst. A cancer pattern may consist of reads in which all linked Cst are
methylated, indicated by “1111111” (Panel A). The tissue RRBS data have been processed h a bioinformatic
pipeline in order to identify the most promising markers (Panel B). The principles of the serum DNA methylation
assay are trated in Panel C.
FIGURE 3 depicts serum DNA methylation analysis in women with benign and malignant conditions of the
female genital tract. Pattern frequencies for the different regions and CA125 levels analysed in Serum Set 3 samples
are shown and horizontal bars denote the mean (Panels A-C; ns not significant; *p<0.05, **p<0.01, ***p<0.001;
Mann-Whitney U test compared to HGS; H, Healthy; BPM, benign pelvic mass; BOT, borderline s; NET, non-
epithelial tumours; OCM other cancerous malignancies; NHGS, non-high grade serous n cancers; HGS, high
grade serous; OC ovarian cancers). Based on Set 1&2 analyses cut-off thresholds of 0.0008, 0.0001 and 0.0001 for
regions #141, #204 and #228, respectively, to discriminate HGS OC from H or BPM women were chosen and
validated in Set 3; combining Sets 1-3 the cut-off thresholds have been refined for s #204 and #228 so that
the final cut-offs were 0.0008, 0.00003 and 0.00001, respectively; the sample was called positive if at least one of
the three regions showed a pattern frequency above the cut-off; sensitivities and icities to discriminate HGS
from H&BPM are shown in Panel E. The overlap between CA125 positive s (cut-off >351U/mL) and the three
DNA methylation (DNAme) marker panel in cases and controls is shown in Panel F.
FIGURE 4 depicts the dynamics of serum DNA methylation markers and CA125 as a function of exposure to
carboplatin-based chemotherapy. The changes in pattern frequency of the three s as well as CA125 is shown
before compared to after 2 cycles of chemotherapy (Panels A-D). The changes of markers during chemotherapy and
whether this can predict response (as described in Supplementary Information) to chemotherapy in all patients and
in those who had no macroscopic residual disease after interval-debulking surgery (R0/1) is shown (Panel E).
Definitions of CA125 and DNA methylation positivity are provided in FIGURE 3.
FIGURE 5 depicts the thm which first determines sets of consecutive CpG sites of maximum size, from
which multiple potentially overlapping subsets are derived, which still meet the selection criteria.
FIGURE 6 depicts cancer-specific differentially methylated region (DMR) discovery with Illumina 450K
methylation arrays. (A) Schematic illustration of DMRs that are discovered by the single CpG and range approaches.
Each horizontal line of lollipops indicates neighbouring Cst in a single DNA molecule ted from the indicated
tissue. Filled lollipop indicates a methylated CpG, and an ed lollipop indicates an unmethylated CpG. 450K
methylation arrays measure the ratio (% of methylation) of methylated and unmethylated molecules at a given single
CpG location. See Supplementary Information for s on the DMR discovery s. row” ('1‘) Single CpG
40 DMRs (high scoring); “left/right—arrow" ((--)) Range of DMR (high scoring); asterisk (*) Not fied as DMRs
because of the methylation in WBCs, “hash” (#) Not fied as high scoring DMRs with single CpG approach
because the methylation difference between OC and other control tissues (=colon, lung, liver, rectum, endometrium,
fimbriae and benign ovarian tissue) is not large enough. Identified as DMRs with range approach because the pooling
of neighbouring CpG information increases statistical robustness. (B) Example of the methylation data for a high
scoring DMR. The #228 targeted BS reaction was designed for this DMR.
FIGURE 7 depicts a ure for the ion of cell-free DNA from a plasma or serum biological sample.
FIGURE 8 s pattern frequencies for the different s analysed in Serum Set 1 samples. H, Healthy;
BPM, benign pelvic mass; NHGS, non-high grade serous ovarian cancers; HGS, high grade serous ovarian cancers.
Horizontal bar denotes mean. ns not significant; *p<0.05, Mann-Whitney U test compared to HGS.
FIGURE 9 depicts pattern frequencies for the ent regions analysed in Serum Set 2 samples. H, Healthy;
BPM, benign pelvic mass; BOT, borderline tumour; NET, non-epithelial tumours; OCM, other cancerous malignancies;
NHGS, non-high grade serous ovarian cancers; HGS, high grade serous ovarian cancers. Horizontal bar denotes
mean. ns not significant; * p<0.05; ** p<0.01; *** p<0.001, Mann-Whitney U test compared to HGS.
[27] FIGURE 10 s coverage (number of reads) for the three different regions ed in Serum Set 3
samples. H, Healthy; BPM, benign pelvic mass; BOT, borderline tumour; NET, non-epithelial s; OCM, other
cancerous malignancies; NHGS, non-high grade serous ovarian cancers; HGS, high grade serous ovarian cancers.
Horizontal bar denotes mean. ns not significant; * ; Mann-Whitney U test compared to HGS.
FIGURE 11 depicts CA125 levels measured in the NACT (the neoadjuvant chemotherapy) Serum Set
samples. Samples taken before chemotherapy, after the first cycle of chemotherapy, and after the second cycle of
chemotherapy. ns not significant; ** p<0.01; hitney U test compared to before chemotherapy.
FIGURE 12 depicts pattern frequencies for the top 3 reactions measured in NACT Serum Set samples.
Samples taken before chemotherapy, after the first cycle of herapy, and after the second cycle of
herapy. * ; ** p<0.01; ** p<0.01; Mann-Whitney U test compared to before chemotherapy.
[30] FIGURE 13 depicts coverage (number of reads) for the top 3 reactions measured in NACT Serum Set
samples. Samples taken before chemotherapy, after the first cycle of chemotherapy, and after the second cycle of
chemotherapy. ns not cant; Mann-Whitney U test compared to before chemotherapy.
The present invention, and particular non-limiting aspects and/or embodiments thereof, can be described in
more detail as follows:
In a first aspect, the invention relates to a method of determining the presence or absence of, or
response to therapy against, an ovarian cancer in a woman, said method comprising the steps:
0 ing a biological sample from said woman, said sample comprising cell-free DNA of said woman; fl
0 Determining, in at least one molecule of said cell-free DNA, the methylation status at one or more Cst d
within one or more of the nucleotide sequences independently selected from the group consisting of: SEQ ID
NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30
and 31 (for example, within one or more of the nucleotide sequences sed in one or more of the
respective DMRs of the present invention independently selected from the group consisting of DMR#: #141,
#204, #228, #144, #123, #129, #137, #148, #150, #154, #158, #164, #176, #178, #180, #186, #188,
#190, #192, #200, #202, #208,#210, #213, #214, #219, #222, #223, #224, #225 and #226), or a
nucleotide sequence present within about 2,000bp (such as within about 200bp) 5’ or 3’ thereof, or an c
variant and/or complementary ce of any of said nucleotide sequences,
m, the presence in at least one of said cell-free DNA molecules of one or more: (i) methylated Cst associated
with (such as located ) one or more of the hyper-methylated DMRs of the present invention (eg, as identified in
40 TABLE 1A), for example associated with (such as located within) one or more of said nucleotide sequences
independently selected from: SEQ ID NOs: 1, 2, 3, 4, 10, 12, 14, 15, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29 and
; and/or (ii) un-methylated Cst associated with (such as located within) one or more of the hypo-methylated
DMRs of the present invention (eg, as identified in TABLE 1B), for example associated with (such as located within)
one or more of said nucleotide sequences independently selected from: SEQ ID NOs: 5, 6, 7, 8, 9, 11, 13, 16, 17, 22
and 31, indicates the presence of, or a d response to therapy against, an ovarian cancer in said woman.
The genomic sequence and genome coordinates (hg19) of one class of the regions of the genome used in
the present ion as a source of epigenetic s, ie those where the presence of methylation at one or more
Cst therein (or associated therewith, such as within about 2,000bp - such as within about 200bp - 5’ or 3’ thereof),
and represent the hyper-methylated cancer-specific differentially methylated regions (DMRs) of the present
ion, are set out in TABLE 1A. Any of such Cst (including those of an allelic variant and/or mentary
sequence of any of the respective said nucleotide sequence/s) is one considered “associated with” the respective
hyper-methylated -specific DMR of the present invention.
TABLE 1A: Identity, source, genome-coordinates and genomic sequences of the hyper-methylated DMRs of the
present invention
AmP 9°Ii n . . 5 QE ID
Data Ampllcon genomlc sequence
DMR coordinates Class N0.
basis antC Gs are underlined)
(hg19) P
CATCCGGAGGCCCAGGGGTGAGGAC"TQCCAQGGAAGG
78004395- AGGCACAQATTCAGCCCATGACACCGCCACCTQGQTG
141 RRBS Hyper 1
178004530 GTGC"GTAGGGGGAAGCTCAGGCAC"CACQAGGACAGGA
CCCGGGGAA"CCGC"G
GATA"TCGG"GGAGAGCCGCAGC"GCC@CCGCGGGGCCC
chr1:151810784— CAGGCGCAGCACGC"CTCGCGCGr‘GGGCCGCAGCTGGCAG
204 RRBS Hyper 2
151810937 CACAGGAAGTCAGG"GGAAGAGQGCGGCGTGGGQGCC
gooGCGGCGCGGCGAGTGCGGGCTGG"A"CGGC
chr2'219736276- TGGGCGAGC"GCTGCAGr‘GCGGcr‘GCCAGGQCC
228 450K 219736386 CCGcGGGCGGGCCCC"CCCQGCCCTCCGGCCFECCQGC Hyper 3
AcccCQGACCCCCTGGCCCCGCGGGCTCC
CCTGACGTGGGTCCCCCAGGGQGQTGCCAAG
chr19:58220413- GCTTAGAQCTTTQF‘GCAGGAGGGACGAQAC"CCCCTC
144 RRBS Hyper 4
58220552 Aged“TgrcocCCCAACTQGQCTTGCTATTCTGA
"CCGG"GAACACACC"CAGA
"CCCCGGAG"CCGGAGCTCAGGCCAGr‘GGCAGr‘CGACCCA
chr17:70112132- GcccCQAGAC"ccc"CACGCQCTCCAAAACCAAAAQG
154 RRBS Hyper 10
70112268 ACACGAAGC"GGG"GAAGcgr‘AGCTr‘GCAGGAG
CCAGGGAGA"GCGC"CT
GAC"CGCGAGGWW“CCAGCAGC"CATTCGGGACGGCGG
chr4:174427917- "GTCTAGTCCAG"CCAGGGr‘AAC"GGGC"C"C"GAGAGTC
164 RRBS 12
174428054 CGACC,1CCA go CTGGGAGQAGTGG TQAGT,1 ,1 ,1 ,1 CAGA Hyper
"Gcr‘GGGAACCGr‘CGcr‘T
GGCAGGAGCGCCCCAC"A"GCGCAAGCCCG"GGCC"GGAG
chr19:13215409— AGCGC"GAAGG"GGGAGGGGGAAGAGGGGCAGAACCCCCG
178 RRBS Hyper 14
13215550 EGGAGQAGCGCACAGC"GCECCCCGTGGCQCW‘CGG
GAATCGCTGGU‘CCGGCTU‘GG
cTGCAGAAGCGCACTTTGC"GAACACCCCGAGGACG"GCC
chr3:192125846- TCTCGCACAGGGAGQCCCGTC""TGCTGGGGCTGGAGQ
180 RRBS Hyper 15
192125980 GQCTTGGAGGCQACACTQGr‘QCTGTTGGACTCCCTC
GCCTGCCGCTr‘CTGC
GTCAGACGAGAGCCTGGGGTCAAFGTQAGGTGGAGQAQ
chr9'79629064-
190 RRBS 79629172 QCTGGCAQGCAACCCTGAGCC"GCGCGGCC§G§CTA" Hyper 18
CCCCTGGCTCr‘CCGCTGCTGGcr‘GGACCC
CGGr‘AGGr‘CA"CCAGCAGCAGGGCTCCAQTQGTCTE"
chr12:75601294— EA"GCCCCAGAAGGCCAGCTCCchr‘QAAGAGQGCCg
192 RRBS Hyper 19
75601437 QCACAQ"CTGcGGGGCAGTGCAGCWGCQGTGQGflG
"AAr‘TGAGCACA"AGGCGAAGACG
38999180- AATCAGCCCAGCAACCGGCGACCCCAAGCGCGGQACCGC
200 RRBS 138989294 AAAGGGAGTGCT"GCCCATCCGCGT""GAAAGCAGAU‘TT Hyper 20
""C"@GCAGGAACACAGGAC"CACC"GCCAGTGG
202 RRBS chr1:2987508- Gr‘GCGAACAAGACCGGGCGTT"CGCCGCCGACGCGAAGGG Hyper 21
2987655 GC"G"C"G"GCGCGGCGTTGCGGGCCCTCCGCGCG"GGGG
TGTGCGTGTTCGGGTTQQGTTCTGTGTGTGCACQ
GCGGGCCTGC"CAGAG"CGGGACCACCG
"GCA"ACAGA""AC"G"AGGACCAT""CC"G"GCC""T"A
210 450K f?£§§f§i§}3499 AAAAATCCA“whoTEEN“TAAATACACAAAAACCAAAGAT Hyper 23
"T""ACAAC"CC
CCGC"CGGGAA"GGGAA"A"AGC"ACATA"GGGAAAACGC
chr2106776938-
213 450K 106277040 gG"GCAGGGAGAAAACCAA"TCAGTGAGGAG§§GAGG§§C Hyper 24
AGGAC"GTGGAGTGTGCATCCGG
chr3141516260- cTGC""AAAGGCGCAGAGGAGCAGCTGGGAAggAGAACAA
214 450K 141516353 AGgchCAGGcccccc"ggGAGGAAGGAAGGAGAGAGccc Hyper 25
CAGGAAACAGC"GA
GGAT AAG ,TGG WGGHGEHAAA A An AENGTGAGA ATGGGGATGGQGA
chr16:30484157-
219 450K GCTG c GGG CT T c ggG GGGAGGAGG Hyper 26
CAGGGGAAGGGACA"G"G"C"
dw3311809437- TAGGC"ACAGGAAGAGGCA""TCC"A"AGA"GA§§GC"G"
222 450K Hyper 27
111809506 AAAA"""TAAGC"GAG""CC"CCAGGAAG"
AA A A A“G G G G GGHHGT T" A"AA" A TA A A A TTT "AA
dw10fl20489250 “G G GHG GHGG G
223 450K 0 CACGGAAGTG TGCAA ACAACC CT GTACATCAG Hyper 28
-120489333 CAGT-—
GG"CCCCC"CCCCGAGCCA"GAAGAGCTGCCTG§§GCCAT
chr111874037-
224 450K 1874133 C""GGCCC"ggCACCngTC"CTG"CACCCCAGGCCCCTG Hyper 29
TAACT"GC"TAACGC"T
GAAGC""GACACTCC"GGCCCCAAACACTGCCTGGCTACA
chr7142422193-
225 450K '
ACACGA"A"CCAGGGACAGA"ACC"TCCATGTACAGCAAG Hyper 30
142422278 —
CTGTGG
The genomic sequence and genome coordinates (hg19) of the other class of the regions of the genome
used in the present invention as a source of epigenetic markers, ie those where the absence of methylation at one or
more Cst therein, (or ated therewith, such as within about 2,000bp - such as within about 200bp - 5’ or 3’
thereof), and represent the hypo-methylated cancer-specific DMRs of the present invention, are set out in TABLE 1B.
Any of such Cst (including those of an allelic variant and/or complementary sequence of the respective said
nucleotide ce/s) is one considered “associated with” the respective ethylated cancer-specific DMR of
the present invention.
TABLE 1B: Identity, source, genome-coordinates and genomic sequences of the hypo-methylated DMRs of the
present invention
AmPlicon . . SEQ ID
DMR Data . on c sequence
. coordlnates Class N0.
# basus (relevant Cst are underllned).
(h919)
1271152- GCGAAGCAGGAGTAGC"GCCGGGCCCCAQAGCCTCQTC
123 RRBS 12712'71 @Tr‘cr‘GGTTQGGT""CTCQAGTTTTGCTACCAGCQA Hypo 5
GGCTG"GQGGCAAC"GGGTCAGCC"CCCGTCAGGAGAGA
AAC"C"GC"GAG"GAGC"CACAAACAGGGCATAACCGAGA
chr11 _ 69054638-
129 RRBS CGCGGGAATGCC"GGGTCGCCGQCAGTCACCGGGCAGGG Hypo 6
69054'757
CCGCCCTCCCCTGTGGGTCAGCAAAAACGG"GTCAAGTGA
ACTCCGCCACACACACAGCTGTACCCGGCACAACACGCGG
chr12:132896275 CCACAGGTCACC"CAGGTQCCF‘QGGTGCTCCTCCCGCA
137 RRBS Hyp0 7
-132896404 GccCCAggTAGACAGAAGACA""CCTQQGGCCTGGGTGCC
CAGCCTCCCG
GAGGTAATGGAAGCGGCCATCCTTGTCCTCGCTCCGCGCC
2359599-
148 RRBS 72359718 TGGC"GAAGQATCGGGGTCGAACACGTTCACGTCTTTGA Hypo 8
ACAQGGCGCTG"G"CATGGGTGTCCGGATGCTATACAT
GCGGGCACCTGTAG"CCCAGCTACTCGGGAGGCTGAGGCG
150 RRBS chr7.156735029- _ _
_ Hyp0 9
GGAGAATGGCG"GAACCCGGGAGGCGGAGC"TGCAGCGAG
156735165 CQAGATCGCGCCACQCACTCCAGCCTGGGQACAGAGC
GAGAC’ICCG’IC'IAAAAA
GAcTc"GTC"CAAAAAAGAAAAAAAr1AGGGccGGGCGQG
chr16:74441696- r"GGCTAQCWG"CATCCAGCACFTTGGGAGGCQAGG
158 RRBS Hypo 11
74441831 EGG"GGA"CA§AGG"§GGAGAT@ATACCATCCTGGG
"AACACGGr‘GAAACCC
"AACCCAT"TCW“"A""AAA"TGCA'IGAAGAAGGCCGGGQ
chr6:119107203- GCGGr‘GGC"CACGCC"G"AA"CCCAGCACTTTGGGAGGCQ
176 RRBS Hyp0 13
119107340 gAGGgGGCGGATACGAGGTAGGAGATGAGACCACGG
"GAAACCCCGTC"C"AC"
CGTG"TAGCCAGGA"GG"C"CGACCTCC"GACCTCGTGAT
chr22:21483239- GCCTQGCCTCCCAAAGTGCFEGGAFTAAAGGQ
186 RRBS Hyp0 16
21483384 ’1GAGCCACCGCGCQGGCQAGACTC"G"CT"AAAAAAAA
AAGGCCr‘GGGCTGr‘GGCAcr‘TTGGGA
AGAGTFECACTccGAAGAC"CCAGATTQAGAGTTGCGG
chr19:18497131- AAACGU‘ACGAGGACCTGC"AACCAGGU‘GCGGGCCAACC
188 RRBS Hyp0 17
18497271 AGAGC"GGGAAGA"r1§AACAchccr1§chcGGcccc
TGCAGTCGGATACTACGCC
ATWGTCCGGGCACGGTGGCTAQCCTGTAA"
chr8:55467518- CCCAGCAC""r"GGGAGGCQAGGQGGQGATAQAGG"
208 RRBS Hyp0 22
55467638 CAGGAGAr1§AGAcCATCTGGCGAACA"GG"GAAACCTC
GGGGGGAC"G"CGr‘TAATTCACTGccr‘AATGACCGCGGCC
chr1
226 450K 3086542 CGCGCGC"CQAG’IM’IQGGTGATG’IA’IGTGGACTGTGC Hypo 31
ACACCTCG’IGG
In particular embodiments, the present invention may not include (or not e the use of) one or more of
the specific epigenetic s (eg the presence of absence of methylation at one or more Cst therein, that are
within (or associated therewith, such as within about p - such as within about 200bp - 5’ or 3’ of) one or more
of the DMRs set forth in TABLE 1A or TABLE 1B), for example, the present invention may not encompass one, two,
three, four, five, siX, seven, eight, nine, ten, or about 12, 15, 20, 25 28, 29, or 30 of the DMRs independently
selected from the group consisting of DMR#: #141, #204, #228, #144, #123, #129, #137, #148, #150, #154,
#158, #164, #176, #178, #180, #186, #188, #190, #192, #200, #202, #208,#210, #213, #214, #219, #222,
#223, #224, #225 and #226. In certain of such embodiments, the present invention may not encompass DMR #144
(SEQ ID NO. 4).
As set out herein, the epigenetic marker (eg the presence/absence of methylation at a CpG) may be within
the nucleotide sequence of a DMR of the present invention, or may be present within about 2,000bp (such as within
about 200bp) 5’ or 3’ of such DMR sequence; ie is upstream or downstream of the DMR sequence disclosed herein.
This is because (CpG) “islands” are present throughout the genome and the cancer-specific pattern of
ation/un-methylation described herein may equally be detectable elsewhere in such “island” such at one or
more Cst located within about 2,000bp (eg about 200bp) 5’ or 3’ of the DMR sequence disclosed herein. Following
the disclosure herein, the person of ordinary skill will readily recognise that tion of the human genome
sequence can identify other Cst potentially useful epigenomic s within any of such “islands” such as around
or ated with any of the DMRs of the t invention, and hence such other epigenomic markers (eg other
Cst within about 2,000bp - such as within about 200bp - 5’ or 3’ of such DMR sequence) are specifically envisioned
as being within the scope of the present invention. In certain embodiments, one or more of said Cst is located
within about 1,750, 1,500, 1,250, 1,000, 750, 500, 250, 200, 150, 125, 100, 75, 60, 50, 40, 30, 25, 20, 15, 10 or 5
base pairs 5’ of a DMR described herein; or within about 1,750, 1,500, 1,250, 1,000, 750, 500, 250, 200, 150, 125,
100, 75, 60, 50, 40, 30, 25, 20, 15, 10 or 5 base pairs 3’ of a DMR described herein.
[37] In r embodiment, the DMR of the present invention may be a t of the respective ce given
herein. For e, by the deletion, addition or substitution of one or more (such as 2, 3, 4, 5 or more than 5)
base pairs compared to the respective sequences. As will be understood by the person of ordinary skill, such variants
can exist in any tion of women, such as by being an allelic variant or a SNP.
As will also be appreciated by the person of ordinary skill, any of such ces may be represented by (or
analysed as) a complementary ce to any of the sequences set out herein.
As used herein, “determining” may be understood in the broadest sense as any recognition, including
detection, localisation, diagnosis, classifying, staging or quantification of n cancer. Determining may be
performed as set out herein. In the context of the present invention, determining is, preferably, performed in t
of the woman in-vitro, for example as an in vitro method of diagnosis. That is, the biological sample comprising cell-
free DNA is obtained from the woman, and the method of determining (or, eg diagnosis) is ted on such
sample that is isolated and ted from said woman. For example, the biological sample is processed in a
laboratory and/or in plastic or glass receptacles to analyses that the ree DNA of said woman by a method of the
present invention.
As will be appreciated, a method that determines the response to therapy against ovarian cancer in a
woman can be understood as a method of monitoring the increase (or reduction) of ovarian cancer in a woman
previously diagnosed (eg by other s or tests) with ovarian cancer; in particular providing a method of
monitoring - in an dual-specific manner — the s of (chemo)therapy administered to said woman in
reducing or othenNise treating the ovarian cancer, or other symptoms thereof.
It will be understood by the person of ordinary skill that “determining” the presence or absence of (or
response to therapy against) n cancer may not be, in every and all circumstance, 100% accurate. Such
determination (or diagnoses) may be ed as a likelihood of the present or absence of the ovarian cancer, and/or
interpreted in the context of the false-positive and/or false-negative rates of such a method or test. As is
conventional in diagnostic tests, such rates can also be represented by the sensitivity and/or icity of the test.
Accordingly, in particular embodiments of the present invention, the tests or methods hereof e a test
for the determination of ovarian cancer that has a sensitivity and/or icity that is superior to that provided by a
CA125 test, and/or has non-overlapping false-positives and/or false-negatives with a CA125 test. Also envisioned are
embodiments of the present invention wherein a methods or test may be ed having: (i) a sensitivity (ie true-
positive rate) of greater than about 30%, 40%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 88%, 90%, 92%,
94%, 95%, 96%, 97%, 98%, 99% or 99.5%, in particular r than about 90%, 95% or 98%; and/or (ii) a
specificity (ie, true-negative rate) of greater than about 30%, 40%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%,
88%, 90%, 92%, 94%, 95%, 96%, 97%, 98%, 99% or 99.5%, in particular r than about 55%, 60%, 70% or
80%. For example, in one embodiment, a test or method of the present invention may have a specificity of greater
than about 95% (such as about 98%) and a sensitivity of greater than about 60% (such as about 63%). In another
embodiment, a test or method of the present invention may have a specificity of greater than about 85% (such as
about 90%) and a sensitivity of greater than about 55% (such as about 58%). In yet another embodiment, a test or
method of the present invention may have a specificity of greater than about 98% (such as r than about
99.5%) and a sensitivity of greater than about 70% (such as greater than about 75%), for e if applied to a
general population. As will be appreciated, such test parameters can depend on the population of women being
screened, and in particular the prevalence of OC in such population. In this regard are presented two examples: (1)
in a population which has a dramatically increased prevalence of OC (eg BRCA mutation carriers who have an OC
40 lifetime risk of up to 60%), a lower specificity may be applicable as the rate of false positives will be substantially
lower and a false-positive result would have substantial less impact in such women - who may eventually opt for risk
reducing surgery anyway; and (2) in a general population g, the prevalence of OC in those women actually
tested using the present invention may be “artificially increased” by conducting a pre-screen for CC (eg, by using
ROCA or other diagnostic tests/methods as described elsewhere herein) and then conducting a test of the present
invention only in the sub-population of women who have an intermediate or elevated OC risk as determined by such
pre-screen (which may be about 8% of general female population), and in this sub-population of women, a lower
specificity may also be applicable.
The term “ovarian cancer” is art recognised, and encompasses any cancer that forms in tissue associated
with the ovary; in particular those that result in abnormal cells that have the y to invade or spread to other parts
of the body. The most common type of ovarian cancer, comprising more than 95% of cases, is ovarian carcinoma.
There are five main subtypes of ovarian carcinoma, of which high-grade serous (HGS) is most common. The other
main subtypes include: low-grade serous, endometrioid, clear cell and mucinous carcinomas. These tumours are
believed to start in the cells covering the ovaries, though some may form at the Fallopian tubes. Other types of
ovarian cancer include germ cell tumours and sex cord stromal tumours. For the e of the present invention,
the term an cancer” can also include peritoneal cancer and Fallopian tube cancer, in each case in women, as
both are high-grade serous, have analogous biology to ovarian cancer and have the same treatment ties as
ovarian cancer.
The various aspects and embodiments of the present invention, may apply to any one (or more) of such
specific types/subtypes of ovarian cancer, and in particular the discrimination of one types/subtypes of ovarian cancer
from others or from other disorders (such as gynaecological disorders). For example, in certain embodiments, the
present invention is used to discriminate ovarian cancer from benign pelvic mass, and/or high-grade serious (HGS)
n cancer from less severe or aggressive forms of n cancer, and/or or chemotherapy-resistant from
chemotherapy-responsive ovarian cancer.
[45] In other s or embodiments of the present ion, the test may determine (or diagnose) the
presence or absence of a cancer in said woman other than ovarian cancer (instead of, or as well as, determining the
presence or absence of, or the response to therapy against, ovarian cancer). Such other cancer may be another
gynaecological cancer (such as uterine cancer, vaginal , cervical cancer, and vulvar cancer) or a cancer of the
colon or breast. Such aspects or embodiments are particular envisioned for the present invention which makes use
of one or more epigenetic markers (eg, one or more methylated Cst, in particular the related Cst thereof) located
within (or within about 2,000bp - such as within about 200bp - 5’ or 3’ of) a nucleic acid sequence comprised in DMR
#204 [SEQ ID No. 2], optionally where the present ion makes use of one or more r epigenetic markers
within one or more other DMRs of the present ion (such as #141, #228 and/or #144 [SEQ ID NOs: 1, 3,
and/or 4, respectively]; in particular #141, and #228).
[46] The ical sample to be provided in this aspect of the present invention may be obtained from the
woman (eg, a woman having, suspected of having or being investigated for having, ovarian cancer) by any
procedure, s or step that the person of ordinary skill will recognise. For example, a biological sample may be
obtained by surgery, biopsy, swab, tion of biological fluids etc. The biological sample may be a sample of tissue
and/or fluid of the woman. Examples of a biological fluid include whole blood or a blood on (eg, such as plasma
or serum). In alternative es, the sample may be a biological fluid selected from the group consisting of: urine,
, sweat, tears, phlegm, beast milk, breast aspirate, vaginal secretion, vaginal wash and colonic wash.
In one embodiment, the biological sample may be a liquid biological sample selected from the group
consisting of: a blood sample, a plasma sample and a serum . In more particular embodiments, the sample is
a plasma or serum sample from the woman, or is urine from the woman female. In certain embodiments, the sample
40 is substantially (or essentially) free from cells, and/or is not a whole blood sample.
Methods of collecting such biological samples will be known to the person of ordinary skill, in particular the
collection of whole blood (eg by -puncture of a suitable vein of the woman), and the subsequent preparation
of plasma or serum from the whole blood (such as described in the es hereof). In particular embodiments,
the blood may be collected, stored and/or transported in a cell-free DNA blood collection tube, such as one with a
formaldehyde-free vative that stabilises nucleated blood cells. Such stabilisation would be expected to prevent,
or reduce, the release of genomic DNA (eg from nucleated blood cells), enhancing the ion of high-quality cell-
free DNA which can be further used in the method or other aspects of the present ion. The use of such tubes
in the present invention can, in certain embodiments, reduce the need for immediate plasma preparation. For
example, ree DNA is stable for up to 14 days, at room temperature, allowing ient sample collection,
ort and storage over such period. Suitable blood collection tubes include the Free DNA BCT®” of Streck
Inc, such as their research grade or CE-marked versions of this product.
Accordingly, in certain embodiments, the whole blood collected, for example collected in such a free DNA
blood collection tube, may be processed within about 14 days of collection, such as within about 10 days, 7 days, 5
days, 4 days, 3 days or 2 days, or between about 30 mins and 24 hours (such as within about 12 or 8 hours) of
collection. Between collection and processing (for example during storage and/or transport) the sample may be kept
at ambient (such as room) temperature, or may be maintained at a reduced temperature by refrigeration of use of
cooling materials. Suitable reduced temperatures include about 10°C, 4°C or lower, such as about 0°C, -18°C or -
70°C, or lower such as about -200°C (as may be provided by storage in liquid nitrogen).
[50] Steps of subsequent sing can include, centrifugation or other methods to separate intact cells (such
as red and nucleated blood cells) from the biological sample, preparation of plasma or serum from a blood sample
and/or extraction of cell-free DNA from the biological. Suitable methods for extraction of cell free DNA, in particular
from plasma or serum are described in the examples herein. For example, the QIAamp ating Nucleic Acid
and/or DNeasy Blood and Tissue extraction product series of Qiagen, as well as automated systems for DNA
extraction such as the QiaSymphony (Qiagen), Chemagen 360 (PerkinElmer). The same, analogous or modified
ures may be used to subsequently process other biological fluids, such as urine, tears, breast aspirate or
vaginal swabs, to isolate cell-free DNA therefrom.
The biological sample from the woman comprises cell-free DNA of said woman. The term “cell-free DNA” (or
“chNA”) is art recognised, and includes the meaning of DNA that is found outside of a cell, such as in a biological
fluid (eg blood, or a blood fraction) of an individual. In particular embodiments, the cell-free DNA may be circulating.
lating” is also an art-recognised term, and includes the meaning that an entity or substance (eg chNA) is
t in, detected or identified in, or isolated from, a circulatory system of the individual, such as the blood system
or the lymphatic . In particular, when chNA is “circulating” it is not located in a cell, and hence may be
present in the plasma or serum of blood, or it may be present in the lymph of tic fluid.
[52] The cell-free DNA present in the ical sample may arise from different sources (ie, tissues or cells)
present in or of the woman. For example, chNA may derive from ted (such as white) blood cells and/or other
“normal” cells of the body such as ying (or apoptotic/necrotic) epithelial or other cells. Such chNA can be
deemed “somatic” chNA as it is derived from cells that are assumed to comprise a normal genomic complement,
genetic and epigenetic make up of the woman. In addition to such somatic chNA, the biological sample may contain
chNA derived from other sources, and hence the total chNA present in, or ted from, the biological sample
(such as plasma or serum) may be an admixture of chNA derived from two or more different sources, each source
providing chNA which may have a different c complement and/or genetic or epigenetic make up. In the
present ion, the determination of the presence or absence (or response to therapy t) of ovarian cancer
in a woman is based on a differential epigenetic make up — as described for the first time herein for the DMRs of the
40 present invention — of chNA d from cells of the ovarian cancer compared to that of the somatic chNA present
in the biological sample. chNA derived from a tumour (such as an ovarian cancer cell) can be described as
circulating tumour DNA (“ctDNA”). In the present invention, the determination of the presence or absence (or
response to therapy against) of ovarian cancer is based on the (eg -molecule) analysis of certain epigenetic
markers present on the ctDNA derived from ovarian cancer. However, the chNA t in the biological sample may
WO 09212
contain chNA from sources other than, or in additional to, ctDNA d from ovarian . For example, the
chNA may comprise an admixture of c chNA of the woman, and ctDNA derived from one or more other
cancers (or tumorous tissues/cells) that may be present in the woman (such as breast cancer). Furthermore, if the
woman is pregnant, the chNA may comprise chNA derived from the foetus and/or the placenta of such foetus (Lo
et al 1997, Lancet 350:485), or if the woman has received a tissue, cell or blood transplant/transfusion donated by
another individual, the chNA of the woman may comprise DNA derived from the cells of such other individual.
The amount of total chNA isolated from a biological sample, in ular from a blood or blood-fraction
sample, may differ from woman to woman and sample to sample (such as, dependent on the storage, transport,
temperature and other environmental conditions the s is subjected to, as described in the example). For
e, between about 0 ng (ie, absence, or essentially absent) and 5000 ng chNA per mL of plasma/serum, such
as about between about 2 ng/mL or 10 ng/mL and about 2000 or 1000 ng/mL, in particular between about 2 ng/mL
or 10 ng/mL and about 500 ng/mL or between about 15 ng/mL or 20 ng/mL or 30 ng/ml or 40 ng/ml or 50 ng/mL
and about 500 ng/ ml, 400 ng/mL or 300 mg/mL or 250 mg/mL or 200 mg/mL, such as (eg in cases when blood is
ted in a free DNA blood collection tube) between about 2 ng/mL or 20 ng/mL and about 500 ng/mL. In any of
such embodiments (in particular, when the total chNA is at an amount of between about 2 ng/mL or 20 ng/mL and
about 500 ng/mL), the ctDNA (such as that derived from the ovarian cancer) comprises at (or more than) about
0.001%, 0.0025%, 0.005%, 0.0075%, 0.01%, , 0.05%, 0.075%, 0.1%, 0.25%, 0.5%, 0.75%, 1%, 2%, 3%,
4%, 5%, 7.5% or 10% of the total chNA, such as between about 0.001% and about 10%, or between about 0.1%
and about 10%, or between about 0.5% and about 10%, or between about 0.5% and about 5%, or between about
1% and about 5%, and/or the frequency of an epigenetic marker of the present invention (such as one associated
with DMR #141, #204, or #228) is at (or more than) about one molecule of the epigenetic marker to about 3, 5, 10,
, 20, 25, 50, 60, 75, 100, 150, 200, 250, 500, 750, 1000, 1500, 2000, 3000, 4000, 5000, 10000 or more than
10000, such as about 100000 molecules of total chNA (or fragments) presenting in or isolated from such biological
sample.
[54] Cell-free DNA present in, or isolated from, the biological sample (such as plasma or serum) is, typically,
fragmented. In certain embodiments, the average fragment size of such chNA may be between about 50 bp and
5000 bp, for e between about 50 bp and 3000 bp, between about 50 bp and 3000 bp, between about 50 bp
and 2000 bp, 50 bp and 2000 bp, such as n about 75 bp and 1000 bp or between about 75 bp and 750 bp, or
between about 100 bp and 300 bp, such as n about 150 bp and 200 bp. The average fragment size (and
amount/concentration) of chNA may be determined by any suitable methodology, as will be apparent to the person
of ordinary skill, including by capillary electrophoresis analysis and/or size fractional analysis, such as the nt
er and the High Sensitivity Large Fragment Analysis Kit (AATI, USA). Such characterisation can occur prior to
the determination step, as its outcome may be used to influence the number of molecules to be analysed and/or the
number of those molecules exhibiting the cancer-specific DNAme marker (as described elsewhere herein).
[55] The inventors have identified that, for certain of the DMRs of the t invention, one or more of the
Cst therein have particular relevance for the association of such CpG’s/s’ methylation status to the ce or
absence of, or response to therapy against, an ovarian cancer in a woman. The identify of those Cst (each, a
“relevant CpG") is underlined in TABLE 1A and TABLE 1B, as applicable, and the genomic position (hg19) of the
cytosine (C) of each such relevant Cst for such DMRs of the present invention is set forth in TABLE 1C.
TABLE 1C: Genome-coordinates of the Cs for each relevant Cst of the DMRs of the present invention
DMR# Genome coordinates (hg 19) of the Cs for relevant Cst Class
chr5:178004422178004442178004468
141 Hyper
178004504
chr1:151810811151810816151810835
204 151810843151810852151810890151810899— Hyper
151810904151810909
chr2:219736312219736319219736343
228 HWer
219736361
chr19:58220440582204465822046658220482-
144 HWer
5822049458220513-58220516
123 chr16:1271180127119212712121271239 Hypo
129 chr11:6905467869054700-69054709 Hypo
132896310132896333132896351
137 HW0
132896381
148 chr2:723596337235964872359682 Hypo
56735054156735078156735093
150 HW0
156735110156735118156735140
154 chr17:701121777011219370112221-70112237 Hyper
158 chr16:74441733744417717444178774441801 Hypo
164 74427997174428018-174428027 Hyper
176 chr6:119107242119107282-119107287 Hypo
178 chr19:13215489—1321549513215510-13215521 Hyper
180 chr3:192125900192125927192125945-192125949 Hyper
186 chr22:21483289—2148331721483329—21483332-21483337 Hypo
188 chr19:18497159—1849722618497239 Hypo
chr9:79629090796291037962912879629135-
190 Hyper
chr12:75601322756013317560136175601373-
192 HWer
7560137975601403-75601408
chr9:138999208138999213138999240
200 Hyper
138999264
chr1:2987558298757729875812987598
202 HWer
29876102987629
208 chr8:554675485546758155467592-55467606 Hypo
210 chr12:123713553 Hyper
213 chr2:106776975106777009-106777015 Hyper
214 chr3:141516291141516317 Hyper
219 chr16:30484193-30484218 Hyper
222 chr3:111809470 Hyper
223 chr10:120489294 Hyper
224 chr11:18740701874093 Hyper
225 chr7:142422236 Hyper
226 chr1:3086485308649230864963086509 Hypo
An epigenetic marker of, or for use in, the present invention may comprise the presence/absence, as
able, of methylation at a CpG associated with (such as located within) any of the DMRs of the t invention
(or within about 2,000bp - such as within about 200bp - 5’ or 3’ thereof), and in particular the presence/absence, as
applicable, of methylation at one of the relevant Cst associated with a given DMR of the present invention as set
forth in TABLE 1C. However, as set out herein, the ination of the presence or absence of (or response to
therapy against) an ovarian cancer in a woman may be enhanced if, in respect of one or more of such DMRs, the
methylation status at a plurality of Cst for such DMR is determined.
Accordingly, the present invention specifically includes embodiments where the methylation status is
ined at a number being two, three, four, five, six, seven, eight, nine, ten, about 12, about 15, about 20, about
or more of said Cst located within said nucleotide sequence and in particular at such number of - or up to the
maximum number of — any Cst (or the relevant Cst as set forth in TABLE 1C) associated with a given DMR of the
present invention. In such embodiments, the presence in at least one of said cell-free DNA molecules of at least one,
up to the respective said number (such as a number between about three and about fifteen) of methylated Cst or
un-methylated Cst (as applicable) located within one or more of said nucleotide sequences indicates the presence
of, or a reduced se to y against, an n cancer in said woman.
For example, the present invention includes embodiments where the methylation status is determined at
two, three, four, five, six, seven, eight, nine, ten, 11, 12, 13, 14 or 15 Cst (such as between about four and about
ten) located within a hyper-methylated DMR (eg, those set forth in TABLE 1A) of the t invention (or associated
therewith, such as within about 2,000bp - such as within about 200bp - 5’ or 3’ thereof), and wherein the presence
of at least one methylated such CpG associated with such a hyper-methylated DMR of the invention, such as all such
Cst or at least all of the applicable relevant Cst in such DMR as set forth in TABLE 1C (such as at all two, three,
four, five, six, seven, eight, nine, ten, 11, 12, 13, 14 or 15, up to the maximum number of such Cst ated with
said DMR), indicates the presence of, or a reduced response to therapy against, an ovarian cancer in said woman.
Preferably, in such ments, the presence of methylation at all of the relevant Cst (see TABLE 1C) for a given
methylated DMR (eg, those set forth in TABLE 1A) indicates the presence of, or a reduced response to therapy
against, an ovarian cancer in said woman.
As another example, the present invention also includes embodiments where the methylation status is
determined at two, three, four, five, six, seven, eight, nine, ten, 11, 12, 13, 14 or 15 Cst (such as between about
four and about ten) located within a hypo-methylated DMR (eg, those set forth in TABLE 1B) of the present invention
(or associated therewith, such as within about 2,000bp - such as within about 200bp - 5’ or 3’ thereof), and wherein
them of at least one methylated such CpG associated with such a ethylated DMR of the invention,
such as all such Cst or at least all of the applicable relevant Cst in such DMR as set forth in TABLE 1C (such as at
all two, three, four, five, six, seven, eight, nine, ten, 11, 12, 13, 14 or 15, up to the maximum number of such Cst
ated with said DMR), tes the presence of, or a reduced response to therapy against, an ovarian cancer in
said woman. Preferably, in such embodiments, them of methylation at all of the relevant Cst (see TABLE 1C)
for a given hypo-methylated DMR (eg, those set forth in TABLE 1B) indicates the presence of, or a reduced response
to therapy against, an ovarian cancer in said woman.
As will be apparent to the person of ordinary skill, the m number of Cst for which such
determination of methylation status may be made will be the number of Cst located within the sequence that is
analysed. For example, for DMR #141 (SEQ ID No. 1), the wild-type sequence shows that 7 Cst are located
therein (of which all 7 are underlined in TABLE 1A, are further identified in TABLE 1C and are the relevant Cst for
such DMR), and hence such number of Cst would represent a maximum number of Cst in t of such
ce for which the methylation status may be determined and hence used to investigate the presence of, or a
40 reduced response to therapy against, an n cancer in said woman.
The status of methylation at any of such Cst may be determined to be absent (un-methylated) or to be
present (methylated), such as in the form of methylcytosine and/or hydroxymethylcytosine and/or cytosine, in
particular 5-methylcytosine (5mC) or 5-hydroxymethylcytosine (5th) or 5-formylcytosine (5fC) (Li & Liu, 2011;
Journal of Nucleic Acids, article ID 870726. Ito et al, 2011; Science 333:1300). In one embodiment, the present
invention relates to the ination of the 5-methylation and/or oxymethylcytosine status at one or more Cs
in said Cst, wherein the presence of one or more 5-methylcytosine and/or 5-hydroxymethylcytosine in the Cst (in
particular; in the relevant Cst for a DMR, as set out in TABLE 1C) indicates the ce of, or a reduced response
to therapy against, an ovarian cancer in said woman. Any of those Cst investigated which are determined not to
se 5-methylcytosine, are typically un-methylated cytosine, but in certain embodiments one or more may
comprise modifications other than 5-methylcytosine, such as 5th or 5fC. Investigation of the respective
modification comprised in Cst is art know, including methylation-sensitive restriction enzyme or bisulphite
conversion/analysis (eg for 5mC and/or 5th) and reduced bisulphite sequencing (redBS-Seq) (eg, for 5fC), as may
be conducted by or products obtained from Cambridge Epigenetix Ltd (UK). Alternatively, single-molecule DNA
sequencing/analysis ques (such as those utilised in the PacBio or re instruments described elsewhere
herein) may be used to determine the status and form of the methylation present at the Cst that are interrogated
as part of the present invention.
As well as the present invention including embodiments were the methylation status at one or more Cst
(in particular, at one or more nt Cst) is ined located within a single DMR of the present ion (or
associated therewith, such as within about 2,000bp - such as 200bp - 5’ or 3’ thereof), for example a DMR selected
from the group consisting of #141, #204 and #228 (SEQ ID NOs.: 1, 2 and 3, respectively), it specifically ons
other embodiments wherein such Cst are d within a plurality of DMRs of the present ion (or associated
therewith, such as within about p - such as within 200bp - 5’ or 3’ thereof). Also as described herein, the
determination of the presence or absence of (or response to therapy t) an n cancer in a woman may be
enhanced if, in respect of such plurality DMRs, the methylation status of at least one (or more) Cst of such DMRs is
determined, especially those embodiments where in respect of each of such plurality of DMRs, the methylation status
of a plurality of Cst (such as two, three, four, five, six, seven, eight, nine, ten or more than ten, such as 11, 12, 13,
14 or 15, or between about four and about ten), and in particularly of the applicable relevant Cst for a DMR, is
determined.
[63] Accordingly, in certain embodiments of the t invention, the methylation status at one or more Cst
(in particular, of the applicable relevant Cst) located within a number of two, three, four, five, six, seven, eight,
nine, ten or more than ten (such as 11, 12, 13, 14 or 15, or between about four and about ten) of said nucleotide
sequences (in particular, within at least two, three or four nucleotide sequences) is ined; wherein, the
ce in at least one of said cell-free DNA molecules of one or more (such as between about four and about ten):
(i) methylated such Cst (eg the relevant Cst set out in TABLE 1C) located within one or more of said nucleotide
sequences of the hyper-methylated DMRs (eg, those of TABLE 1A); and/or (ii) un-methylated such Cst (eg the
relevant Cst set out in TABLE 1C) located within one or more of said nucleotide sequences of the hypo-methylated
DMRs (eg, those of TABLE 1B), indicates the presence of, or a reduced response to therapy, against an ovarian
cancer in said woman. In certain of such embodiments, one or more other Cst within the nucleotide sequence(s)
may be either methylated or un-methylated (or their methylation status undetermined), wherein said pattern of
methylation can also indicate the ce of (or reduced response to therapy against) n cancer in said
woman. For example, one pattern of methylation that indicates the presence of (or reduced response to therapy
against) ovarian cancer in said woman may be for a hyper-methylated DMRs (eg, those of TABLE 1A) that all (or all
but one, two or three) of the relevant Cst set out in TABLE 1C for such DMR are methylated, and that all other
40 Cst are either methylated or un-methylated (or their methylation status is undetermined); ie that for DMR #228, a
pattern of methylation of linked Cst therein of “X111X111” indicates the presence of (or reduced response to
therapy against) ovarian cancer in said woman (where “1” represents the presence of a methylated CpG and “X”
represents the ce of either a methylated or an un-methylated CpG; and the relative position of the non-
relevant CpG for #228). In another e, one pattern of methylation that indicates the presence of (or reduced
response to therapy against) ovarian cancer in said woman may be for a ethylated DMRs (eg, those of TABLE
1A) that all (or all but one, two or three) of the relevant Cst set out in TABLE 1C for such DMR are un-methylated,
and that all other Cst are either methylated or un-methylated (or their methylation status is undetermined). In
certain embodiments of the present invention, the pattern of methylation/un-methylation for a given DMR that is
associated with the presence of (or reduced response to therapy t) n cancer in said woman is shown in
Table 2B.
The present invention additionally provides for particularly advantageous nucleotide sequences associated
with one or more Cst (in particularly at least one of the applicable relevant Cst), the methylation status of which
is associated with the presence or absence of, or response to therapy against, an ovarian cancer in a woman. As
described above, such nucleotide sequences include those selected from the group consisting of DMR#: #141, #204,
#228, #144, #123, #129, #137, #148, #150, #154, #158, #164, #176, #178, #180, #186, #188, #190, #192,
#200, #202, 210, #213, #214, #219, #222, #223, #224, #225 and #226; in particular #141 and/or #204
and/or #228 and/or #144 and/or #154 and/or #158 and/or #186 and/or #188 and/or #202 such as preferably
#141 and/or #204 and/or #228 (SEQ ID NOs: 1, 2 and 3, respectively), or in certain other embodiments a
nucleotide sequence present within about 2,000bp (such as within about 200bp) 5’ or 3’ f, and atively, in
each case, an allelic variant and/or a complementary sequence of any of said nucleotide sequences.
Accordingly, in a particular embodiment, the method of the present invention said nucleotide sequence(s)
is/are #141 and/or #204 and/or #228 (SEQ ID NOs: 1, 2 and/or 3); for example, at least one of said nucleotide
sequences is #141; or an allelic variant and/or complementary sequence of any of said nucleotide sequences. In an
alternative embodiment, the method of the present invention said tide sequence is #144 (SEQ ID NO 4), or an
allelic variant and/or complementary sequence of any of said nucleotide sequences; which embodiment may also be
include the determination of methylation status at Cst (in ularly at the applicable relevant Cst) located in
one or more of the nucleotide sequence #141 and/or #204 and/or #228 (SEQ ID NOs: 1, 2 and/or 3). As set out
elsewhere, also envisioned are ments where the Cst are located in a nucleotide sequence present within
about 2,000bp (such as within about 200bp) 5’ or 3’ of each or any of the respective DMRs. In particular of such
embodiments, said nucleotide ces and the relevant Cst thereof are, respectively, those set out in TABLE 1D,
or an allelic variant and/or mentary sequence of any of said nucleotide sequences.
TABLE 1D: Genomic sequences of the non-primer portion of particular DMRs of the present ion
Marker Genome coordinates
DMR# coordinates (relevar?t C Gs arequnderlined)]Marker enomic se uence SEQ ID
(hg 19) of the Cs for
(h919) P relevant Cst '
chr5:178004422 ECCAQGGAAGGAGGCACAEATTCAGCCCA 3&312334141722604442-
141 TGACACCGCCACCTCGGCGTGGTGCTGTAGGG 156
-178004505 GGAAGCEAGGCACEAEG 178004460
— 471-178004504
chr1:151810811-
151810814
gooGcGGGGCCCCAGGQCAGCAQCTCTQ gfifligigiggig
chr1:151810811 cGcG"GGGC§CAGCTGGCAGCACAGGAAGTC
204 151810845 157
-151810917 CAGG"GGMGAGQGQGQTGGGQGCCQG
151810887
CGCGGCGCGGC
— 893
151810904
151810909
chr2:219736312-
chr2:219736301 CGGCTGCCAGGQCCCCGCGGGCGGGCCCCTC 317
228 158
-219736362 CCQGCCCTCQGCCTGCCQGCACCCCQ 219736335
219736352-219736361
chr19:58220440
chr19:58220438 ———AA—— iiiigiégiigiigiggi
144 CAGGAGGGACGACGACTCCCCTCACGCCTTCG 159
-58220517 TGGCCCCAAc—Tcfice — — 58220482
— — 58220500
58220516
As shown in the examples, a particularly useful test is provided by those embodiments of the present
invention in which the methylation status may be determined at one or more Cst associated withw of a plurality
of the DMRs described herein. For e, more than one (such as two, three, four, five, six, seven, eight, nine or
ten) of such nucleotides sequence may be investigated for the presence or absence of methylated Cst d
therein. In particular, where at least one methylated CpG (such as a plurality of methylated GpCs) — in particular of
the respective relevant Cst - is determined in any one of the plurality of such nucleotide ces associated with
a hyper-methylated DMR analysed (such as DMR #141, #204, #228 and/or #144), then a determination may be
made that ovarian cancer is present in said woman, or that n cancer in a woman is not responding to
(chemo)therapy. Alternatively, where at least one un-methylated CpG (such as a plurality of un-methylated GpCs) —
in particular of the respective relevant Cst - is determined in any one of the plurality of such nucleotide sequences
associated with a hypo-methylated DMR analysed (such as those set forth in TABLE 1B), then a determination may
be made that ovarian cancer is present in said woman, or that n cancer in a woman is not responding to
(chemo)therapy. As will also be understood, the plurality of nucleotide sequences analysed for the ce or
absence of methylated Cst located therein may include at least one nucleotide sequence associated with a hyper-
methylated DMR (such as those set forth in TABLE 1A, and in particular DMR #141, #204, #228 and/or #144 as set
forth in TABLE 1D) m at least one nucleotide sequence associated with a ethylated DMR (such as those set
forth in TABLE 1B), wherein the determination of at least one methylated CpG (such as a plurality of ated
GpCs) — in particular of the respective relevant Cst — located in said methylated DMR m the
determination of at least one un-methylated CpG (such as a plurality of un-methylated GpCs) — in particular of the
respective relevant Cst — located in said ethylated DMR may be used to determine that n cancer is
present in said woman, or that n cancer in a woman is not responding to (chemo)therapy.
Accordingly, in a particular embodiment of the method of the present invention the methylation status may
be determined at one or more of said Cst located within each of the tide sequences so analysed; wherein,
the presence in at least one of said cell-free DNA molecules of one or more: (i) methylated Cst (in particular, the
applicable relevant Cst set forth in TABLE 1C) located within any one of said tide sequences associated with
the hyper-methylated DMRs (eg as set forth in TABLE 1A); and/or (ii) un-methylated Cst (in particular, the
applicable relevant Cst set forth in TABLE 1C) located within one or more of said tide sequences associated
with the hypo-methylated DMRs (eg as set forth in TABLE 1B), indicates the presence of, or a reduced response to
therapy t, an ovarian cancer in said woman. For example, the method includes embodiments where the
methylation status of one or more Cst (in particular, of the applicable relevant Cst set forth in TABLE 1C) d
in ich of the nucleotide sequence #141 and #204 and #228 (SEQ ID NOs: 1, 2 and 3) - such as at least one (such
as all) of such CpG in each of said ces — is determined for at least one molecule of said cell-free DNA, and
wherein the ce in at least one of said cell-free DNA molecules of one or more methylated Cst located within
any one of said nucleotide sequences (such as methylation at all GpCs, or all relevant Cst, therein, or methylation
at all but one, two or three of such GpCs) tes the presence of, or a reduced response to therapy against, an
ovarian cancer in said woman. In particular of such embodiments, one or more (such as all) of said nucleotide
sequences (and the applicable relevant Cst) are, respectively, those set out in TABLE 1D, or an allelic variant and/or
complementary ce of any of said nucleotide sequences.
40 [68] One particular feature described in the examples is the presence of patterns of methylation/un-methylation
at Cst associated with the same DMR, in particular at the relevant Cst for such DMR. Such examples support the
ion that the investigation, analysis and/or determination of such patterns of ation/un-methylation are
particularly useful or advantageous tools for determining presence or e of, or response to therapy against, an
ovarian cancer in a woman. In particular, to provide tests that have a performance that enables them to be used in
diagnostic settings; such as having a sensitivity and/or specificity as set out herein. The number of Cst associated
with a given DMR for which the methylation status is determined will depend on the length of nucleotide sequence
analysed and the number of Cst present n. For a given nucleotide sequence associated with (such as within,
or within about 2,000bp - such as within about 200bp - 5’ and/or 3’ of) a DMR of the present invention, the number
of Cst for which the methylation status is determined can range from two or more (such as three, four and five, up
to the maximum number of Cst within such nucleotide sequence, and/or up to about nine, ten, 11, 12, 13, 14, 15,
18, about 20, about 25 or about 30. In particular embodiments, the methylation status is determined at a number of
between about 5 and about 15 of said Cst located within the nucleotide sequence(s), and in particular at such
number of the relevant Cst for the nucleotide sequence(s) (eg, as set forth in TABLE 1C). In certain embodiments
of the present ion, the number of (eg relevant) Cst for which the methylation status is determined the
pattern of methylation/un-methylation for a given DMR that is ated with the presence of (or reduced response
to therapy against) ovarian cancer in said woman is show in Table 2B.
Accordingly, in certain s of the present invention, the methylation status may be determined at a
number of n about 2 and about 15 (for example, between about four and about ten, such as five, six, seven,
eight or nine) of said Cst (in particular of the relevant Cst set forth in TABLE 1C) located within said nucleotide
sequence(s) - in particular within the nucleotide sequence(s) selected from: #141, #204 and/or #228 (SEQ ID NOs:
1, 2 and/or 3), or an allelic variant and/or complementary ce thereof; wherein the presence in at least one of
said cell-free DNA molecules of at least said number of methylated Cst (in particular of methylated relevant Cst
set forth in TABLE 1C) d withinw of said nucleotide sequences indicates the presence of, or a reduced
response to therapy against, an ovarian cancer in said woman.
[70] In specific of such embodiments, the methylation status may be determined at about 7 Cst (in particular,
the 7 relevant Cst) located within nucleotide sequence #141 (SEQ ID NO 1) and/or at about 16 Cst (in particular,
the 16 relevant Cst) d within nucleotide sequence #204 (SEQ ID NO 2) and/or at about 7 Cst (in particular,
the 7 relevant Cst) located within tide sequence #228 (SEQ ID NO 3) and/or at about 11 Cst (in particular,
the 11 relevant Cst) located within nucleotide sequence #144 (SEQ ID NO 4) — for example those Cst (in
particular, the applicable relevant Cst) located within SEQ ID N05: 156, 157, 158 and/or 159, respectively - or in
each case an c variant and/or mentary sequence of any of said nucleotide sequences. In particular
embodiments, the methylation status of all Cst, or at least all of the relevant Cst, in the given nucleotide
sequence may be determined. In one embodiment, the presence of ation at all of said Cst in a given
nucleotide sequence for the hyper-methylated DMRs #141, #204, #228 and/or #144 can indicate the presence of
(or reduced response to therapy against) ovarian cancer in said woman. In other embodiments, the presence of
methylation at all but one, two or three of said Cst in one or more of said nucleotide sequence can indicate the
presence of (or reduced response to y against) ovarian cancer in said woman. For example, all of the relevant
Cst for DMR #141, #204, #228 and/or #144 may be determined to be methylated, and one or more other Cst
therein they may be either methylated or un-methylated (or their methylation status rmined), wherein said
40 pattern of ation can also indicate the presence of (or d response to therapy t) ovarian cancer in
said woman. In certain ments of the present invention, the number of (eg relevant) Cst for which the
methylation status is determined the pattern of methylation/un-methylation for DMR #141, #204, #228 and/or #144
that is associated with the presence of (or reduced response to y against) ovarian cancer in said woman is
show in Table 2B.
WO 09212
As will now be apparent to the person of ordinary skill, and as shown in the examples within a clinical
setting to be superior and/or complementary to a CA125 test (FIGURES 3E and 3F), one particular embodiment of
the present invention is based on the analysis and determination of the ation n of three sets of Cst (in
particular; of the applicable relevant Cst), each set associated with the respective one or three DMRs: #141, #204
and #208; wherein the ce of a (marker) methylation pattern in any one of said DMRs determines the presence
or e of, or se to therapy against, an ovarian cancer in a woman. Therefore, one specific embodiment of
the method of the present invention includes where the methylation status is determined at about 7 Cst (in
particular; the 7 relevant Cst) located within nucleotide ce #141 (SEQ ID NO 1) m at about 16 Cst (in
particular, the 16 relevant Cst) located within nucleotide sequence #204 (SEQ ID NO 2) E at about 7 Cst (in
particular, the 7 relevant Cst)located within nucleotide sequence #228 (SEQ ID NO 3) — for example located within
SEQ ID N05: 156, 157 and/or 158, respectively - or in each case an allelic variant and/or mentary ce
of any of said nucleotide ces; wherein, the presence in at least one of said cell-free DNA molecules of at least
said number of methylated said Cst (in particular, said relevant Cst) located within any one of said nucleotide
sequences indicates the presence of, or a reduced se to therapy against, an ovarian cancer in said woman. As
bed above, in certain of such embodiments other Cst within such nucleotide sequence may (or may not) be
analysed for their methylation ; and if their methylation status is determined then they such Cst may be
determined to be either methylated or un-methylated, and the presence of, or a d response to therapy
against, an ovarian cancer may be determined in said woman.
For one example of such embodiment, the determination of the presence of methylation (in at least one of
said cell-free DNA molecules, such as more than 10, 20, 50, 100, 500 or 1000, or another number as set out below)
at all 7 of the relevant Cst located within nucleotide sequence #141 (SEQ ID NO 1) indicates the presence of, or a
reduced response to therapy t, an ovarian cancer in said woman, regardless of the methylation status of any
other CpG therein and/or regardless of the methylation status of Cst located within nucleotide sequence #204
(SEQ ID NO 2) or nucleotide sequence #228 (SEQ ID NO 3). As a first alternative example of such embodiment, the
determination of the presence of methylation (in at least one of said cell-free DNA molecules, such as more than 10,
, 50, 100, 500 or 1000, or another number as set out below) at all 16 of the relevant Cst located within
nucleotide sequence #204 (SEQ ID NO 2) indicates the presence of, or a reduced se to therapy against, an
ovarian cancer in said woman, less of the methylation status of any other CpG therein and/or regardless of the
methylation status of Cst located within nucleotide sequence #141 (SEQ ID NO 1) or tide sequence #228
(SEQ ID NO 3). As a second alternative example of such embodiment, the determination of the presence of
methylation (in at least one of said cell-free DNA molecules, such as more than 10, 20, 50, 100, 500 or 1000, or
another number as set out below) at all 7 of the relevant Cst located within nucleotide sequence #228 (SEQ ID NO
3) indicates the presence of, or a reduced response to therapy against, an ovarian cancer in said woman, less
of the methylation status of any other CpG therein and/or regardless of the methylation status of Cst located within
nucleotide sequence #141 (SEQ ID NO 1) or nucleotide sequence #204 (SEQ ID NO 2). As will be now be
appreciated, in an alternative embodiment, the presence of, or a reduced response to therapy against, an ovarian
cancer in said woman may be also indicated when the presence of ation is determined at all of the nt
Cst located within each of nucleotide sequences 141 (SEQ ID NO 1), #204 (SEQ ID NO 2) m #228 (SEQ ID NO
3). In such an alternative embodiment (and as described elsewhere herein), the number of cell-free DNA molecules
40 in which any of such methylation ns is determined may be less than if only one of such DMRs is found to have
such a methylation pattern. In certain embodiments of the present invention, the number of (eg relevant) Cst for
which the methylation status is determined the pattern of methylation/un-methylation for DMR #141, #204, #228
and/or #144 that is associated with the presence of (or reduced response to therapy against) ovarian cancer in said
woman is show in Table 23.
In any of the embodiments of the present invention, the biological sample can be further processed, such as
comprising a step of isolating cell-free DNA therefrom. Such isolation can include particular steps of centrifugation
(such as density gradient ultracentrifugation, Jonathan et al (2015), J Cancer Prev Curr Res 3:00064), treatment with
ionic solutions and/or organic solvents to selectively solubilise/precipitate nucleic acids (such as cell-free DNA),
on of (cell-free DNA) selective binding and tion es (such as magnetic beads) and/or filtration or
chromatographic steps; and in particular, steps of lysis of sample, absorption to a silica membrane (or column or
beads), removal of residual inates and/or on of pure nucleic acids, such as cell-free DNA. Other methods
of chNA isolation can include rapid okinetic isolation directly from blood (Sonnenberg et al (2014), Clin Chem
60:500).
[74] In certain of such embodiments, the biological sample (such as plasma or serum) may be processed to
isolate the ree DNA generally according to a process as set out in FIGURE 5. For example:
Lysing samples: Free-circulating c acids in ical fluids are usually bound to proteins or enveloped
in vesicles, which may utilise an efficient lysis step in order to release nucleic acids for selective binding to the
column (or to Solid Phase Reversible Immobilisation — SPRI — agnetic] beads). Hence, samples may be lysed
under highly denaturing conditions at elevated temperatures in the presence of proteinase K and appropriate buffer,
such as Buffer ACL from Qiagen (cat. no. 19076), which together provide for inactivation of DNases and RNases and
complete release of nucleic acids from bound proteins, lipids, and vesicles.
Adsorption to a silica ne: Binding conditions can be adjusted by adding an appropriate buffer, such
as Buffer ACB (Qiagen) to allow binding of the circulating nucleic acids to the silica membrane. Lysates may then
then be transferred onto a separation column (such as the QIAamp Mini column, Qiagen), and circulating nucleic
acids adsorbed from a large volume onto the small silica membrane as the lysate is drawn h by vacuum
pressure. Appropriate salt and pH conditions can ensure that proteins and other contaminants, which can inhibit PCR
and other downstream enzymatic reactions, are not retained on the separation column. A vacuum manifold (e.g., the
QIAvac 24 Plus with the QIAvac Connecting System) and a vacuum pump capable of producing a vacuum of —800 to
—900 mbar (e.g., QIAGEN Vacuum Pump) may be used for the ol. A vacuum regulator can be used for easy
monitoring of vacuum pressures and convenient vacuum release.
Removal of residual contaminants: Nucleic acids remain bound to the membrane, while contaminants can
be efficiently washed away during a plurality of wash steps, such as 2 or 3 wash steps. In a single step, highly pure
circulating nucleic acids can be eluted in an appropriate buffer (such as in Buffer AVE, Qiagen), brated to room
ature.
Elution of pure nucleic acids: Elution can be performed using Buffer AVE. The elution volume may be 50 ul
(or greater, such as 100u| or 150ul). If higher nucleic acid concentrations are required, the elution volume can be
reduced, such as by using 20 ul (or 50ul). Low n volume leads to highly concentrated nucleic acid eluates. For
downstream applications that use small starting volumes (e.g., some PCR and RT—PCR assays), a more trated
eluate may increase assay sensitivity. For downstream ations that use a larger starting volume, the elution
volume can be increased up to 150 ul. However, an increase in elution volume can decrease the concentration of
nucleic acids in the eluate. Eluted nucleic acids can collected in 1.5 ml microcentrifuge tubes or in microtitre plates. If
the purified circulating nucleic acids are to be stored for up to 24 hours, they can be stored at 2—8°C; and/or for
storage longer than 24 hours at —15 to —30°C.
40 [79] In certain embodiments of the present invention, the cell-free DNA may be ted to an agent that
differentially modifies said DNA based on the methylation status of one or more of the Cst. Such a modification can
facilitate the detection of differences in the methylation status. However, as described elsewhere herein, methods are
available to detect differences in the ation status of Cst without use of such a ing agent.
Accordingly, the present invention also es those embodiments of the method that include a step of
treating said DNA with an agent that entially modifies said DNA based on the methylation status of one or more
Cst located within. Such agents will be known to the person of ordinary skill and e the use of one or more
methylation sensitive restriction enzyme and/or of a bisulphite-based reaction. The use of bisulphite or methylation-
sensitive restriction enzymes to study differential methylation will be well known to the person of ry skill, who
may apply teachings of standard texts or adaptation of published methods such as Poon et al , Nygren et al
(2010) or Yegnasubramanian et al (2006, Nuc Acid Res ).
A methylation ive is a restriction enzyme that is sensitive to the DNA methylation . Cleavage of
such a restriction enzyme’s ition sequence may be blocked, or impaired, when a particular base in the
enzymes recognition site is ed, eg methylated. In particular embodiments of all aspects of the invention, the
agent comprises a methylation-sensitive restriction , such as a methylation-sensitive restriction enzyme
disclosed herein; ing such embodiments that comprise two, three, four, five or more of such methylation-
ive restriction enzymes. In particular embodiments, the t agent comprises: at least one methylation
sensitive ; at least one methylation sensitive restriction enzyme; and/or an agent selected from the group
consisting of: AatII, AciI, AclI, AfeI, AgeI, AgeI-HF, AscI, AsiSI, AvaI, BceAI, BmgBI, BsaAI, BsaHI, BsiEI. BsiWI,
BsmBI, BspDI, BerI, BssHII, BstBI, BstUI, ClaI, EagI, FauI, FseI, FspI, HaeII, HgaI, HhaI, HinPlI, HpaII, pr99I,
prCH4IV, KasI, MluI, NaeI, NarI, NgoMIV, NotI, NotI-HF, NruI, Nt.BsmAI, Nt.CviPII, PaeR7I, PluTI, PmlI, PvuI, PvuI-
HF, RerI, SacII, SalI, SalI-HF, SfoI, SgrAI, SmaI, SnaBI, TspMI and ZraI. In particular embodiments, said reagent is
one selected from the group consisting of: BstUI, HhaI and HpaII.
Treatment of DNA with an agent comprising bisulphite (bisulfite) converts un-methylated cytosine residues
to uracil, but leaves 5-methylcytosine es unaffected. Thus, bisulphite treatment introduces specific changes in
the DNA sequence that depend on the methylation status of individual ne residues, yielding single nucleotide
resolution information about the methylation status of a segment of DNA. Various analyses can be performed on the
altered sequence to retrieve this information, including the use of PCR primers and/or probes and/or sequencing that
can distinguish between such singe-nucleotide changes. As described above, other agents that may uses in methods
to determine methylation at Cst include oxidative bisulphite (eg for analysis of 5th).
Bisulphite modification may be conducted using eg the EZ—96 DNA methylation kit (Zymo Research), and/or
may include the steps of adding an effective amount of a bisulphite reagent to each sample, and incubating (eg in
the dark) at about 50°C for 12-16 hours (e.g., using a thermal cycler). After such incubation, prior to analysis, a step
of incubating the sample at 0-4°C (e.g., on ice or using a thermal cycler) for 10 minutes may be included.
[84] In particular embodiments of the present invention, said agent may be bisulphite and said determining step
may comprise the detection of at least one bisulphite-converted cytosine (such as one in a CpG) within one or more
of the nucleotide sequences selected from the group ting of a sequence produced or producible following
hite conversion of a sequence comprised within a DMR selected from the group consisting of DMR#: #141,
#204, #228, #144, #123, #129, #137, #148, #150, #154, #158, #164, #176, #178, #180, #186, #188, #190,
#192, #200, #202, #208,#210, #213, #214, #219, #222, #223, #224, #225 and #226; such as a sequence
consisting of at least about 10 contiguous bases (preferably at least about 15 uous bases for any SEQ ID other
than SEQ ID NO: 58) comprised in a sequence selected from the group consisting of SEQ ID NOs (see TABLE 2A):
32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61
and 62 (such as SEQ ID NO: 32, 33, 34 and/or 35, or in particular of SEQ ID N05: 32 and 33 and 34, optionally also
40 35), or an allelic variant and/or complementary sequence of any of said nucleotide sequences. In particular
ments, said number of uous bases is at least about 16, 18, 20, 22, 24, 26, 28, 30, 35, 40, 45, 50, 55,
60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 10, 140, 150 or 160 bases, such as n about 80 and about 160,
such as between about 100 and about 160, in each case, independently, up to the maximum number of bases within
the sequence selected from said group; wherein one or more of the bases identified by “Y” therein is a U or T (in
particular, of a C within a CpG, such as of a relevant CpG of a hypo-methylated DMR) and, preferably, where one or
more of another of the bases fied by “Y” therein is a C (in particular, of a C within a CpG, such as of a relevant
CpG of a methylated DMR), or an allelic variant and/or complementary sequence of any of said nucleotide
sequences. In particular embodiments, two, three, four, five, six, seven, eight, nine, ten or more than ten of the
bases identified by “Y” therein is a U or T (preferably T), such as all of the bases identified by “Y” therein is a U or T
(preferably T), or all but one, two, three, four, five, six, seven, eight, nine, ten or more than ten of the bases
fied by “Y” therein is a U or T (preferably T), in particular where such other one, two, three, four, five, six,
seven, eight, nine, ten or more than ten of the bases identified by another “Y” is a C within a CpG, such as of a
relevant CpG of a hyper-methylated DMR).
[85] In ular of such embodiments, the method of the t ion may also include those wherein
said agent is bisulphite and said determining step comprises the detection of at least one (non-natural) bisulphite-
converted cytosine within a nucleotide sequence having a length of at least about 15 bp comprised in a bisulphite
conversion of a sequence comprised within DMR #141 and/or #204 and/or #228 (SEQ ID N05: 32, 33 and/or 34,
respectively), wherein one or more of the bases identified by “Y” therein is a U or T and, preferably, where one or
more of the bases identified by “Y” (in particular, those within a CpG, such as one or more (or all) of a relevant CpG)
n is a C, or an allelic variant and/or complementary sequence of any of said nucleotide sequences. Such a
nucleotide sequence may be at least about 16bp, 18bp, 20bp, 25bp, 30bp, 35bp, 40bp, 45bp, 50bp, 55bp, 60bp or
70bp, for example up to about 90bp, 100bp or 150bp, such as between about 100bp and about 160bp.
In particular embodiments, the sequence detected may be one comprised in a hite conversion of a
sequence comprised within DMR #141 and/or #204 and/or #228 and/or #144 (SEQ ID N05: 32, 33, 34 and/or 35,
respectively), such as SEQ ID N05: 32 or 33 or 34, wherein all (or all but one, two, three, four or five) of the
cytosines of Cst located (in particular of the nt CpG) in the analysed sequence are detected as a C (ie, such
cytosines are determined to be methylated) and all other cytosines located in the analysed sequence (in particular,
the cytosines not of a CpG therein) are detected a U or T (ie, such other cytosines/Cst are determined to be un-
methylated).
As will now be apparent, such a detected BS converted ce will be a non-natural sequence, as any un-
methylated cytosine (such as one outside a CpG) will have been converted to U by the bisulphite treatment, and
detected as either a U or a T.
In other certain embodiments of the present invention, the methylation status of the one or more the Cst
t in the cell-free DNA may be determined without use of an agent that differentially modifies said DNA based
on such methylation. For example, single molecule sequencing/analysis of DNA may be used to determine such
methylation status. es of such technologies include those utilised in the: (1) PacBio instruments (Pacific
Biosciences) that use Single Molecule, Real-Time (SMRT) sequencing, based on zero-mode waveguides (ZMWs) and
phospholinked nucleotides. ZMWs allow light to illuminate only the bottom of a well in which a DNA
polymerase/template complex is immobilized. olinked nucleotides allow observation of the immobilized
complex as the DNA polymerase produces a completely natural DNA strand. Such instruments can be used for the
direct detection of epigenetic cations (Mol Genetics & cs, 2016; 291:1491); and (2) Nanopore
instruments (Oxford re) that use nanopored membranes to detect variations in current flow, characteristic to
the base/modified-base, as single strands of DNA pass through such nanopore (Nature 467:190). Accordingly, in
40 certain embodiments of the present invention the methylation status at said one or more Cst is determined using
single le DNA sequencing or analysis, such as by SMRT or nanopore sequencing.
Analysis of the cell-free DNA present or ed from the biological sample may, in some embodiments, be
subjected to an amplification process, for e prior to or as part of the step of determining the methylation
status of the one or more Cst associated with the DMR.
Accordingly, certain embodiments of the present invention may include a method that also comprises a step
of amplifying one or more regions of said cell-free DNA to produce DNA prior to or as part of said ining step,
and preferably after any optional step of treating with said agent. If more than one region of cell-free DNA is to be
ed, this may occur as a lex or pool (eg, conducted in a single mixed reaction), or each region may be
amplified separately and/or individually, with the possibility that such independent amplified regions are subsequently
mixed or pooled so enable pooled and/or multiplex analysis thereon. As will be apparent, any regions of DNA so
amplified, in ular those amplified in in-vitro processes, will be synthetic (of in-vitro produced) DNA molecules.
Amplification of regions of cell-free DNA may occur by any suitable method, including polymerase chain
reaction (PCR) and rolling circle amplification. Those embodiments of the present invention that comprise PCR
ication can further comprises specific steps that are related to the ce of PCR, such as any of those
described herein, or in particular the steps of: (A) providing a reaction mixture comprising a double-stranded target
DNA, a pair of primers (for example, a pair of primers disclosed ) designed to amplify a region of such DNA
(such as a DMR as described herein) wherein the first primer is complementary to a sequence on the first strand of
the target DNA and the second primer is complementary to a sequence on the second strand of the target DNA, Taq
rase, and a plurality of free nucleotides comprising adenine, thymine, cytosine and guanine; (B) g the
reaction mixture to a first ermined temperature for a first predetermined time to separate the strands of the
target DNA from each other; (C) cooling the reaction mixture to a second predetermined temperature for a second
ermined time under conditions to allow the first and second primers to hybridise with their complementary
sequences on the first and second s of the target DNA, and to allow the Taq polymerase to extend the primers;
and (D) repeating steps (B) and (C) at least 20 times. The person of ordinary skill will readily be able to design such
PCR s for use in the method of the invention, for example by use of primer design algorithms and programs
such as Clone Manager Professional 9 (Sci-Ed Software), Vector NTI (Life Technologies), or web-based tools such as
those found from bi.nlm.nih.gov/tools/primer-blast/ or molbiol-tools.ca/PCR.htm.
In embodiments utilising amplification of regions of cell-free DNA, include those wherein said amplified
region(s) comprises at least one of the nucleotide sequences to be analysed for the methylation status of one or
more Cst; such as the methylation status at a plurality of Cst (in particular of the relevant Cst) associated in
any of DMRs of the t invention; in particular DMR #141, #204 and/or #228.
Any amplified region may also comprise other sequences, such as (non-natural) synthetic sequences that
are used to identify the source (eg sample/woman) and/or the reaction. Such “molecular barcoding” is art-known.
[94] In particular embodiments, said amplification may comprise the use of the primer-pair(s) for the respective
nucleotide sequence(s) as independently selected from the group of primer-pairs set forth in each row of TABLE 3.
For example, for that embodiment of the present invention utilising the DMRs #141, #204 and #228, the applicable
regions of cell-free DNA may be amplified with the s comprising (eg, consisting of) the sequences set forth in
SEQ ID N05 94 and 125; 95 and 126; and 96 and 127, respectively. In particular embodiments, for any of said
primers comprising a Y, such primer may be a mixture of (degenerate) primers wherein the base at each Y is either a
C or a T; and for those of said primers comprising a R, such primer may be a mixture of erate) primers
wherein the base at each R is either a G or an A.
Analysis of the methylation status of the Cst within the nucleotide sequence of sts (such as
associated with or located within a DMR of the present invention) can be conducted by any suitable methodology.
40 For example, the present invention includes those method wherein the methylation status of said Cst is determined
by a technology selected from the group consisting of: ation specific PCR/MethylLight (eg, via use of real-time
quantitative PCR), Epityper, nucleic acid chip-hybridisation, c acid mass-spectrometry, xMAP (Luminex)
Methylated DNA precipitation (MeDIP, in which methylated DNA fragments are isolated/enriched via an
antibody raised against 5-methylcytosine (5mC)), Raindance (and other droplet l PCR methodology — ddPCR)
and nucleic acid sequencing, preferably, (single) strand sequencing, nanopore sequencing, hite sequencing,
such as targeted bisulphite sequencing. Sequencing (such targeted bisulphite sequencing) may be conducted to
enable ultra-high coverage. Also envisioned are embodiments wherein said determination step may be ted as
a pool and/or essentially simultaneously when in respect of two, three, four or more of said tide sequences.
As described above, the present in invention include embodiments where the ation status at said one or more
Cst may be determined using single le DNA sequencing or analysis, such as by SMRT or nanopore
sequencing.
It will be apparent to the person of ordinary skill that bisulphite-modified DNA ation sites may be
detected using eg methylation-specific PCR (such as using primers and/or probes that selectively bind to the
bisulphite-modified sequences) and/or by the subsequent use of restriction enzymes the recognition site of which is
created upon such bisulphite-modification. Methylation-specific PCR (“MSP”) is described by Herman et al
(U56200756, EP0954608 and d family members); and a further development of MSP using probe-based PCR
(known as “MethylLight”) is described by Laird et al (U56331393, EP1185695 and related family s).
Alternative methods of detecting differences in sequences that have been converted by bisulphite-
modification include mass-spectrometry methodologies (eg MASS-Array of Sequenom) or bead-chip technologies
such as the Infinium MethylationEPIC Array or Infinium HumanMethylation450 BeadChip logies of Illumina.
In certain of said embodiments, the methylation status of said Cst may be determined by bisulphite
sequencing, such as by single-read and/or high coverage bisulphite sequencing, such as described in the examples.
As described in the example, one advantage of the present ion is that the analysis of cancer-specific
DNAme ns from ctDNA is that a greater c range can be achieved than with alternative tests, such as
CA125. The dynamic range desired for such a DNAme pattern-based test for n cancer is related to the number
of molecules of said cell-free DNA (and/or amplified DNA) that are analysed in the method. For example, the more
such molecules are investigated for the presence (or absence) of the cancer-specific epigenetic markers, the greater
the dynamic range can be achieved; such as the detection of cancer-specific s in very rarely found ctDNA
les present in the total chNA of the woman.
Accordingly, in certain embodiments, the method of the present invention includes those when the
methylation status of said CpG(s) is determined in multiple molecules of said cell-free DNA and/or amplified DNA
enting each of said nucleotide sequences.
As will be appreciated, the detection of more than one molecule ng the cancer-specific DNAme marker
would increase the confidence in the determination of the presence of (or reduced se to therapy against)
ovarian cancer that has been returned by the test. Accordingly, in particular of such embodiments, the method can
include where the presence in at least a plurality of said cell-free DNA molecules of one or more methylated or
methylated (as applicable) Cst located (in ular, the relevant Cst) within one or more of said nucleotide
sequences indicates the ce of, or a reduced response to therapy against, an ovarian cancer in said woman. In
such embodiments, the ity of cell-free DNA molecules with one or more of said methylated or methylated (as
able) Cst located may be a number that is at least 2, 3, 4, 5, 6, 7, 18, 9 or 10, or at least about 15, 20, 25,
, 35, 40, 45, 50, 55, 60, 70, 80, 90, 100, 125, 150, 175 or 200, or a greater number such as greater than about
500, 1,000, 5,000, 7,500, 1,000, 2,500, 5,000 or greater than 5,000 molecules.
To achieve the desired performance characteristics of the test (such as in terms of sensitivity, specificity
40 and/or dynamic range), a greater number of total cell-free DNA molecules may need to be analysed than the number
of those exhibiting the cancer-specific DNAme marker (ie, one or more methylated or un-methylated — as applicable -
Cst). For example, in particular embodiments of the present invention, the methylation status of said CpG(s) is
determined in a number of molecules of said cell-free DNA and/or amplified DNA representing each of said
nucleotide sequences selected from the group ting of at least about: 1,000, 5,000, 10,000, 50,000, 100,000,
200,000, 500,000, 1,000,000, 1,500,000, 2,000,000, 2,500,000, 3,000,000, 3,500,000, 4,000,000 and 5,000,000
les, or more than 5,000,000 molecules.
The total number of DNA molecules to be analysed and/or that number of which, when exhibiting the
cancer-specific DNAme marker, determines the ce of (or reduced se to therapy against) ovarian ,
can differ from test to test, sample to sample, woman to woman or population to population. For example, particular
such numbers may apply when the woman carries a typical amount of or proportion of ctDNA and total chNA, and
another when she, or the sample obtained from her, is atypical in response of total/ctDNA quality or amount/ ratio.
Accordingly, the method of the present invention includes those embodiments wherein a fraction or ratio of,
or an absolute number of, cell-free DNA molecules in said sample having said ated or un-methylated (as
applicable) CpG(s) located within said nucleotide sequence(s) is estimated. To aid the process of determining the
presence or e of, or response to therapy against, an ovarian cancer in a woman, the present ion also
includes certain embodiments comprising a step of comparing said fraction or ratio with a standard or cut-off value.
For example, if the measured fraction or ratio is r than such standard or cut-off value, then the test is
interpreted to indicate the presence of an ovarian cancer in said woman; or it is interpreted to indicate a reduced
response to a therapy against an ovarian cancer in said woman, such as tence of the 0C or no response of
such CC to such therapy. Exemplary standard or cut-off values for such fraction or ratio of cancer-specific
patterns/markers for n of the DMRs of the present invention include about 0.0008 for DMR #141 and/or about
0.00003 for DMR #204 and/or about 0.00001 for DMR #228.
As described above, improved performance of the test of the present invention is achieved by various
means; including by the analysis of the methylation status of multiple Cst (eg a particular DNAme marker pattern)
associated with multiple DMRs and/or the analysis of le cell-free DNA les for such multiple Cst at such
le DMRs. Hence, an excess over a standard or cut-off value for the number of DNAme marker patterns found
at my of the multiple DMRs can be a ularly advantageous embodiment for the test of the present invention.
Accordingly, the test of the present invention includes those particular embodiments wherein a fraction or ratio of
cell-free DNA molecules with said methylated or hylated (as applicable) CpG(s) present in each of said
nucleotide sequence(s) is estimated and compared to a respective standard or cut-off value; wherein any one of such
fraction or ratios being greater than its tive standard or cut-off value indicates the presence of, or a reduced
response to therapy against, an ovarian cancer in said woman. For example, if the methylation status of Cst
d in each of DMRs #141 m #208 m #228 is determined in a test of the present invention, and the fraction
or ratios of a SEQ ID No 63 at DMR #141 is greater than about 0.0008 g the fraction or ratios of a SEQ ID No 64 at
DMR #204 is greater than about 0.00003 g the on or ratios of a SEQ ID No 65 at DMR #228 is greater than
about 0.00001, then the presence of (or reduced response to therapy again) n cancer is determined for the
woman. Alternatively, the use of multiple DMRs would enable a decision rule to be d that takes into account
the multiple DMRs by using a different cut-off for some markers depending on how many markers are positive for
existing cut-off values in a single sample. Generally, for example, lower individual cut-offs can be applied the more
DMRs that are found to give a positive result. Another example could be to define a “hyperplane” of f values in
N-dimensional space (N = number of markers measured), and for any combination of marker , it can be
determined if they fall “below” (=positive) or “above” tive) the hyperplane. Finally, a logistic regression model
could be applied that determines, for any combination of marker values, the likelihood of the outcome to be positive.
40 Accordingly, the invention also es embodiments that may incorporate such analysis approaches when two or
more of the DMRs of the invention are ed.
As described herein, the present invention also provides advantages in that the standard or cut-off value
used in respect of a particular DNAme marker can be adapted, for example in response to desired characteristics of
the test or in response to the characteristics of the chNA isolated of the woman.
Accordingly, certain embodiments of the test of the present invention include those where said standard or
cut-off value(s) is/are modified for a given sample based on one or more of the following factors: (i) the amount or
concentration of total cell-free DNA present in said sample; and/or (ii) a baseline value of said fraction or ratio
previously determined for said woman; and/or; (iii) a value of said fraction or ratio ined from multiple samples
from a population of women representative of said woman; and/or (iv) the specificity and/or sensitivity and/or
dynamic range desired for said method of determination. In particular embodiments, said standard or cut-off value(s)
may be increased when chNA blood collection tubes such as Streck Tubes, are used. For example, in such
embodiments, the applicable said standard or f value(s) may be increased by a factor of about 2, 5, 10, 20, 50,
100, 200, 500 or 1000, or by a factor that is greater than 1000.
[108] In particular of such embodiments, the standard or cut-off value may be reduced for a given sample that
has an amount and/or concentration and/or quality of total ree DNA present in said sample that is r than
a standard or cut-off value. Suitable methods for the inspection, estimation or determination of amount and/or
concentration and/or quality of total cell-free DNA include those described elsewhere . For example, if the
quality of the total chNA of the woman is lower than ed (such as a higher average fragment size than as
described herein), and/or if the total chNA amount is higher (in each case indicating that somatic DNA may have
been released from eg WBCs during sample collection, transport, storage and/or processing), then the standard or
f value used for the respective fraction or ration for the DNAme marker can be reduced. This allows for more
possibility to adapt the test to the individual situation or woman taking the test.
As a further embodiment of the test, it may be practiced multiple times on a given woman, such as 2, 3, 4,
5, 6, 7, 8, 9, 10, about 15, about 20 or more than about 20 times (such as about 50 times). Such a repeated test can
enhance the (early) detection of ovarian cancer in the woman and/or the long-term se to therapy against (or
monitoring of) ovarian cancer. Accordingly, the test may include those embodiments when it is practiced on multiple
samples; wherein each sample is collected from the same woman at different time points. For example, said multiple
samples are collected from said woman with an interval between them selected from the group consisting of about:
2 days, 3 days, 4 days, 5 days, 7 days, 10, days, 14 days, 21 days, 24 days, 3weeks, 4 weeks, 5 weeks, 6 weeks, 6,
weeks, 8 weeks, 3 months, 4 months, 5 , 6 months, 8 , 12 months, 18 months, 2 years, 3 years and 5
years.
In certain of such embodiments, it may be that the test of the present invention is conducted as part of a
routine screen of one or more women, such as part of an annual screen for the presence or absence of ovarian
cancer. For certain women (or groups thereof), the period of repeat g may be shorter. For example, women in
high risk groups (such as those with BRAC 1/2 ve/ and/or a family history of ovarian cancer and/or belonging to
certain sub-populations eg Ashkenazi women) may be tested more ntly, for e every 6, 3, 2, or 1 month.
Furthermore, those women for which n cancer has already been sed (and perhaps already d with
chemotherapy) may be repeat-tested using the present invention at a frequency of about every 6, 3, 2, 1 month, or
even more frequently such as once about every two weeks or about every week.
As has been shown for the based ROCA test, a deviation or change from an earlier t-specific
standard or cut-off value can provide a further enhanced test for ovarian cancer. Accordingly, for those embodiments
of the present invention where a woman is tested le times, the presence of, or a reduced response to therapy
against, an ovarian cancer in a woman is indicated by - in comparison to a previous sample of said woman - the
40 presence of, or an increase in the absolute number of, or an increase in the fraction or ratio of, cell-free DNA
molecules in said sample having said methylated or un-methylated (as applicable) CpG(s) located within said
nucleotide sequence(s).
As shown by the examples herein, the test of the present invention can be used in combination with other
tests for n cancer; in particular with those which reduced (or no) overlap of false positives and/or false
negatives to the test of the present invention. Exemplary such tests, including those based on CA—125, HE4,
transthyretin, oprotein A1, betamicroglobin and transferrin (such as ROCA, ROMA and OVA1) are described
in more detail elsewhere herein.
ingly, in n embodiments of the present invention, one or more additional steps may be
conducted in respect of such other tests for ovarian cancer. In particular; one optional an additional step may
comprise that of determining (eg by an in-vitro ure), from a blood sample from said woman, the amount
present therein of one or more proteins independently selected from the group consisting of: CA—125, HE4,
transthyretin, apolipoprotein A1, -microglobin and transferrin; wherein, either or both of: (i) the presence in at
least one of said cell-free DNA molecules of one or more methylated or un-methylated (as applicable) Cst located
within one or more of said nucleotide sequences (such as by an excess of any one of the DNAme marker patterns of
the present invention being in excess of a standard or cut-off value); or (ii) an amount of said protein(s) present in
said blood sample is greater than a standard or cut-off value for such amount or n; indicates the presence of,
or a reduced response to therapy against, an ovarian cancer in said woman. As will be appreciated, such additional
step related to the other test for n cancer may be ted either before or after conducting the DNAme-
based aspects of the test. Indeed, the conduct of one (or other) of the tests may be dependent on the outcome of
the first, for example to provide additional sensitivity and/or sensitivity to the other all determination, test or
diagnosis.
In such embodiments, the protein may be determined by a ROCA, a ROMA and/or an OVA1 diagnostic test.
As described elsewhere herein, the test of the present invention may be applied to different types of ovarian
cancer. For example, in certain embodiments the present invention the n cancer may be an invasive ovarian
cancer, such as an invasive epithelial ovarian cancer; in particular one selected from the group ting of: high
grade serious (HGS), endometroid, ell and mucinous ovarian cancers. In alternative embodiments, the cancer
may be peritoneal cancer or Fallopian tube cancer.
In particular; the test of the present invention may be used (or ) for distinguishing the presence of
ovarian cancer (such as one described elsewhere herein) from the presence of a benign pelvic mass in the woman.
In other embodiments, the test of the present invention may be used (or useful) for determining the
response of a woman ing from ovarian cancer to a therapy comprising chemotherapeutic agent(s) against said
ovarian cancer (such as one described elsewhere herein). For example, such a test may be conducted to predict the
risk of death of said woman, in particular from risk of death by n cancer that is not responding to
(chemo)therapy.
In certain of such embodiments, the test of the present invention may be practiced on said woman after
one, two, three, four and/or five cycles of said (chemo)therapy.
And in further such embodiments, said sample may be obtained from said woman within a period after
completion of said cycle or (chemo)therapy that is selected from the group consisting of about: 2 hours, 4 hours, 6
hours, 12 hours, 18 hours, 24 hours, 36 hours, 48 hours, 3 days, 4 days, 5 days, 6, days, 7 days, 8 days, 10 days, 12
days, 14 days, 16, days, 18 days, 21 days, 24 days, 4 weeks, 5 weeks, 6 weeks, and 8 weeks.
In particular such embodiments, it may be that a lived increase in the ratio or fraction of the DNAme
marker is observed shortly after said )therapy. t being bound by theory, this may arise due to
death/lysis of cancer cells in response to the (chemo)therapy and their shedding of ctDNA into the blood stream of
40 the woman. Accordingly, the test of the present invention may include the monitoring of such short lived (eg for 1, 2,
3, 5, 7, or 14 days) increase in DNAme marker(s) as an indication of (initial) response/success of the
(chemo)therapy. The test may then be ed to monitor the reduction of the DNAme marker(s) in chNA after
such increases, and whether the ratio or fraction of the DNAme marker increases at a later time (indicating a reduced
response to therapy t, and/or the recurrence of, the ovarian cancer.
In such embodiments of the present invention, said therapy includes one or more chemotherapeutic
agent(s), such as those one that is used and/or is approved (eg, by the European Medicines Agency in Europe and/or
by the Food and Drug Administration in the US) for the treatment of a cancer, in particular for the treatment of
ovarian cancer. In alternative such embodiments, the chemotherapeutic agent may be one in development on the
date hereof, or in the future. Examples of such chemotherapeutic agent include one or more independently selected
from the group consisting of: a platinum-based antineoplastic (such as carboplatin, cisplatin, oxaliplatin, nedplatin,
picoplatin or satraplatin) and a taxane (such axel or docetaxel). In particular; the chemotherapeutic agent may
be one selected from the group consisting of: carboplatin, paclitaxel, docetaxel, cisplatin, liposomal doxorubicin,
gemcitabine, trabectedin, etoposide, cyclophosphamide an angiogenesis inhibitor (such as bevacizumab) and a PARP
inhibitor (such as olaparib). Other PARP inhibitors in development e: veliparib (ABT-888) from Abbot, MK4827
from Merck, AG-014699 of Pfizer and Iniparib (351-201) of Sanofi-Aventis. Other angiogenesis inhibitors in
pment e aflibercept, AMG386, nib, sorafenib, sunitinib and pazopanib. Antibody-drug conjugates in
development include T—DM1, IMGN388, uzumab mertansine, AN-152, Sl(dst)-PE38, S, SAR566658,
VBfi-845, Thio Hu3A5-VC—MMAE, CDX—014, MEDI-547, SGN-75 and MDX—1203. In particular embodiments, the
chemotherapeutic agents may be carboplatin, cisplatin, paclitaxel or docetaxel, or may be combination therapies
A particular form of (chemo)therapy that may be used in the treatment of ovarian cancer, and one following
which the test may be conducted, is neoadjuvant (chemo)therapy (“NACT”).
One ular advantage of the test of the present invention is that it can provide individual-specific
therapeutic options. For example, in certain embodiments of the test of the present invention, if said woman is
ined to respond to (for example, has responded to) said (chemo)therapy, then said woman may be
designated as being eligible for tumour de-baulking surgery. As will be recognised, if a woman is determined to
respond to such chemotherapy then tumour de-baulking y is an intervention that could prove life-saving. In
contrast, if a woman is determined to not respond to said )therapy, then said woman may not be le for
such invasive tumour de-baulking surgery. However, in such ments, she may be designated as eligible for
therapy with one or more second-line chemotherapeutic agent(s) against said ovarian cancer. The response to
therapy with such second-line chemotherapeutic agent(s) may also be determined using a test of the present
invention, and if such second-line chemotherapy leads to a response (such as determined sooner by a test of the
present invention), then such woman may then be designated as being eligible for tumour de-baulking surgery.
[124] Said second-line )therapy includes one or more chemotherapeutic agent(s) independently selected
from the group consisting of: carboplatin, paclitaxel (such as alone, and as a weekly ent), docetaxel, cisplatin,
liposomal doxorubicin, abine, tedin, etoposide, cyclophosphamide, an angiogenesis inhibitor (such as
bevacizumab) and a PARP tor (such as olaparib), or any of those chemotherapeutic agent(s) described above.
The second line chemotherapeutic agent may, in same embodiments, be the same as that used in said first therapy;
but in such alternative embodiment said (same) subsequent chemotherapeutic agent is used at a different dosage,
different administration route, ent treatment regimen and/or in ation therapy together with other
treatment modalities. For example, carboplatin in combination with paclitaxel is commonly used as first line therapy,
and carboplatin (alone) may be used as the second line therapy, such as if the patient is relapse-free for 12 .
In this way, the test of the t invention provides a faster and more accurate test for determining their
40 response to (chemo)therapy t n cancer, such that the most appropriate, or additional, eutic
interventions can be made; ultimately increasing the success of treatment for ovarian cancer, an increase in
progression free survival, overall survival and/or quality of life (such as may be measured by pain suffered or
reported and/or pain-killer use).
In a first related , the invention relates to a method of ining the methylation status at one
or more Cst of cell-free DNA comprising the steps:
0 Providing a biological sample, said sample comprising cell-free DNA; fl
0 Determining, in at least one le of said cell-free DNA, the methylation status at one or more Cst (such
as one or more relevant Cst) d within one or more of nucleotide sequences,
W, said one or more of the nucleotide sequences are independently ed from the group consisting of: SEQ
ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and
31 (for example, within one or more of the nucleotide ces comprised in one or more of the respective DMRs
of the present invention independently selected from the group consisting of DMR#: #141, #204, #228, #144,
#123, #129, #137, #148, #150, #154, #158, #164, #176, #178, #180, #186, #188, #190, #192, #200, #202,
#208,#210, #213, #214, #219, #222, #223, #224, #225 and #226), or a nucleotide sequence present within
about 2,000bp (such as within about 200bp) 5’ or 3’ thereof, or an allelic variant and/or complementary sequence of
any of said nucleotide sequences.
In a second related aspect, the invention relates to a method of detecting one or more: (i) methylated
Cst associated with (such as located within) one or more of the hyper-methylated DMRs of the present ion;
and/or (ii) un-methylated Cst associated with (such as located ) one or more of the hypo-methylated DMRs
of the t invention, in each case comprised in at least one molecule of cell-free DNA of a woman comprising the
steps:
0 Providing a biological sample, said sample comprising cell-free DNA of said woman; fl
0 ining, in at least one molecule of said cell-free DNA, the ation status at one or more Cst (such
as one or more nt Cst) located within one or more of the nucleotide sequences independently selected
from the group consisting of: SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20,
21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31 (for example, within one or more of the nucleotide sequences
comprised in one or more of the respective DMRs of the present invention independently selected from the
group consisting of DMR#: #141, #204, #228, #144, #123, #129, #137, #148, #150, #154, #158, #164,
#176, #178, #180, #186, #188, #190, #192, #200, #202, #208,#210, #213, #214, #219, #222, #223,
#224, #225 and #226), or a nucleotide sequence present within about 2,000bp (such as within about 200bp 5’
or 3’) thereof, or an allelic variant and/or mentary sequence of any of said nucleotide sequences,
m, the presence in at least one of said cell-free DNA molecules of one or more: (i) ated Cst associated
with (such as located within) one or more of the methylated DMRs of the present invention (eg, as identified in
TABLE 1A), for example associated with (such as located within) one or more of said nucleotide sequences
independently selected from: SEQ ID NOs: 1, 2, 3, 4, 10, 12, 14, 15, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29 and
; thereby s said methylated CpG(s) in the cell-free DNA of said woman; and/or (ii) un-methylated Cst
associated with (such as located within) one or more of the hypo-methylated DMRs of the present invention (eg, as
identified in TABLE 13), for example associated with (such as located within) one or more of said nucleotide
sequences independently selected from: SEQ ID NOs: 5, 6, 7, 8, 9, 11, 13, 16, 17, 22 and 31; thereby detects said
un-methylated CpG(s) in the cell-free DNA of said woman.
In a third related aspect, the invention relates to a method of diagnosing and ng a woman having
an ovarian cancer comprising the steps:
40 0 Providing a biological sample from said woman, said sample comprising cell-free DNA of said woman;
0 Detecting, in at least one molecule of said cell-free DNA, whether one or more methylated or un-methylated
Cst (such as one or more relevant Cst) is located within one or more of the nucleotide sequences
independently ed from the group consisting of: SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14,
, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31 (for example, within one or more of the
nucleotide sequences comprised in one or more of the respective DMRs of the present invention independently
selected from the group consisting of DMR#: #141, #204, #228, #144, #123, #129, #137, #148, #150,
#154, #158, #164, #176, #178, #180, #186, #188, #190, #192, #200, #202, #208,#210, #213, #214,
#219, #222, #223, #224, #225 and #226), or a nucleotide sequence present within about 2,000bp (such as
within about 200bp) 5’ or 3’ thereof, or an allelic variant and/or complementary sequence of any of said
nucleotide sequences;
0 sing the woman with an ovarian , such as an ovarian cancer that does not respond to a first
therapy, when one or more of: (i) said methylated Cst associated with (such as located within) one or more
of the hyper-methylated DMRs of the present invention (eg, as identified in TABLE 1A), for example associated
with (such as located within) one or more of said nucleotide sequences independently selected from: SEQ ID
NOs: 1, 2, 3, 4, 10, 12, 14, 15, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29 and 30 is detected; and/or (ii) un-
methylated Cst associated with (such as located within) one or more of the ethylated DMRs of the
present invention (eg, as identified in TABLE 13), for e associated with (such as located within) one or
more of said nucleotide ces independently selected from: SEQ ID NOs: 5, 6, 7, 8, 9, 11, 13, 16, 17, 22
and 31 is detected; fl
0 Treating said diagnosed woman by:
o Administering, or recommending administration of, an ive amount of a chemotherapeutic agent to a
woman diagnosed as having an ovarian cancer, such as one that does n_ot respond to the first therapy; or
0 Conducting, or recommending the conduct of, tumour debaulking y to a woman diagnosed as
having an ovarian cancer that does respond to the first therapy.
In such related aspect, the chemotherapeutic agent and/or the first therapy may be one as described
elsewhere herein.
In certain embodiments of such related aspect(s), the methylation status of said CpG(s) may be determined
according to one or more of the ponding embodiments of the other aspects of the present invention; including
for e, that said cell-free DNA of the woman may be subjected to an agent that differentially es said DNA
based on the ation status of one or more of the Cst, and/or that the methylation status of the one or more
the Cst is determined without use of such an agent (such as, by single molecule sequencing/analysis of DNA). In
certain embodiments of such related aspect(s), the methylation status of said CpG(s) may be determined by the
detection of a nucleic acid of the third aspect, such as the detection of a (eg non-natural) nucleic acid comprising at
least about 15 contiguous bases comprised in SEQ ID No. 32, 33, 34 and/or 35.
In further certain embodiments of such related aspect(s), the/a biological sample may be collected and/or
further processed ing to one or more of the corresponding embodiments of the other aspects of the present
invention. For example, the ical sample may be ed from a woman having or suspected of having ovarian
, or suspected to not have responded to therapy against ovarian cancer. In any such embodiments, the
biological sample may be, or may be obtained by, any of the corresponding embodiments of the other aspects of the
present invention.
In further of such embodiments, the method of detecting said methylated or un-methylated (as applicable)
CpG(s) (in particular, one or more relevant Cst) may se the step of determining the ce or absence of,
or response to therapy against, an ovarian cancer in said woman, wherein the detection in at least one of said cell-
40 free DNA les of one or more methylated un-methylated (as applicable) said Cst located within one or more
of said nucleotide sequences tes the presence of, or a reduced response to therapy against, an ovarian cancer
in said woman.
In a second aspect, the invention relates to a chemotherapeutic agent for use in a method of therapy of
ovarian cancer in a woman, wherein said chemotherapeutic agent is administered to a woman within about three
months of said woman having been predicted and/or determined, using a method of the first aspect, to n_ot d
to a therapy against ovarian cancer.
In a related second aspect, the invention also relates to a method of treating ovarian cancer, comprising
administering an effective amount of a chemotherapeutic agent is administered to a woman within about three
months of said woman having been ted and/or determined, using a method of the first aspect, to n_ot respond
to a therapy against ovarian cancer.
In certain embodiments of such second , the chemotherapeutic agent is one that is used and/or is
approved (eg, by the European Medicines Agency in Europe and/or by the Food and Drug Administration in the US)
for the treatment of a , in ular for the treatment of ovarian cancer. Examples of such chemotherapeutic
agent e one or more independently selected from the group consisting of: carboplatin, paclitaxel, docetaxel,
cisplatin, liposomal doxorubicin, gemcitabine, trabectedin, etoposide, cyclophosphamide an enesis inhibitor
(such as bevacizumab) and a PARP inhibitor (such as olaparib). In other embodiments, the chemotherapeutic agent
may be any one of those described elsewhere herein.
In any embodiments of such second aspect, the chemotherapeutic agent is administered to said woman
within about 3 months, or about 70, 56, 53, 49, 46, 42, 39, 35, 32, 28, 25, 21, 18, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4,
3, or 2 days or less, such as within about 24, 20, 18, 15, 12, 10, 8, 6, 5, 4, 3 or 2 hours, or within about 1 hour, of
said prediction and/or determination. Also envisioned by the t invention, is that such chemotherapeutic
agents can be used in combination formulations and/or combination treatment regimens with another
chemotherapeutic agent, other pharmaceutical agents and /or medical intervention such as radiation treatment or
surgery.
A chemotherapeutic agent may be administered to said woman by the applicable or tional mode of
administration, such as intravenously, intramuscularly, intradermally, orally.
In such second aspect, said prediction and/or determination is made using a method of the first aspect.
That is, an embodiment of such method of the invention may be practiced, such as to determine or to predict (eg by
an increased likelihood) that said woman has not responded (or will not respond) to a first therapy against the
ovarian cancer she is suffering from; or that she has not responded (or will not respond) completely, sufficiently
and/or within a predetermined period of time (such as about 12 months, 6 months, 4 months, 3 months, 2 months,
or about 4 weeks or 2 weeks, or about 1 week).
A first y against the ovarian cancer may be surgery, such as tumour de-baulking surgery, or it may be
treatment with a chemotherapeutic agent such as one described above. Whilst in one embodiment, the uent
chemotherapeutic agent used after said tion and/or determination is ent to a chemotherapeutic agent
used for said first therapy, in another aspect said subsequent chemotherapeutic agent is the same as that used in
said first therapy; but in such ative embodiment said (same) uent chemotherapeutic agent is used at a
different dosage, different administration route, different treatment regimen and/or in combination therapy together
with other treatment modalities.
In the context of the invention, an effective amount of a chemotherapeutic agent can be any one that will
elicit the biological, physiological, cological, eutic or medical response of the woman that is being
sought by the pharmacologist, pharmacist, medical doctor, or other clinician, eg, lessening of the effects/symptoms
of the ovarian cancer.
40 [141] In a third aspect, the invention relates to a nucleic acid comprising a nucleic acid ce consisting of
at least about 10 contiguous bases (preferably at least about 15 contiguous bases for any DMR other than DMR
#222) comprised in a particular (eg non-natural) sequence derived from one selected from the group consisting of
one set out in TABLE 1A, TABLE 1B or TABLE 2A (for example, a sequence consisting of at least about 10 contiguous
bases (preferably at least about 15 contiguous bases for any DMR other than DMR #222) sed in a sequence
producible by (such as produced ing) hite conversion of a sequence comprised within a DMR selected
from the group consisting of DMR#: #141, #204, #228, #144, #123, #129, #137, #148, #150, #154, #158, #164,
#176, #178, #180, #186, #188, #190, #192, #200, #202, 210, #213, #214, #219, #222, #223, #224,
#225 and #226; such as a sequence consisting of at least about 10 contiguous bases (preferably at least about 15
contiguous bases for any SEQ ID other than SEQ ID: NO:58) comprised in a sequence selected from the group
consisting of: SEQ ID N05: 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54,
55, 56, 57, 58, 59, 60, 61 and 62 (such as SEQ ID NO: 32, 33, 34 and/or 35), or an allelic variant and/or
complementary sequence of any of said tide sequences. In particular embodiments, said number of
contiguous bases is at least about 16, 18, 20, 22, 24, 26, 28, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95,
100, 110, 120, 10, 140, 150 or 160 bases, such as between about 80 and about 160, such as between about 100
and about 160, in each case, independently, up to the maximum number of bases within the sequence ed from
said group.
TABLE 2A: DMR-correspondence and possible sequences of the hite-converted DMRs of the present invention
. . . . SEN%ID
DMR# Blsulphlte-converted ampllcon sequence (all Cst are underllned)
"A""YGGAGGT"TAGGGGTGAGGAT""g§""Ag§GGAAGGAGGTATAggATTTAG""TATGA"ATX§
141 "TA"""ggGgg"GGTG"TG"AGGGGGAAG""TAGGTA"""AngAGGATAGGA""ggGGGAA""g§T 32
GAHAHnYGGHGGAGAGHXEHAGHHGmAYGHXQXQGGGHAHHAGGXQTAGTAYGHHAHXEXEXEHGGG
204 "g§"AG""GG"AG"A"AGGAAG"""AGG"GGAAGAGYGGYGGYGTGGGYGG"”YGGYGYGGYGYGGY 33
EAGHG_§GGHHGGHAHX§GH
G44AHA“GGGXQAGHHGm“GHAGHGYGGHAGHHAGGXEHHAYGYGGGXEGGHHHHHHHHXEGHHHTH
228 34
KEG“finGmAXEGHAHfinAXQGAHHAHHHGGTHHYGYGGGHHHHH
AAHAGGHHAGAYGTGGGHfinAT“AGGGYGGYGHXEHTAAGGHHHAGAYGHHAHYGHGHAGGAGGGAX
144 —AYGAF1I—1r1r'lr'lTTr'lAEr'n—‘Ir'lr'lflr'lGGr'lr1r'lr1AAr1riflGEr'lr'lr'n"!Gr'lr1ATTr'lr'lr1GAr1r1EGI—‘IGAAF1AF1AF1 35
AHHAGA
GYGAAGHAGGAGHAGHAGHXEGGHHAHAYGAGHHnnzgnnYGHHHHGGHHXEGGHHHHHHXEAGHTn
123 36
AGAHAHHAGHXEAGGHAGHGXEGGHAAHAGGGHHAGTT“HHXQHHAGGAGAGA
AA""""G""GAG"GAG"""A"AAA"AGGGTA"AA"X§AGAYGYGGGAA"G"""GGG"X§"YGYG"AG
129 ———— 37
AHAHXEGGHAGGGHXEHHA“A“THAGHGGGHHAGHAAAAAXEGHGHTAAGHGA
AnnnYGHHAHAHAHAHAGHHGHAHAYGGHAHAAHAYGYGGHTAHAGGTNAHHHHAGGHYGHTTXEGG
137 38
AGAA“nfinAXEHAGHHAHAXEHAGAHAGAAGAHAHTfinAXEGGHAHGGGTGHHHAGHHHHHXE
GAGGHAAHGGAAGYGGHHAHfinfinGmTnAYGTHnYGYGHHAGGHAGAAGYGAHXEGGGHXQAAHAXE
148 39
AHHAXEHHfinTGAAHAXEGGXEHHGmGmNAHGGGHGHHAXEGAHGHHAHAHAH
GYGGGTA”""GTAG"T""AG""A""YGGGAGG""GAGGYGGGAGAA"GGg§"GAA""YGGGAGGYGG
150 'lr'lGr'IAGEAGTEAGAI—‘IYGYGF'IF'IAF'IEF'IAF'IF'Ir1TAGr1r1r'IGGGEAI—‘IAGAGEAGATF'ITEI—‘IF'IF'IAA 40
nfinnYGGAGHAXEGAGHHTAGGTHAGTGGTAGHXEATHNAGTTnAYGAGAHHTHHHHAXETYGHHHH
154 AAAA""AAAAXQGAGT""AATAXQAAG"TGGG"GAAG"X§"AG"""G"AGGAG"”AGGGAGA"GX§" 41
GA“finAGHTnAAAAAAAGAAAAAAATAGGGTXEGGYGYGGHGGHAHAYGHHHGHHAHTTHAGHAHHH
158 "GGGAGG"X§AGGX§GG"GGAT"AX§AGGTXQGGAGA"X§A"A""AT"""GGG"AA"AX§GTGAAA" 42
GA“nYGYGAGGHfinTnNAGHAGHHTAN“AXEGGAXQGXEGHGHHNAGHHHAGTHHAGGGHAAHHGGG
164 I"II"II"II"II"IF1GAGAGI"!F1EAI’1I"!TI"!F1AI’1EGI"!F1I’1GGGAGEAGTGGI"!F1EAGI"!F1I’1AGAI’1GI’1I’1GGGAAI’1EI’1X 43
“AAA“NATTTnfinNAHHAAAHTGHAHGAAGAAGGHXEGGYGYGGHGGHAHAXEHHHGTAAHTHHAGH
176 Ar'lr'lr'lr'lGGGAGGF'IEAGGEGGEGAF'IF'IAEAGGF'Ir'lAGGAGAr'IEAGAI—‘IF'IAEGF'IGAAATF'IF'IEF'IF'IF'IF'I 44
178 GG"AGGAGg§""""A""ATGggTAAG""g§"GG""TGGAGAGg§"TGAAGGTGGGAGGGGGAAGAGG 45
GG"AGAATTT"YGYGGGAGYGAGYG"A"AG"TG"YGTTTYG"GG"YG""TYGGGAATYG""GG"""Y
gGT"T"GG
r'lTGr'IAGAAGETATI—‘ITF'IGr'lr'lGAAr'lAr'lr'lr'lYGAGGAEI—‘IGF'IF'Ir'lr'lr'lETAr'lAGGGAGYGI—‘Ir'lYGTr'Ir'Ir'Ir'IGr'I
180 r'lGGGGF'ITGGAGEGEF'IF'Ir'lGGAGGr'IYGAr'IAr'Ir'lEGTEr'II—‘IGF'IF'IGGATr'n"!r1TTEI—‘IF'IF'IGF'IEF'IF'IF'IF'IF'IG 46
ygnGnnAGTnAGGAnGGnnNYGAnnnnnnGAnTTygnGAnnAGnnygnnnngTnnnnnAAAGnGnn
186 "AAAGGXETGAG””A"YGYG""X§GG""X§AGA""T"1""G""""""""AAAAAAAAAAGG""""""GGG""""G"1 47
GGnAnnnnGGGA
AGAG'I'IG'IA'IT"YGAAGA"""TAGA"""EAGAG’ITGYGGAAAYG"TAEAGGA'I""G'TIAA'TIAGG
188 r'lr'lGEGGF'ITAAF'IF'IAGAGF'IF'IGGGAAGAI"!r'lEAATAI—‘IEAF'IF'Ir'lflr'lr'lr'lEGTr'ITTr'IGr'IAGr'Ir'IEGAI—‘IAF'I 48
mAyGrm
G""AGAX§AGAG"""GGGG""AA"G"YGAGG"GGAGX§AYG"TGG"AX§G"AA""""GAG"""GYGY
190 49
EGH“EGETHAFWrmrmGGrmrm“£quGrmGGrmGGAmm
EGHAGGH“ArmHAGHAGTAGGGW“TAEHEGWfiyGfiyGATGfiTTHAGAAGGmAGW
192 YGAAGAGYGG""YG"A"AYG"""GYGGGGTAGTG’IAG"“I'IG’IEG'IGYGG'IAG’IAA"TGAG’IA’IA’IA 50
GGEAAGAE
AAT"‘AGT""‘AG"‘AA"‘YGGX§A"‘"1'""‘AAGYGYGGYGA"YG"‘AAAGGGAG"‘G""""TGT"WA”""YGYGW”1
200 51
AGAT'1mHmHmHXEGHAGGAATAHAGGAHHTAHHHGHHAGHGG
G"GEAA’IAAGA’YGGGE’W"flr‘fl"YGAYGYGAAGGGG"“IGT"TG'IGYGYGGE'I'IGEGG'W"
202 TerGYGYerGGGGu—wGu—wGENGr-uGETGr-ur-uEGGr-ur-uEGr-n—wr-ur-uGTGr-uGr-uGr-uAr-uYGYGGGr-ur-uTGTTr-uAG 52
AGTEGGA’I’IA’IYG
AHAWAAWrmG“NEGGHAEGHGGWrquGnmGHAAWAGHAWWGGGAGGHEAGGEGG
208 53
AYGAGG""AGGAGATEAGA’TIA"T""GGEAA'IA"GG’IGAM'I'I’IE
AHAGAHNAN—1GrqAGGAnNAN—1runrunGrqGrqNTnTTAAAATnNTrunnnnTTEnnTnAnTTnAT
A An G T A AAn n 54
"E""EGGAA"1GGGAA'1ATAG'1I"A"‘A"‘A"1GGGAAAAYGYGGTG"‘AGGGAGAAAA"1 I'"AA"1T'1AG'1GA
213 55
GGAGXQGAGGX§"AGGA""G"GGAG"G"G"A"TX§G
""G""TAAAGGYG"AGAGGAG"AG""GGGAAXEAGAATAAAGXQG""AGG"""""""X§GAGGAAGG
2 14 56
AAGGAGAGAG"1""1""AGGAAA""AG"1"GA
GGAHGAAGGAHHHNTGTATnAnnGmGAHGGHnAnGGyngGTTGnnnGGGnnnnnnnnnnnngTAG
219 57
G"AAGGGAGGAGG"AGGGGAAGGGA"A"GTG"Tr1
NAGGTnAnAGGAAGAGGTAnmmmmNATAGAHGAXEGHHGHAAAAHHNTAAGHHGAGHHHHHHTAGGA
222 58
AAGAGAGAG"GGT"GA"AA""AG"AGAGAGAGGTTT""AA"""AXQGAAGTG"""G"AA"A"AA""T
223 59
mmqunAnArmAGmTGn
GGnrunmmnnnnnYGAGnnAnGAAGAGTHGrqmmGEGHHATrunquGTnTnETAnnTETnrm—qnGrm—qA
224 60
r1mmrqAGGnnnnnGnAAnnqunnTAAflnnn
GAAGH r'lr'lGAnAnnranGGn r'lr'l r'IAAAr'IAr'IqunnquGTrqAnAAnAflAnAnTTAGGGAHAGAHAHTmm I”!
225 61
“A“GHAHAGHAAGFWGHGG
GGGGGGA"1""G""YG"1 ""AA"1 """"A"‘TGT"1TAATGA"‘YGYGG"‘TYGYGYG"‘T"1YGAGTAA"‘YGGGTGA"‘G"1
226 62
ATGTGGAWGHGHAHAWWEHGG
Each Y, independently either C or T/U
In certain embodiments of such aspect, one or more of the bases identified by “Y” in such sequences of
contiguous bases is a U or T (preferably, a T). As will now be apparent to the person of ordinary skill, such
sequences (ie, those comprising a U and/or a T at one or more bases identified by “Y”) are non-natural sequence as
the ce is produced following conversion of a cytosine in a natural sequence by bisulphite. In ular of such
embodiments, such a nucleic acid of the t invention comprising two, three, four, five, six, seven, eight, nine or
ten (up to the maximum number of “Ys” present in such sequence of contiguous bases) Us and/or Ts; and in more
particular of such embodiments, such a c acids may comprise at least one, two, three, four, five, six, seven,
eight, nine, ten or more than ten (up to the maximum number of Cst present in such sequence of contiguous
bases) Cs at any of the bases identified by “Y” therein, such as those “Ys” within Cst (such as relevant Cst)
d in such sequence of contiguous bases. In particular embodiments, two, three, four, five, six, seven, eight,
nine, ten or more than ten of the bases identified by “Y” therein may be a U or T (preferably, a T), such as all of the
bases identified by “Y” therein may be a U or T (preferably, a T), or all but one, two, three, four or five of the bases
identified by “Y” therein is a U or T (preferably, a T) and ably all other Y’s therein (in particular; those in Cst)
may be Cs.
In other embodiments, such a nucleic acid of the invention ses a nucleic acid sequence consisting of
said number of contiguous bases - for example, at least about 10 uous bases (preferably at least about 15
contiguous bases for any SEQ ID other than SEQ ID: NO:89) - comprised in a particular (non-natural) sequence
ed from the group consisting of those set forth in TABLE 2B: SEQ ID N05: 63, 64, 65, 66, 67, 68, 69, 70, 71,
72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92 and 93 (such as SEQ ID NO: 63, 64,
65 and/or 66, or SEQ ID N05: 63 and 64 and 65), and in particular of such embodiments, said nucleic acid comprises
a sequence ed from said group, or in each case an allelic variant and/or complementary sequence of any of
said nucleotide sequences. As will be apparent, typically a bisulphite converted [un-methylated) cytosine would be
detected as a T, particularly after an amplification (such as a PCR) step. However, certain detection logies (for
example, those able to detect single molecules) may be able to directly detect a hite ted (unmethylated
) cytosine as a U. Accordingly, the sequences of TABLE 2B are also oned to encompass the
analogous sequences where, instead of a T representing a bisulphite ted (un-methylated) cytosine, such T is
instead a U. The location of such Ts (eg, C in the genome sequence outside of Cst) will readily be identifiable by
the person of ordinary skill by comparison of the sequences presented in this TABLE 2B to the corresponding
genomic sequence presented in TABLE 1A or TABLE 1B, as applicable.
TABLE 2B: Particular patterns of epigenetic markers associated with the presence of ovarian cancer detected by
particular (non-natural) ces of the DMRs of the present invention
Total
Marker Detected sequence for No. of SEQ
DMR No. 0C specific pattern
coordlnates marker (relevant Cst relevant ID
# of of meth lation
(hg 19) y
are underlined) Cst N0.
QF‘F‘AQGGAAGGAGGr1Ar1Ag
ch r5: 178004422- GArmTAGWWAHGAHAACGHT
141 7 7 1 63
178004505 gm.HEGEHGGHGHHGfiGG
GGGAAG......AGG..A......A..§
QF‘CGCGGGGTF‘WAoogw
G..A_F........CGCGCGHGGGHE
ch r1: 15181081 1- G"AGT"GG"AG"A"AGGAAGT
204 18 16 1111111111111111XX 64
151810917 “NAGGHGGAAGAGEGEGE
"GGGQGW‘EGCGCGGYGYG—
chr2' 219736301- YGGF‘"GF‘F‘AGGQTW‘CGCGG
228 GYGGGF'IF'Ir'lr'lr'lr'lr'lr'lEGr'lr'lr'lTT 9 7 X111X1111 65
219736362
EGHrmeanAmmg
GGEGE..§WAAGGWHAG
chr19:58220438- ACG""""CG"G"AGGAGGGAC
144 11 11 11111111111 66
58220517 EAEAH..............A§...WT§
EHGGWWAAWEGE
Ch r 61 :1271180_ _GAG—G—GGG
123 r'IEGGr'Ir'Ir'Ir'Ir'Ir'IEAGr'Ir'Ir'Ir'IGr'I 7 7 0000000 67
1271240
"EAGG""G"GE
chr11'69054672- "G"GGGAA"G"""GG
129 G"YG"YGE”AG""A“‘EGG’I 8 4 XO0XXO0X 68
69054732 AGGGHYGH....T..........G..G
chr12:132896310-
137 7 7 0000000 69
132896382
111YG11111111G111G11111TGGTTG
chr2:72359624- AAG11GA1111GGGGTYGAATAYG
148 11fiG—111111GAA1AT—GGGY 10 5 X0000XXXOX 70
72359687
_GGGAGG111 111GAGG1_GGGAGAA
11 GGF—GTGAAr“rm—GGGAGGEG
chr7:156735054—
150 AG1111111GA1G11_GAG1111_GAGA11: 11 11 00000 71
156735141
fl1111A11E11A1111AGT1111G
G11YGA1 1111AG 111111§AGA
70112163- r1r1r1r1r1ACGTCG 1r1r1r1AAAAr
154 7 6 X111111 72
70112238 AAAACGGAG11, 11AA11A§AAG
1111GGG GAAG g
YGGGYGEG11GG111111A_G11111
chr16:74441727- G1111AT111111AG11A11111111GGGAG
158 9 7 XX0000000 73
74441802 GAGG1_G1GG11GGA1111AEA
1GGGAGA111_G
YGGGAYGGYGG11G111111AG
chr4:174427946- AG111111AGGG""AA”"GGGFVW"
164 7 4 XXX1111 74
174428028 T11GAGAG11TG_GA1WE
G111111GGGAGc_GAG11GG1111§
YGGG11G11GG11GG111111AYG111111
chr6:119107238- G11AA11111111AG11A11111111GGGAG
176 9 4 XO0XO0XXX 75
119107313 GTEAGGEGGYGGATTAYGA
GG11TAGGAGA11YG
YG11 GG1 1GGAGAGYG1111GAA
chr19'13215437- GG'.GGGAGGGGGAAGAGGGG1
178 AGAA1111 111YGc_GGGAGc_GAGg 10 5 XXX1111X1X 76
13215527
AG1111G11c_G1111 TYG11G1G1
@111111YG
YG11G1 111YG11A11AGGGAGG
chr3:192125880- G1111YG1111111111G1111GGGG11TGG
180 AGEGETTTGGAGGTEATA 9 6 XX1X11111 77
192125950
1110_G111G§
YG"GA"”AG"”YG"""EG"T
chr22:21483273- 1111AAAG11G1111GGGA1111AAA
186 GG1_1G111GAG1“"A’mGr‘Gr‘EGG 8 6 XX000000 78
EAGA11111111G11—111111AAAAAA
EAGAG'WGYGGAAAYGW‘AY
18497159- 11111G1111AA1111AGG1111G
188 YGGG1111AA 11AGAG 111GGGAA 9 4 0XXXX000X 79
18497245
GATTEAA A11TGA ETT
chr9:79629090- @AGG"GGAGC_GAC_G GG11A
190 §G11AA11111111GAG111111GCGCG 8 8 11 80
79629145
GTr-‘EGEHHAW11""
ETEGTT11E11§A11G111111T
chr12:75601322- AGAAGG1111AG11111111111111111§A
192 AGAGQG"11§11A11Ag111111G 11 11 11111111111 81
75601409
EGGGTAG11 11AG111111G11§G
chr9:138999208- flGfiA’"
200 G111111111111G 7 7 1111111 82
138999265 AG11AGA111111111111
YG11YG11YGAYGYGAAGGGGT11
chr1:2987530- G111111G11GcGCGGYGT11GYGGG
202 1111CGCGCG11GGGG11GTGG 18 11 XXXXX11XX111111111 83
2987630
G11G11GETGTTEGGTTEGT
111111G11G111G111G11A11CGCG
208 chr8:55467547- A2""TG"AA"T"TAG"ATT" 6 6 000000 84
55467607 "GGGAGG"EAGGEGGEGA
""AEAGG’I’IAGGAGA'IE
chr12:123713533- ""r“""AAAA’I’IT’I’ITT’I’ITTC
210 - 1 1 1 85
123713562 9 A
chr2' 106776970' GAAAACGCGGHGHAGGGAGAA
213 AA""AA“"I'IAGTGAGGAGQG 4 4 1 11 1 86
106777018
AGGQHA
chr3:141516288- GAACGAGAA"AAAGCGG""AG
214 3 3 111 87
141516321 GrmfirwngoAG —
Chr16:30484192- GCG""G""G"TTGGGTT""TT
219 T—....C_GTAGGTAAGGGAG 2 2 11 88
30484232
h : 11 1 4 -
222 $122093? 69 NN 1 1 1 89
chr10:120489276- AGAGAGG’I"T’I’IAATTr‘ACGG
223 — 1 1 1 90
298 AA
chr11:1874066- TrmGCGGnrqumTGGnTTTC
224 — 3 3 111 91
1874099 EHAT%_GHTHW.
chr7:142422227-
225 Gr'lr'IAr'IAAr'IAEAI—‘IATF'Ir'IAG 1 1 1 92
142422245
chr1:3086483- A""G"GG"TTGTGTG""TTGA
226 G..AA—..T_GG — 7 7 0000000 93
3086511
In sequences, each Y, ndently, C or T/U
In methylation pattern, each ndently: 1 = methylation, 0 = un-methylation and
X = either methylation or un-methylation
In a fourth aspect, the invention relates to a nucleic acid probe that is complementary to the particular
(eg tural) sequence of a nucleic acid of the third aspect, preferably wherein said nucleic acid probe is labelled.
In n of such embodiments, the label is a able moiety such as detectable fluorescent moiety.
Examples of le fluorescent moieties include, but are not limited to, 6-carboxyfluorescein (6-FAM), VIC, HEX,
Cy3, Cy5, TAMRA, JOE, TET, ROX, R—phycoerythrin, fluorescein, rhodamin, Alexa, or Texas Red. Said nucleic acid
probe may further comprise enhancers and/or quencher molecules Iowa Black FQ, ZEN, Iowa Black RQ, TAMRA,
Eclipse, BHQ-l.
Such a nucleic acid probe has utility to detect the nucleic acid of the invention to which it is mentary,
such as in the/a method of the first aspect of the invention, such as by hybridisation (and detection thereof) between
said probe and its mentary nucleic acid of the invention.
In particular embodiments of said aspect, a nucleic acid probe of the present invention ential may bind
to its complementary nucleic acid of the ion depending on the methylation status of one or more CpCs within
said nucleic acid ce. For example, a nucleic acid probe may be designed to bind only (or preferably) to: (i) a
nucleic acid used in the method of the t invention when an un-methylated cytosine in a CpG has been
converted to U or T (following bisulphite treatment of an un-methylated such CpG); compared to (ii) a nucleic acid
used in the method of the present invention when said cytosine has not been converted following bisulphite
treatment (ie, when such CpG comprises 5-methylcytosine). As will now be apparent to the person of ordinary skill,
such specifically (or entially) for binding/hybridisation nucleic acid probes may be designed using routine
methodology following the disclosure of the complementary sequences herein; and will readily be usable in array
based and/or PCR—based detection technology, such as MethylLight, MSP, or BeadChip (eg Illumina Epic arrays).
In a fifth aspect, the invention relates to a PCR primer pair for ying a nucleic acid sequence
consisting of at least 10 contiguous bases (such as the number of contiguous bases described elsewhere herein, and
preferably at least 15 contiguous bases for any SEQ ID other than SEQ ID NO:58) comprised in a sequence selected
from the group consisting of: SEQ ID N05: 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50,
51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61 and 62 (such as SEQ ID NO: 32, 33, 34 and/or 35), or a nucleotide
sequence present within about p (such as within about 200bp) 5’ or 3’ thereof, or an allelic variant and/or
complementary sequence of any of said nucleotide sequences.
In certain embodiments of such aspect, at least one primer of said pair may include a sequence
corresponding to at least one (eg non-natural) bisulphite-converted CpG; such a primer pair having particular y
in amplifying (eg by PCR amplification) bisulphite converted sequences. Indeed, in other embodiments, the primer
pair may be a degenerate primer pair such that two version of at least one of said primer pair are t such that
both the bisulphite-converted CpG (ie the CpG is un-methylated and converted to WT) and the non-converted CpG
(ie the CpG comprises 5-methylcytosine and remains as C) are amplified/detected.
In particular ments, a primer pair of the present invention is one selected from the group primer-
pairs set forth in each row of TABLE 3.
TABLE 3: Particular primer pairs and predicted amplicon size
DMR# Primer ce 1 5?:ng Primer sequence 2 SEE)? Amspgémn
141 GAGGTTTAGGGGTGAGGAT" 94 TTCCCCRAATCCTAT 125 136 bp
204 EA’IA"TYGGTGGAGAGTYGTAGT"G" 95 ACCRATACCAACCCRCACTC 126 154 bp
228 G....T..A..GGGYGAGTTG....G..AG..G 96 fié-AAACCCRCRAAACCAAAAAA 127 111 bp
144 G’ITTGAYGTGGG'I'IT'ITTAG 97 zgfifigéifiicmcmmc 128 140 bp
123 EXGMGr‘AGGAGr‘AGT"G"YGGGT"T 98 232::EggéACRAAAAACTAAC 129 120 bp
129 é:;:;::;TGAG"GAG"T'IATMA’IA 99 Xgécm‘AACACCRTTTTTACTA 130 120 bp
137 QEQEfgggTATATATAGHNGHAWY 100 CRAAAAACTAAACACCCAAACC 131 130 bp
148 GAGG"AA"GGAAGYGG""A"“I'IT’IG 101 giggizgigmccmmcmcc 132 120 bp
150 GYGGGTA..T..GTAGTT.1..AG....A..T 102 :::T"TAAACRAAATCTCRCTC" 133 137 bp
154 :g;::GGAG""YGGAG’I’ITAGGT"AG 103 :fiigigiTCTCCCHAACTCCH 134 137 bp
158 :2;;:TGTT"”AAAAAAGAAAAAAAT 104 :2:;::EACCRTATF"ACCCAAA 135 136 bp
164 Sgr‘YGYGAGG’“"T’I’IAGTAGT'ITA 105 :fiSRACRATTCCCAACATCTA 136 138 bp
176 gfi;::ég:T"“I'I’IA'I'IAAATTG’IAT 106 :2:§§AAACRAAATTTCACCRT 137 138 bp
178 EETAGGAGYG""’"IA'I’IA'IGYGTAAG 107 ECAAAACCRAAACCAACRATTC 138 142 bp
180 :::gg:gé:GYG"A"T"”G'ITGAATAT 108 égéfiggRACMACRAAAAAA 139 135 bp
186 ES::;::§ET"AGGATGGT’I'IYGATT“I 109 ESCCAAAA’IACCACAACCCAAA 140 146 bp
188 AEAG""G’IA’ITTYGAAGA’I’I’ITAGA" 110 igiTAAAwTCCRAACTACAA 141 141 bp
190 G’ITAGAYGAGAG"TTGGGG’I’IM'IG" 111 ZEEXECAACCAACMCRMMA 142 109 bp
192 i:G"AGG""AT""AGTAGTAGGG"”" 112 SEESXECRCCTATATACTCAAT 143 144 bp
200 :éT’IAGT""AG’IAATYGGYGA’IT’I’IA 113 giggiéczxAATAAATCTATA 144 115 bp
202 M’IAAGA"YGGGYGTT" 114 EE‘EHAAHCCCRACHCHAMCAA 145 148 bp
208 §::2;TF"AA"TTTGFTYGGGTAYGGTGG 115 :fiéigggACCZ-WAW‘CRCCA 146 121 bp
210 G’IAAAAAATMAGGAA’IATG 116 g:g§:§g§:§:gACTA"AAAAC 147 92 bp
213 EggéGGGMTGGGMTATAGHTAN 117 ACACAC'ICCACAATCC 148 103 bp
214 QQG’W"AAAGGYG"AGAGGAG"AG"" 118 gé::;CC"AAAACTCTC 149 94 bp
219 :EéggéigcémTT"TGTAT"A""G"G 119 éfiCACA’IA'ICCCTTCCCCTAC 150 101 bp
222 120 23:33:32.2?2222222222 151 70 bp
223 AAGAGAGAG’IGGTTGA'IAA'WAG'DAG 121 igiégzéigigigmmmym 152 84 bp
224 EEET’I’I"TT’IT’IYGAG’ITA’IGAAGAG 122 :figigfigé-AATTACAAAA 153 97 bp
225 :flgg::A’IA’IT’I"TGG’I’IT’IAAA" 123 E::§ETATACA"AAAA 154 86 bp
226 ggggoATTGTYGWAATWAWGT" 124 :gigifiigATACACAA’ICCAC 155 91 bp
Each Y, independently, C or T; each R, independently, G or A
In a sixth aspect, the invention relates to a plurality of nucleic acids comprising least two, three, four,
five, six, seven, eight, nine, ten or more (such as about 12, 15, 20, 25 or 30) nucleic acid sequences of the third
aspect and/or of the nucleic acid probes of the fourth aspect and/or of the PCR primer pairs of the fifth aspect (for
example, such PCR primers for amplifying at least 15 contiguous bases of SEQ ID NO: 32, 33, 34 and/or 35, in
particular at least 3 pairs of primers for amplifying at least 15 uous bases of at least SEQ ID NO: 32, 33 and
In certain embodiments of such aspect, said plurality of nucleic acids may be in any form that is applicable
to the practice of the invention (or its storage or preparation), such as in the form of an ure or an array. For
e, such arrays may se a microtitire plate or a hybridisation chip.
As will now be apparent to the person of ordinary skill, any of such nucleic acids (including the probes
and/or PCR primer pairs) of the t invention may be synthetic (ie, synthesised by chemical and/or enzymatic
means/methods practiced in-vitro), and/or may be isolated and/or are not natural occurring or are used or present in
a non-natural composition or mixture. Furthermore, any of the methods of the present ion may produce (and
hence a composition or any nucleic acid of the present invention may comprise) an in-vitro-produced nucleic acid
molecule, such as a DNA product of a PCR reaction (eg a “PCR product”). One or more of such in-vitro-produced
nucleic acid molecules may be non-natural because they comprise a nucleotide primer and/or probe that includes at
least one non-natural substituted base, able label or bases, such a nucleic acid molecule having been
generated by polymerase extension (or partial nuclease digestion) or bisulphite or enzymatic conversion of such
c acid (eg a labelled primer and/or probe), and hence providing at least a fraction of such nucleic acid
molecules that include a non-natural base or detectable label, such that even though the nucleic acid sequence of
the nucleic acid les may othenNise comprise a naturally occurring sequence (or fragment f), such an in-
vitro-produced nucleic acid molecule is non-natural by virtue of (at least) the non-natural base and/or detectable
label that it includes.
In a seventh aspect, the invention relates to a kit (for example, one for determining the presence or
absence of, or response to therapy against, an ovarian cancer in a woman), such as a kit of parts comprising two or
more separate compartments, holders, s or containers (eg each holding a different component of the kit),
n said kit comprises:
0 two, three, four, five, six, seven, eight, nine, ten or more (such as about 12, 15, 20, 25 or 30) nucleic acid
sequences of the third aspect and/or of the nucleic acid probes of the fourth aspect and/or of the PCR primer
pairs of the fifth aspect (for example, such PCR primers for amplifying at least 15 contiguous bases of SEQ ID
N05: 32, 33, 34 and/or 35, in particular at least 3 pairs of primers for amplifying at least 15 contiguous bases
of at least SEQ ID NO: 32, 33 and 34) and/or the population of nucleic acids of the sixth aspect; fl
0 optionally, said kit further sing:
(i) a printed manual or computer readable memory comprising instructions to use said synthetic nucleic acid
sequence(s), labelled nucleic acid s) and/or population of nucleic acids to practice a method of the first
aspect and/or to produce or detect the nucleic acid sequence(s) of the third aspect;m
(ii) one or more other item, component or reagent useful for the practice of a method of the first aspect and
and/or the production or detection of the nucleic acid sequence(s) of third aspect, including any such item,
component or reagent sed herein and/or useful for such practice, tion or detection.
In certain embodiments said kit further comprises one or more additional components. For example, such a
kit may comprise one or more (such as two, three, four, all) of the following:
0 means to collect and/or store a biological sample, such as blood, to be taken from said woman, preferably
wherein said means is a blood collection tube;m
0 means to extract DNA, preferably cell-free DNA, from the sample to be taken from said woman, preferably
wherein said means is a ree DNA extraction kit;w
0 an agent to entially modify DNA based on the methylation status of one or more Cst located within said
DNA, preferably wherein said agent is hite;m
0 one or more reagents to detect a nucleic acid ce, preferably for detecting the sequence of a bisulphite-
converted tide sequence;m
o a printed manual or er readable memory comprising ctions to fy, obtain and/or use one or
more of said means, agent or reagent(s) in the context of a method of the first aspect.
In some embodiments, any method of the invention may be a computer-implemented method, or one that
is assisted or supported by a computer. In some ments, information reflecting the ination, detection,
presence or absence of one or more methylated or un-methylated (as applicable) Cst d within one or more of
said nucleotide sequences comprised in at least one molecule of cell-free DNA of a woman in a sample is obtained by
40 at least one processor; and/or information reflecting the determination, detection, presence or absence of one or
more methylated Cst located within one or more of said nucleotide sequences comprised in at least one molecule
of cell-free DNA of a woman in a sample is provided in user readable format by another processor. The one or more
sors may be coupled to random access memory operating under control of or in conjunction with a computer
operating system. The processors may be included in one or more servers, clusters, or other computers or hardware
ces, or may be implemented using cloud-based resources. The ing system may be, for example, a
distribution of the LinuxTM ing , the UnixTM operating system, or other open-source or proprietary
operating system or rm. sors may communicate with data storage devices, such as a database stored on
a hard drive or drive array, to access or store program instructions other data. Processors may further communicate
via a network interface, which in turn may communicate via the one or more networks, such as the Internet or other
public or private networks, such that a query or other t may be received from a client, or other device or
service. In some embodiments, the computer-implemented method (or the one that is assisted or supported by a
computer) of detecting the ination, detection, presence or absence of one or more methylated Cst located
within one or more of said tide sequences comprised in at least one molecule of cell-free DNA of a woman in a
sample may be provided as a kit.
In an eighth aspect, the invention relates to a to a computer program product comprising: a computer
readable medium encoded with a plurality of instructions for controlling a computing system to perform and/or
manage an operation for determining the presence or absence of, or response to therapy against, an ovarian cancer
in a woman, from a biological sample from said woman, said sample comprising cell-free DNA of said woman, and
determining, in at least one molecule of said cell-free DNA, the methylation status at one or more Cst located
within one or more nucleotide sequences in accordance with a method of the first aspect; said operation comprising
the steps of:
0 receiving a first signal representing the number of les of said cell-free DNA comprising one or more
methylated or un-methylated Cst (such as relevant Cst) d within one or more of the nucleotide
sequences independently selected from the group consisting of: SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31 (for example, within one or
more of the nucleotide sequences comprised in one or more of the respective DMRs of the present invention
independently selected from the group ting of DMR#: #141, #204, #228, #144, #123, #129, #137,
#148, #150, #154, #158, #164, #176, #178, #180, #186, #188, #190, #192, #200, #202, #208,#210,
#213, #214, #219, #222, #223, #224, #225 and #226), or a nucleotide sequence present within 200bp 5’ or
3’ thereof, or an c variant and/or complementary ce of any of said nucleotide sequences; fl
0 determining a classification of the presence or absence of, or response to therapy against, an n cancer in
said woman based on their being at least one molecules of said cell-free DNA sing one or more: (i) said
methylated Cst associated with (such as located within) one or more of the hyper-methylated DMRs of the
present invention (eg, as identified in TABLE 1A), for example associated with (such as located within) one or
more of said nucleotide sequences independently selected from: SEQ ID NOs: 1, 2, 3, 4, 10, 12, 14, 15, 18, 19,
, 21, 23, 24, 25, 26, 27, 28, 29 and 30; and/or (ii) said un-methylated Cst associated with (such as located
within) one or more of the hypo-methylated DMRs of the present invention (eg, as identified in TABLE 13), for
example associated with (such as d within) one or more of said nucleotide sequences independently
selected from: SEQ ID NOs: 5, 6, 7, 8, 9, 11, 13, 16, 17, 22 and 31.
In certain embodiments of a computer program product of the present invention the operation further
comprises steps of: receiving a second signal representing the number of molecules of said cell-free DNA comprising
said tide sequence(s); and estimating a fraction or ratio of molecules of said cell-free DNA comprising one or
more methylated or un-methylated (as applicable) Cst located within one or more of the nucleotide ces
40 within all of said tide sequence(s).
In particular embodiments of the computer program product of the present invention, said classification is
determined by comparing said a fraction or ratio to a standard or cut-off value; such as a standard or cut-off value
described elsewhere herein. Such an embodiment has particular y where different populations of women (such
as patient stratification; or even individualised therapy) is d. The establishment of the applicable standard or
cut-off value for each tion of women will be apparent to the person of ordinary skill, such as by the collection
and analysis of data from a statistically meaningful number of women within the desired population, and/or
stratification of sub-populations from large population studies. In particular of such embodiments, the computer
program may comprise, or the cut-off values may be ated by, a machine-learning algorithm that is trained on
the DMR—based data generated from samples from women with OC vs. control samples, for example, the
(sub)popu|ations of women described herein and/or from samples from other (sub)popu|ations such as UKCTOCS, by
using any number and combination of the methylation patterns/DMRs as described herein. In other embodiments,
the standard or cut-off value may be modified based on the amount of total DNA present in a sample (for example, if
increased such as by contamination from genomic DNA leaking from WBCs) and/or if the average sample size of the
extracted DNA is increased (for example, a fragment size of greater than about 1000bp), which can also indicate
contamination from genomic DNA. By way of none limiting examples, such a standard or f value may be
reduced by factor, such as by a factor of 2, 3, 4, 5, 6, 8 or 10 (in particular; by a factor of 3) if the DNA extracted
from one or more samples used in a study or test exhibits characteristics (such as those described herein) of
contamination from genomic DNA.
[160] In other particular embodiments, the computer program t of the present invention may be for an
operation that further comprises the steps of: receiving a third signal representing: (i) the amount or concentration
of total cell-free DNA present in said sample; and/or (ii) a baseline value of said on or ratio previously
ined for said woman; and modifying said standard or cut-off value for a given sample based on said third
. As will now be apparent to the person of ordinary skill, such patient-specific modification of the standard or
cut-off value can provide increased personalisation of detection (such as by an increase in specificity and/or
sensitivity for dual women), ously to that provided by the ROCA test.
The computer m product of the present invention may include embodiments wherein said first signal,
and optional second signal, is determined from nucleotide sequence and/or methylation status information of a
plurality of said les of said cell-free DNA and/or ied DNA representing each of said tide
sequences, preferably wherein said plurality is a number selected from the group consisting of at least about: 50,
100, 1,000, 5,000, 10,000, 50,000, 100,000, 200,000, 500,000, 1,000,000, 1,500,000, 2,000,000, 2,500,000,
3,000,000, 3,500,000, 4,000,000 and 5,000,000 molecules, or more than 5,000,000 molecules. In particular of such
embodiments, said operation may r comprise the steps of: for each of said molecule’s sequence and/or
methylation status information, determining if said molecule comprises none, one or more: (i) methylated Cst
associated with (such as located within) one or more of the hyper-methylated DMRs of the present invention (eg, as
identified in TABLE 1A), for e associated with (such as located within) one or more of said nucleotide
sequences independently selected from: SEQ ID NOs: 1, 2, 3, 4, 10, 12, 14, 15, 18, 19, 20, 21, 23, 24, 25, 26, 27,
28, 29 and 30;, or a nucleotide sequence present within about 2,000bp (such as 200bp) 5’ or 3’ thereof, or an allelic
variant and/or complementary sequence of any of said tide sequences; and/or (ii) un-methylated Cst
ated with (such as located within) one or more of the ethylated DMRs of the present invention (eg, as
identified in TABLE 1B), for example associated with (such as located within) one or more of said nucleotide
sequences independently selected from: SEQ ID NOs: 5, 6, 7, 8, 9, 11, 13, 16, 17, 22 and 31, or a nucleotide
sequence present within about 2,000bp (such as 200bp) 5’ or 3’ thereof, or an allelic variant and/or complementary
sequence of any of said nucleotide sequences; and calculating said first , and optional second signal, based on
40 said ination for all or a n of said plurality of molecules. In n embodiments, the number of said cell-
free DNA and/or amplified DNA molecules to be ed may be ermined. For example, depending on the
expected stage of ovarian cancer; age or general (or specific) health of the woman or the total number of cell-free
DNA found in the biological sample of the woman, the said number may be of the higher (eg, greater than about
100,000, 500,000, 1,000,000, 1,500,000 or 2,000,000) or lower (eg less than about 100,000, 500,000, 1,000,000,
1,500,000 or 2,000,000) regions of said range. The number of DNA molecules analysed can be modified,
predetermined and/or selected for reasons such as to achieve a particular sensitivity and/or specificity of the test; or
may be increased for a second or subsequent test conducted for a woman who has had a borderline result for a
previous test or where said woman may desire increased sensitivity and/or icity (ie confidence of the test
result) before making a decision on further therapy.
The ability to increase the number of said DNA molecules analysed is one particular advantage of the test of
the t invention, as it enables the dynamic range of the test to be increased (eg, to that d), including to a
dynamic range that is greater than alternative (eg protein-based) tests for CC such as those based on the CA125.
In further embodiments of the computer program t of the present invention, said operation may
further comprise the steps of:
0 receiving a signal representing the amount present, in a sample of blood taken from said woman, of one or
more proteins independently selected from the group consisting of: CA—125, HE4, transthyretin, apolipoprotein
A1, betamicroglobin and transferrin; m
o comparing said a fraction or ratio to a standard or cut-off value for said protein; and
o determining a fication of the presence or absence of, or response to therapy against, an ovarian cancer in
said woman based on their being either of (i) at least one molecules of said cell-free DNA comprising one or
more of said methylated or un-methylated (as applicable) Cst d within one or more of said nucleotide
sequences; and/or (ii) an amount of said protein(s) present in said blood sample is greater than said standard
or cut-off value for such amount or protein.
[164] As will be known to gynecological oncologists, each (or certain combinations) of said ns are associated
with and used for the diagnosis of ovarian cancer. Accordingly, the present invention envisions that it is used in
combination with such protein-based diagnostic tests. In ular, and as set out elsewhere , the
combination of the test of the present invention shows independent sensitivity and/or specificity to CA125 (and/or
other protein-based tests). Importantly, in the data ted below, there was no overlap between the DNAme-
false positives and the CA125-false positives. ore, the application of a test of the present invention with one or
more of such (independent) n-based diagnostic tests would be particularly advantageous to women in that
such a combination would provide greater confidence in the result of such a combined test; for example that their
(combination) result was not a false positive or false ve; ie that they have been tly sed for: (i) the
presence of ovarian cancer (such as HGS ovarian cancer; or one that is not responding, or has not responded, to
chemotherapy ent), or (ii) the absence of ovarian cancer (such as having a benign pelvic mass), or the
e of HGS ovarian cancer (or having an ovarian cancer that is ding, or has responded, to chemotherapy
treatment).
A number of such protein-based tests for ovarian cancer are used, including those which have been
validated in clinical trials and are commercially available. In particular, suitable n-based tests that may be used
in combination with the test of the present invention include tests for CA125 (in particular when ted in a
routine manner for each woman, such as in the ROCA® test of Abcodia Ltd. Refs. 6, 7) and/or HE4 (such as the
ELEXSYS®/COBAS® versions f of Roche Diagnostics), as well as when CA125 and HE4 are used in a combined
test (such as the ROMA — Risk of Ovarian Malignancy Algorithm — test. Moore et al, 2009; Gynecological Oncology
112:49. Malkasian et al, 1988; Am J Obstet Gynecol 159:341) and/or when CA125 is used in a test that also involves
40 other proteins including transthyretin, apolipoprotein A1, betamicroglobin and/or transferrin (such as in the OVA1
test of Aspira Labs. Ueland et al, 2009: Obstet Gynecol 117:1289. Ware Miller et al, 2011; Obstet Gynecol 117:1298).
In other embodiments, the test of the present invention is used in combination with other DNA-based
diagnostic tests for ovarian cancer. For example, determination of the woman’s germline mutational status of BRCA1
and/or BRCA2 gene or any other high risk genes including but not limited to RAD51, PALBZ, ATM, BRIP1, CHEK2,
PTEN, CDH1. Also envisioned for such other DNA-based diagnostic tests for ovarian cancer, are those tests which
may include the analysis of one or more -nucleotide polymorphisms (SNPs) that are ated with 0C. In
other embodiments, the test of the present ion is used in combination with epidemiological-based models for
ovarian cancer, such as those which use various combinations of family history, number of lifetime ovulatory cycles
(eg a on of period taking oral contraceptive pill, number of pregnancies and time of breastfeeding) as well as
body mass index and hormone replacement therapy use.
Any of such other diagnostic tests for ovarian cancer may be used to fy a sub-population of women
who are at a higher/highest risk of developing ovarian cancer, and as bed above, can be used to “artificially
increase” the prevalence of OC (ie, only in that identified group at highest risk). In such sub-populations, then the
specificity of the ive test can be lower without a major impact on the rate of false ves.
In another aspect, the present invention also s to a use of a nucleic acid sequences of the third
aspect of the present invention and/or a labeled nucleic acid probes of the fourth aspect of the t invention
and/or a PCR primer pair of the fifth aspect of the present invention (for example, such PCR primers for amplifying at
least 15 contiguous bases of SEQ ID NO: 32, 33, 34 and/or 35, in particular at least 3 pairs of primers for amplifying
at least 15 contiguous bases of at least SEQ ID NO: 32, 33 and 34) and/or a ity of nucleic acids of the sixth
aspect of the present invention and/or a kit of the seventh aspect of the present invention and/or a computer
program t of the eighth aspect of the present invention, in each case for determining (such in-vitro, including
in an in-vitro diagnostic test) the presence or absence of, or response to therapy against, an ovarian cancer in a
woman. It being envisioned that all embodiments set forth herein for other aspects are also encompassed within
this use of the present invention.
It is to be understood that application of the teachings of the present invention to a specific m or
environment, and the inclusion of variations of the present invention or additional features thereto (such as further
aspects and embodiments), will be within the capabilities of one having ordinary skill in the art in light of the
teachings contained herein.
Terms as set forth herein are generally to be understood by their common meaning unless ted
othenNise. Where the term "comprising" or “comprising of” is used herein, it does not exclude other elements. For
the purposes of the t invention, the term "consisting of" is ered to be a particular embodiment of the
term "comprising of". If hereinafter a group is defined to comprise at least a n number of embodiments, this is
also to be understood to disclose a group that consists of all and/or only of these embodiments. Where used herein,
r” is to be taken as specific disclosure of each of the two specified features or components with or without the
other. For example, “A and/or 8” is to be taken as specific disclosure of each of (i) A, (ll) B and (iii) A and B, just as
if each is set out individually herein. Analogously, the terms “in particular”, “particular” or “certain” (and the like),
when used in the context of any embodiment of the present invention, in each case is to be interpreted as a non
limiting example of just one (or more) possible such embodiment(s) amongst others, and not that such cular”
or “certain” embodiment is the only one envisioned by the present invention. In the context of the present invention,
the terms “about” and “approximately” denote an interval of accuracy that the person skilled in the art will
understand to still ensure the technical effect of the feature in question. The term typically indicates deviation from
40 the indicated numerical value by i20%, 115%, 110%, and for example 15%. As will be appreciated by the person
of ordinary skill, the specific such deviation for a numerical value for a given cal effect will depend on the
nature of the technical effect. For example, a natural or biological technical effect may generally have a larger such
deviation than one for a man-made or engineering technical effect. Where an indefinite or definite article is used
when referring to a singular noun, e.g. "a an" or "the", this includes a plural of that noun unless something else is
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specifically stated. The terms “of the [present] invention ll \\ in accordance with the [present] invention", or “according ,
to the [present] invention” as used herein are intended to refer to all aspects and embodiments of the invention
described and/or claimed herein.
Unless context dictates ise, the descriptions and definitions of the features set out above are not
limited to any particular aspect or ment of the ion and apply equally to all aspects and embodiments
which are described.
All references, patents, and publications cited herein are hereby incorporated by reference in their entirety;
ed that In case of conflict, the present ication, ing definitions, will control.
[173] In view of the above, it will be appreciated that the present invention also relates to the following items:
Item 1. A method of determining the presence or absence of, or response to therapy t, an ovarian cancer in
a woman, said method sing the steps:
0 providing a biological sample from said woman, said sample comprising cell-free DNA of said woman; and
- determining, in at least one molecule of said cell-free DNA, the methylation status at one or more Cst
located within one or more of the nucleotide sequences independently selected from the group consisting
of: SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,
27, 28, 29, 30 and 31, or a nucleotide sequence t within about 2,000bp (such as within about
200bp) 5’ or 3’ thereof, or an allelic variant and/or complementary sequence of said nucleotide
ce(s),
wherein, the presence in at least one of said ree DNA molecules of one or more: (i) methylated Cst
associated with (such as located within) one or more of said nucleotide sequences independently selected
from: SEQ ID NOs: 1, 2, 3, 4, 10, 12, 14, 15, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29 and 30; and/or (ii) un-
methylated Cst associated with (such as located within) one or more of said nucleotide sequences
independently selected from: SEQ ID NOs: 5, 6, 7, 8, 9, 11, 13, 16, 17, 22 and 31, indicates the presence of,
or a reduced response to therapy against, an ovarian cancer in said woman;
preferably wherein said biological sample is liquid biological sample selected from the group consisting of: a
blood sample, a plasma sample and a serum sample.
Item 2. The method of item 1, wherein said Cst for a given tide sequence are identifiable by a genome
position for the cysteine thereof, independently selected from the list of genome positions corresponding to
said nucleotide sequence set forth in TABLE 1C.
Item 3. The method of item 1 or 2, wherein the presence in at least one of said cell-free DNA molecules of one or
more pattern of methylation and/or un-methylation as set forth in TABLE 23 for the respective nucleotide
sequence(s), indicates the presence of, or a reduced se to therapy against, an ovarian cancer in said
woman.
Item 4. The method of any one of items 1 to 3, wherein said nucleotide sequence(s) is/are associated with DMR(s)
40 #141 and/or #204 and/or #228 (eg, SEQ ID NOs: 1, 2, 3 and/or 4), or an c variant and/or
complementary sequence of said nucleotide sequence(s).
Item 5. The method of item 4, wherein the methylation status is determined at one or more of said Cst located
within each of said three nucleotide sequences; wherein, the presence in at least one of said cell-free DNA
molecules of one or more methylated Cst, and/or of one or more pattern of methylation and/or un-
methylation as set forth in TABLE 2B for the respective nucleotide sequence(s), located within any one of said
nucleotide sequences indicates the presence of, or a reduced response to therapy against, an ovarian cancer
in said woman.
Item 6. The method of item 5, n the methylation status is ined at about 7 Cst located within
tide sequence SEQ ID NO 1 and at about 16 to 18 Cst located within nucleotide sequence SEQ ID NO
2 and about 7 to 9 Cst located within nucleotide sequence SEQ ID NO 3; wherein, the presence in at least
one of said cell-free DNA molecules of at least said number of methylated said Cst, and/or of one or more
pattern of methylation and/or un-methylation as set forth in TABLE 2B for the respective nucleotide
sequence(s), located within any one of said nucleotide sequences indicates the presence of, or a reduced
response to therapy against, an n cancer in said woman
Item 7. The method of any one of items 1 to 6, comprising the step of treating said cell-free DNA with an agent that
differentially modifies said ree DNA based on the methylation status of one or more Cst located within;
ably a methylation sensitive restriction enzyme and/or bisulphite;
preferably wherein said agent is bisulphite and said determining step ses the ion of at least one
hite-converted un-methylated cytosine within one or more of the nucleotide sequences independently
selected from those set forth in TABLE 2A (eg, independently selected the group consisting of: SEQ ID N05
32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59,
60, 61 and 62), wherein one or more of the bases identified by “Y” therein is a U or T and, ably, where
one or more of the bases identified by “Y” in a CpG therein is a C, or an allelic variant and/or mentary
sequence of said nucleotide sequence(s).
Item 8. The method of item 7, wherein said agent is bisulphite and said determining step comprises the detection of
at least one bisulphite-converted un-methylated cytosine within a nucleotide sequence having a length of at
least 15bp (such as at least 50bp) comprised in SEQ ID NO 32 and/or SEQ ID NO 33 and/or SEQ ID NO 34,
wherein one or more of the bases identified by “Y” therein is a U or T and, preferably, where one or more of
the bases identified by “Y” in a CpG therein is a C, or an allelic variant and/or complementary sequence of said
nucleotide seq uence(s).
Item 9. The method of any one of items 1 to 8, wherein the methylation status of said CpG(s) is ined in
multiple molecules of said cell-free DNA and/or amplified DNA representing each of said nucleotide sequences;
preferably wherein:
(a) the presence in at least a plurality of said ree DNA molecules of one or more methylated and/or un-
methylated Cst (as able), and/or the presence in at least a plurality of said cell-free DNA molecules of
one or more pattern of methylation and/or un-methylation as set forth in TABLE 2B for the respective
nucleotide sequence(s), located within one or more of said nucleotide sequences, indicates the presence of, or
a reduced response to therapy against, an ovarian cancer in said woman; and/or
40 (b) said plurality of cell-free DNA molecules with one or more of said methylated and/or un-methylated Cst
(as applicable), and/or the presence in at least a ity of said cell-free DNA molecules of one or more
pattern of methylation and/or un-methylation as set forth in TABLE 2B for the respective nucleotide
sequence(s), located is at least 2, 3, 4, 5, 6, 7, 18, 9 or 10, or at least about 15, 20, 25, 30, 35, 40, 45, 50,
55, 60, 70, 80, 90, 100, 125, 150, 175 or 200, or a greater number such as greater than about 500, 1,000,
,000, 7,500, 1,000, 2,500, 5,000 or greater than 5,000 molecules; and/or
(c) the methylation status of said CpG(s) is determined in a number of les of said cell-free DNA and/or
ied DNA representing each of said nucleotide sequences selected from the group consisting of at least
about: 1,000, 5,000, 10,000, 50,000, 100,000, 200,000, 500,000, 1,000,000, 1,500,000, 2,000,000,
2,500,000, 3,000,000, 3,500,000, 4,000,000 and 5,000,000 molecules, or more than 5,000,000 molecules.
Item 10.The method of item 9, wherein a fraction or ratio of, or an absolute number of, cell-free DNA molecules in
said sample having said methylated and/or un-methylated CpG(s) (as applicable) d within said
nucleotide ce(s), and/or having said pattern of methylation and/or un-methylation as set forth in TABLE
23 for the respective nucleotide sequence(s), is estimated.
Item 11.The method of item 10, further comprising a step of comparing said fraction or ratio with a rd or cut-
off value; wherein a fraction or ratio greater than the standard or cut-off value indicates the ce of or a
reduced response to therapy against, an n cancer in said woman;
preferably wherein said standard or cut-off value(s) is/are modified for a given sample based on:
o the amount or tration of total cell-free DNA present in said sample; and/or
0 a baseline value of said fraction or ratio previously determined for said woman; and/or
0 a value of said fraction or ratio determined from multiple samples from a population of women
representative of said woman; and/or
0 the specificity and/or sensitivity desired for said method of determination;
more preferably wherein said standard or cut-off value is/are reduced for a given sample that has an amount
or concentration of total cell-free DNA present in said sample that is greater than a standard or cut-off value.
Item 12.A nucleic acid comprising at least 10 (preferable at least about 15, such as at least 50, for any SEQ ID
other than SEQ ID NO:58) contiguous bases comprised in a ce selected from the group consisting of:
SEQ ID N05 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56,
57, 58, 59, 60, 61 and 62, wherein said nucleic acid sequence includes one or more of the bases identified by
“Y” therein is a U or T and, preferably, where one or more of the bases identified by “Y” therein is a C, or an
allelic variant and/or mentary sequence of said nucleotide sequence;
preferably wherein said c acid sequence comprises at least 15, (such as at least 50) contiguous bases
sed in a ce of SEQ ID N05 32, SEQ ID N05 33 or SEQ ID N05 34, wherein said nucleic acid
sequence includes one or more of the bases identified by “Y” therein is a U or T and, preferably, where one or
more of the bases identified by “Y” therein is a C, or an allelic variant and/or complementary sequence of said
nucleotide sequence; and
more preferably wherein said nucleic acid sequence is sed in a sequence as set forth in TABLE 23 (eg, a
sequence selected from the group consisting of: SEQ ID N05 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74,
75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92 and 93.
Item 13.A nucleic acid primer pair for amplifying a nucleic acid sequence consisting of at least 10 (preferable at
40 least about 15, such as at least 50, for any SEQ ID other than SEQ ID NO: 89) contiguous bases comprised in
a ce selected from the group consisting of: SEQ ID NOs: SEQ ID N05 63, 64, 65, 66, 67, 68, 69, 70,
71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92 and 93, or a tide
sequence present within about 2,000 bp (such as within about 200bp) 5’ or 3’ thereof, or an allelic variant
and/or complementary sequence said tide sequence(s);
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preferably wherein:
(a) at least one primer of said pair includes a sequence corresponding to at least one bisulphite-converted
CpG present in said nucleotide sequence(s); and/or
(b) said primer pair is selected from the group of primer-pairs set forth in each row of TABLE 3.
Item 14. A kit, ably for determining the presence or absence of, or response to therapy against, an n
cancer in a woman, said kit comprising:
0 one or more c acid sequences of item 12 and/or primer pairs of item 13; and
- optionally, said kit further comprising:
(i) a printed manual or computer readable memory comprising instructions to use said c acid
sequence(s) and/or primer ) to practice a method of any one of items 1 to 11 and/or to produce or
detect the nucleic acid sequence(s) of item 12; and/or
(ii) one or more other item, component or reagent useful for the practice of a method of any one of
items 1 to 11 and and/or the production or detection of the nucleic acid sequence(s) of item 12, including any
such item, component or reagent disclosed herein useful for such practice, production or detection.
Item 15.A computer program product sing: a computer le medium d with a plurality of
instructions for controlling a ing system to perform and/or manage an operation for determining the
presence or absence of, or response to therapy against, an ovarian cancer in a woman, from a biological
sample from said woman, said sample comprising cell-free DNA of said woman, and determining, in at least
one molecule of said cell-free DNA, the methylation status at one or more Cst located within one or more
nucleotide sequences in accordance with a method as set forth in any one of items 1 to 11; said operation
comprising the steps of:
0 receiving a first signal representing the number of molecules of said cell-free DNA comprising one or more
methylated and/or un-methylated Cst (as applicable), and/or comprising one or more pattern of
methylation and/or un-methylation as set forth in TABLE 23 for the respective nucleotide sequence(s),
located within one or more of the nucleotide ces independently ed from the group consisting
of: SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,
27, 28, 29, 30 and 31, or a nucleotide sequence present within about 2,000bp (such as within about
200bp) 5’ or 3’ thereof, or an allelic t and/or complementary sequence of said nucleotide
sequence(s); and
- determining a classification of the ce or absence of, or response to therapy against, an ovarian
cancer in said woman based on their being at least one molecules of said cell-free DNA comprising one or
more said methylated and/or un-methylated Cst (as applicable), and/or comprising one or more said
pattern of methylation and/or un-methylation, located within one or more of said nucleotide sequences;
preferably wherein said operation further comprises the steps of:
0 receiving a second signal representing the number of molecules of said cell-free DNA comprising said
nucleotide sequence(s); and
- estimating a fraction or ratio of molecules of said cell-free DNA comprising one or more said methylated
40 and/or un-methylated Cst (as able), and/or comprising one or more said pattern of methylation or
un-methylation, located within one or more of the nucleotide sequences within all of said nucleotide
sequences; and
more preferably wherein said classification is determined by ing said a fraction or ratio to a standard or
cut-off value.
Certain s and embodiments of the invention will now be rated by way of examples and with
reference to the description, figures and tables set out herein. Such examples of the Methods, Results,
Supplementary Information, Discussion, conclusions and other uses or s of the present invention are
representative only, and should not be taken to limit the scope of the present invention to only such representative
examples. Furthermore, any embodiments, text or other descriptions found in such examples are also to
encompassed and ered as part of the description of the present invention.
Patients and sample collection:
[177] We have used a total of 703 tissue and 251 serum samples in seven sets (FIGURE 1). For Serum Sets 1-3
and the NACT Serum Set, women attending the hospitals in London and Prague were invited, consented and 20-40
mL blood obtained (VACUE'I'I'E® 2 Serum Sep Clot Activator tubes, Cat 455071, Greiner Bio One International
GmbH), centrifuged at 3,000 rpm for 10 minutes with serum stored at -80°C. Serum CA125 was analysed for the
validation sets using the CA125 Cobas assay platform (Roche Diagnostics, Burgess Hill, UK). For detailed
information see the Supplementary Information.
Additionally, a seventh validation set may be provided from the UK Collaborative Trial of Ovarian Cancer
ing (UKCTOCS) (Refs. 6, 7, 22). For example, all women (among those in the l arm) who d serum
samples at recruitment and developed invasive epithelial OC within two years of recruitment and the ponding
age and centre d women who did not develop ovarian cancer within five years of tment can be
analysed. Blood samples from all S volunteers can be spun down for serum separation after being couriered
at room temperature to a central laboratory, and aliquoted and stored in liquid nitrogen vapour phase until thawing
and analysed such as described herein; even if only 1 mL of serum per UKCTOCS volunteer may be available.
Isolation and bisulphite modification of DNA:
DNA was isolated from tissue and serum samples at GATC Biotech (Constance, Germany). Tissue DNA was
quantified using NanoDrop and Qubit (both Thermo Fisher Scientific, USA); the size was assessed by agarose gel
electrophoresis. Serum DNA was quantified using the Fragment Analyzer and the High Sensitivity Large Fragment
Analysis Kit (AATI, USA). DNA was bisulfite converted at GATC Biotech.
DNAme analysis in tissue:
Genome wide methylation analysis was performed either by the Illumina Infinium Human Methylation 450K
ip array (Illumina Inc USA, WG-314—1003) as previously described (Refs. 24, 25) or using Reduced
Representation Bisulfite Sequencing (RRBS) at GATC Biotech. For the 450k methylation data we developed a pipeline
in order to select the most promising cancer-specific differentially methylated regions (DMRs) that are most likely to
fulfil the strict specificity criteria of a serum based test (see mentary Information).
For RRBS, DNA was digested by the restriction endonuclease MspI that is specific for the CpG ning
motif CCGG; a size selection of the library provides an enhanced coverage for the CpG-rich regions including CpG
islands, promoters and enhancer ts (Refs. 26, 27). The digested DNA was adapter ligated, bisulfite modified
and PCR amplified. The libraries were sequenced on Illumina’s HiSeq 2500 with 50 bp or 100 bp paired-end mode.
Using Genedata Expressionist® for Genomic Profiling v9.1, we have established a bioinformatics pipeline for the
detection of cancer specific DMRs. The most promising DMRs have been taken fonNard for the pment and
40 validation of serum based clinical assays (see Supplementary Information).
Targeted ultra-high coverage bisulphite sequencing of serum DNA:
Targeted bisulfite sequencing libraries were prepared at GATC Biotech. In brief, bisulfite modification was
performed with 1 mL serum lent. Modified DNA was used to test up to three different markers using a two-
step PCR approach. Ultra-high coverage cing was med on Illumina’s MiSeq or HiSeq 2500 with 75 bp or
125 bp paired-end mode (see Supplementary Information).
Statistical/data analyses:
For DMR discovery the data analysis pipelines are described within the tive sections in the
Supplementary Information. In brief, Genedata Expressionist® for Genomic Profiling was used to map reads to
human genome version hg19, identify regions with tumor specific ation patterns, quantify the ence of
those patterns, and calculate relative pattern frequencies per . Pattern frequencies were calculated as number
of reads containing the pattern divided by total reads covering the n region. The 95%CI intervals for sensitivity
and icity have been calculated according to the efficient-score method (Ref. 28). Differences in pattern
frequencies or coverage have been analysed using Mann Whitney U test.
[188] RESULTS:
Study design:
The samples, techniques and purpose of the three phases of the study — marker discovery, assay
development and test validation — are summarized in FIGURE 1.
DNA methylation marker ery in tissue:
[192] We have used two independent ome-wide approaches in order to discover DMRs which have the
potential for diagnosing ovarian cancer with high sensitivity and specificity. (1) Illumina m Human
Methylation450 BeadChip Array (450K) technology was used to interrogate the methylation status of ~485,000
genomic sites in 218 n cancer (Ref. 28) and 438 control samples (FIGURE 1; see also Supplementary
Information). A set of 19 high scoring and ranking DMRs were selected for targeted-BS based serum assay
development. FIGURE 6 shows an example of a selected top DMR (reaction #228). (2) Using RRBS, we first
determined the methylation pattern frequencies in relevant genomic regions in different tissues. The algorithm that
we have ped scans the whole genome and fies regions that contain at least 10 aligned paired-end reads.
These read bundles are split into smaller regions of interest which n at least 4 Cst in a stretch of, at most,
100 base pairs (bp). For each region and tissue/sample the absolute frequency (number of supporting reads) for all
observed methylation patterns was determined (FIGURE 2A). This led to tens of millions of patterns per
tissue/sample. The patterns were filtered in a multi-step procedure to fy the methylation patterns which
specifically occur in tumour samples. In order to se sensitivity and specificity, respectively, of our pattern
discovery procedure, we pooled reads from different tumour or white blood cell (WBC) samples, respectively, and
scored patterns based on over-representation within tumour tissue. The results were summarized in the specificity
score Sp, which reflects the cancer city of the patterns. After applying a cut-off of Sp 2 10, 2.6 n patterns
for CC remained and were further filtered according to the various criteria demonstrated in FIGURE 2B (and
Supplementary Information).
For the filtered unique cancer specific patterns for CC identified in the Array (n=19) and RRBS (n=45)
approach, respectively, ite sequencing primers have been designed and technically validated, eventually leading
to 31 candidate s, The genome coordinates (hg 19) and genomic sequence of each DMR is shown in TABLE 1A
and TABLE 1B, and the possible bisulphite-converted ces thereof (where “Y” symbolises either a C or a U/T,
preferably a C or a T) are shown in TABLE 2A (with Cst - sites of possible 5-methylcytosine - shown ined).
Serum DNAme assay establishment:
We used ultra-deep BS sequencing (FIGURE 2C) to develop serum assays for the 31 candidate regions in 59
40 serum samples from Set 1 (FIGURE 1 and Supplementary Information and FIGURE 8). Based on sensitivity and
specificity, nine markers have been selected for further validation in Set 2 . In Sets 1&2 combined, the
specificity/sensitivity of the top four candidate s (FIGURE 9) referred to Regions #141, #144, #204 and #228
(#228 was only analysed in Set 2) to discriminate HGS OC from healthy women or those with a benign pelvic mass
at pattern frequency thresholds of 0.0008, 0.0001, 0.0001 and 0.0001 was 95.7%/42.4%, 93.5%/48.5%,
100%/25.0% and 100%/36.8%, respectively. Interestingly region #144 has already been defined as a ing
cell-free DNA marker for , in ular ovarian cancer (Refs. 30, 31). The combination of s #141, #204
and #228 (at least one of these regions with a pattern frequency above the aforementioned threshold) resulted in a
98.1% specificity and a 63.2% ivity. These regions are linked to genes COL23A1, C2CD4D and WNT6,
respectively.
Clinical validation of the serum DNAme assay:
We validated the combination of the three markers in Set 3 (FIGURE 3A-C) ide the CA125 serum
marker (FIGURE 3D). The e coverage (i.e. DNA strands read by the sequencer for each sample and region) is
> 500,000 (FIGURE 10). ng the above indicated cut-off thresholds for the three DNAme markers and 35 IU/mL
for serum CA125 led to specificities of 90.7% and 87.1% and sensitivities of 41.4% and 82.8%, respectively (FIGURE
3E). Due to the fact that Reaction #228 was only analysed in Set 2, we combined Set 2 and Set 3 in order to
redefine the olds. Whereas for #141 the threshold of 0.0008 remained unchanged, for #204 and #228 we
further lowered the pattern frequency threshold to 0.00003 and 0.00001, respectively, leading to a specificity and
sensitivity now of 91.8% and 58.3%, respectively (FIGURE 3E). Importantly, there was no overlap between the
DNAme- and false positive controls (FIGURE 3F).
Serum DNAme to predict response to platinum-based uvant chemotherapy:
We recruited 25 n cancer patients who received carboplatin-based neoadjuvant chemotherapy.
ed with the pre-treatment sample, all three DNAme markers dropped substantially and more dramatically
compared to CA125 after one and two cycles (FIGURE 4A-D and FIGUREs 11, 12, 13). Whereas CA125 dynamics was
not able to discriminate chemotherapy-responders from non-responders (FIGURE 4E and Supplementary
Information), serum DNAme cs (i.e. serum DNAme as defined in Set 2&3, before as compared to after two
cycles) correctly identified 78% and 86% of responders and non-responders (Fisher’s exact test p=0.04) overall and
78% and 100% amongst those women who were left without residual disease after interval debulking surgery
(Fisher’s exact test p=0.007) (FIGURE 4E).
[200] Serum DNAme for early diagnosis of ovarian cancer:
In order to judge whether our marker panel is able to diagnose ovarian cancer early, samples ing OC
diagnosis by up to 2 years ) and matched controls can be used from the control (no screening) - arm of the
S cohort. As at the time of their collection, UKCTOCS samples were not obtained, treated or stored with the
analysis cell-free DNA in mind. Hence, it is to be expected that upon DNA extraction it will be found that either or
both the amount of DNA/mL serum as well as the average DNA fragment size may be higher (such as dramatically
higher) in UKCTOCS samples compared with the other samples used in this study. As has been previously observed
and ed (Anjum et al, 2014, Genome Med 6:47), without being bound by , such effect may be due to
DNA from WBCs leaking into the serum during the 24-48 hour blood sample ort time — in particular in the
warm season). This “contaminating” high quality [genomic rather than tumour] DNA would not only dilute the cancer
signal but also skew the target sequence amplification towards WBC DNA. In order to adjust for these factors, an a
priori decision may be made to reduce the threshold for the three regions by a factor, such as by a factor of 3, and/or
to split the analyses in samples above (high) and below (low) the median amount of DNA.
Such adjustments can enable the three DNAme-marker panel to yet further confirm its validation above and
its utility for the early detection of ovarian cancer. Indeed, it can then be used to identify cases with a specificity of
40 over 70%, 80%, or 90% (such as between about 70% and 80% or between about 80% and 90%) and a sensitivity
of over 45% 50%, 55% or 60% (such as n about 50% and 55% or between about 55% and 60%) [indeed,
the sensitivity may be even higher in CA125 negative (<35U/mL) samples] in samples with a lower than median
amount of DNA and may remain literally unchanged within two years between sample collection and cancer
diagnosis. Given the greater dynamic range of DNAme panel test and the results above, it can have higher sensitivity
but lower specificity compared to that of CA125 using a cut-off of 35U/ml in the early detection of ovarian cancer,
and/or to have no overlap of false positives. The DNAme panel has higher sensitivity but lower specificity compared
to that of CA125 using a cut-off of 35U/ml in the early detection of ovarian cancer.
SUPPLEMENTARY INFORMATION:
Subjects and sample collection:
We analysed a total of 6 sets as ed in FIGURE 1:
1. Set: Ovarian cancer samples (Refs. 51, $2), WBC samples (Ref. S3) and Fallopian Tube samples
(Ref. S4) have been described before. Ten benign pelvic tumours (2X endometriosis-ovarian cyst, 1X fibroma, 2X
papillary serous cystadenoma, 1X mucinous cystadenoma, 2X serous cystadenoma, 1X us cystadeonoma with
Brenner tumour and 1 dermoid cyst), 96 endometrial samples (Ref. 51) (Haukeland University Hospital, Bergen, 52
patients with primary and metastatic samples equalling 87, 8X benign endometrial (all hyperplasia) & 1 cell line) and
170 samples (38 colon (COAD controls), 50 liver (LIHC controls), 75 lung (LUSC and LUAD controls), 7 rectum (READ
ls) from the publically ble The Cancer Genome Atlas (TCGA) repository were analysed.
2. RRBS Set: 11 prospectively collected invasive epithelial ovarian cancer samples (high grade serous n=8,
low grade serous n=1, endometrioid n=1, mean age 54.7 years), one benign tumour (papillary serous
cystadenoma, age = 86 years), 18 normal tissue samples (normal breast n=7 and normal ovarian n=11, mean age =
60.2 years), two normal trial tissues mean age = 68, and twenty three white blood cell samples (breast
cancer ts n=10 & ovarian cancer ts n=13 [11 of which match corresponding OC tissue samples, 1
matches corresponding normal endometrial sample and 1 matches normal ovarian sample], mean age = 57.8) were
assessed by RRBS.
All samples of the RRBS Set were collected prospectively at the University College London al in
London (University College London Hospital, 235 Euston Rd, Fitzrovia, London NW1 ZBU) and at the Charles
University Hospital in Prague (Gynecological Oncology Center, Department of Obstetrics and logy, Charles
University in Prague, First Faculty of ne and General University Hospital, Prague, Apolinarska 18128 00 Prague
2, Czech Republic.). The study was approved by the local research ethics committees: UCL/UCLH Biobank for
ng Health & Disease NC09.13) and the ethics committee of the General University Hospital, Prague approval
No.: 22/13 GRANT — 7. RP — EPI-FEM-CARE tively. All patients provided written informed consent.
3. Serum Set 1: Serum samples from the following volunteers have been collected (at the time of diagnosis,
prior to treatment):
0 Healthy volunteers (n=19, mean age 41.1 years).
0 Women with benign pelvic masses (n=22, mean age 41.3 years) with the following histologies: endometriosis
(n=6), fibroids (n=5), hydrosalpinx (n=1), serous cystadenoma (n=5) and mucinous cystadenoma (n=5).
0 Patients with ovarian cancers (n=18, mean age 62.2 years): endometrioid (n=2) and clear cell (n=1) and high
grade serous (n=15) ovarian cancers; 10 and 8 women had a stage MI and stage III/IV ovarian cancer,
respectively.
All s of Serum Set 1 were collected prospectively at the University College London Hospital in London
and at the Charles University Hospital in Prague. The study was ed by the local research ethics committees:
UCL/UCLH Biobank for Studying Health & e 13) and the ethics committee of the General University
Hospital, Prague approval No.: 22/13 GRANT — 7. RP — EPI-FEM-CARE respectively. All patients provided written
40 ed consent.
4. Serum Set 2: Serum samples from the following volunteers have been collected (at the time of diagnosis,
prior to treatment):
0 Healthy eers (n=20, mean age 42.8 years).
0 Women with benign pelvic masses (n=34, mean age 40.0 years) with the following histologies: endometriosis
(n=7), fibroids (n=8), pelvic inflammatory disease or pelvic s (n=9), serous cystadenoma (n=5) and
mucinous cystadenoma (n=5).
0 Patients with borderline ovarian tumors (n=11, mean age 47.3 years): mucinous (n=6) and serous (n=5)
borderline tumor.
0 Patients with ovarian cancers (n=27, mean age 62.9 years): endometrioid (n=3) and clear cell (n=3), mucinous
(n=2) and high grade serous (n=19) ovarian cancers; 10 and 17 women had a stage 1/11 and stage III/IV
ovarian cancer, respectively.
All samples of Serum Set 2 were collected prospectively at the sity College London Hospital in London
and at the Charles University al in Prague. The study was approved by the local research ethics committees:
UCL/UCLH Biobank for ng Health & Disease NC09.13) and the ethics committee of the General University
Hospital, Prague approval No.: 22/13 GRANT — 7. RP — EPI-FEM-CARE respectively. All patients provided written
informed t.
5. Serum Set 3: Serum samples from the ing volunteers have been collected (at the time of diagnosis,
prior to treatment):
0 Healthy volunteers (n=21, mean age 50.8 years).
0 Women with benign pelvic masses (n=119, mean age 41.4 years) with the following histologies: endometriosis
(n=21), fibroids (n=21), pelvic inflammatory disease or pelvic s (n=7), serous cystadenoma (n=20),
mucinous enoma (n=20) and dermoid cysts (n=29).
0 Patients with borderline ovarian tumors (n=27, mean age 57.1 years): mucinous (n=7) and serous (n=20)
borderline tumor.
0 Patients with non-epithelial tumors (n=5, mean age 55.8 : granulosa cell tumors.
0 Patients with non-ovarian cancers (n=37, mean age 58.3 years): cervical (n=10), endometrial (n=20) and
ctal (n=7) s.
0 Patients with ovarian cancers (n=41, mean age 59.6 years): endometrioid (n=3) and clear cell (n=5), mucinous
(n=4) and high grade serous (n=29) n cancers; 16 and 25 women had a stage 1/11 and stage III/IV
ovarian cancer, respectively.
All samples of Serum Set 3 were collected prospectively at the University College London al in London
and at the Charles University Hospital in Prague; CA125 analysis was med using the CA125 Cobas
assay and platform (Roche Diagnostics, Burgess Hill, UK). The study was approved by the local research
ethics committees. The study was approved by the local research ethics committees: UCL/UCLH Biobank for Studying
Health & Disease (NC09.13) and the ethics committee of the General University Hospital, Prague approval No.: 22/13
GRANT — 7. RP — EPI-FEM-CARE respectively. All patients provided written ed consent.
Of note: For the Serum Sets 1-3 which have been prospectively collected within EpiFemCare there is a
substantial age difference between women who presented with benign pelvic masses and women who presented
with n cancer. We were completely aware of this as the main purpose was to benchmark DNAme markers
against CA125 and to assess whether CA125 false positive controls are also DNAme-false positive. The main source
of false positivity are endometriosis, pelvic inflammatory disease and ds — all conditions which are substantially
more prevalent (or occur ively) in premenopausal (i.e. younger women) whereas ovarian cancer is far more
40 prevalent in older women.
6. NACT (“Neoadjuvant Chemotherapy") Set: Patients (n=25) at the Gynaecological Oncology Centre in
Prague deemed not to be suitable for up-front surgery have been recruited. The average age was 62.8 years. High
grade serous ovarian cancers were the most prevalent histology (n=23) and the ing two patients had clear cell
ovarian cancers. Twenty-four patients received Carboplatin-Paclitaxel combination chemotherapy and one patient
received Carboplatin only. All but two patients had interval debulking y. Among the 23 patients, 14 had no
residual disease, 5 had macroscopic residual e and 4 had copic residual disease (i.e. tumor reaches the
edge of at least one of the resected specimens - according to TNM classification). Twelve patients were deemed to
be platinum-sensitive (no recurrence within 6 months after successful completion of neoadjuvant and adjuvant
chemotherapy and interval debulking y) and eight patients were deemed to be platinum-refractory (n=2, no
response to herapy or progression on chemotherapy) or platinum-resistant (n=6, ence within 6 months
after successful completion of neoadjuvant and adjuvant chemotherapy and al debulking surgery). For 5
patients no data were available on platinum-sensitivity.
All serum samples of the NACT Set were collected prospectively at the Charles University Hospital in Prague.
Each patient provided three samples at the following time-points:
0 At the time of histological diagnosis, prior to chemotherapy.
0 Three weeks after the first cycle of chemotherapy (immediately prior to the second cycle).
0 Three weeks after the second cycle of chemotherapy (immediately prior to the third cycle).
CA125 analysis on the NACT Set was performed using the CA125 Cobas assay and platform (Roche
Diagnostics, Burgess Hill, UK). The study was approved by the local research ethics committees: UCL/UCLH Biobank
for ng Health & e (NC09.13) and the ethics committee of the General University Hospital, Prague
approval No.: 22/13 GRANT — 7. RP — M-CARE respectively. All patients provided written informed consent.
Eighteen and seven patients presented with a stage IIIC and IV ovarian cancer respectively.
In addition to these siX sets, a seventh set could be used to provide further confirmation on the validation of
the present assay provided by the other sets. Such a seventh set could comprise samples from the S
collection. For example, among those women who were randomised into the control arm of UKCTOCS n 2001
and 2005, the subset of such women who developed an invasive epithelial ovarian cancer within 2 years of serum
sample donation and had at least 4mL of non-haemolysed serum available, and such number of women stratified
into those women which developed a high grade serous, mucinous, trioid, clear cell, carcinosarcoma or a
carcinoma not othenNise specified, respectively. The average age at sample donation can be calculated in years; as
can the number of such women, the number of women who were diagnosed within one year and those who were
diagnosed between 1-2 years after sample donation, as well as the respective number of women who were
diagnosed with a stage 1/11 and stage III/IV cancer, respectively. For each of the such cases, three women who did
not p any cancer within the first five years after tment can be d with regards to age at
tment, centre and month of recruitment (controls).
DNA methylation analyses in tissue samples:
DNA isolation: DNA was isolated from tissue samples using the Qiagen DNeasy Blood and Tissue Kit (Qiagen
Ltd, UK, 69506) and 600ng was bisulfite converted using the Zymo methylation Kits (Zymo Research Inc, USA,
D5004/8).
[222] Illumina Infinium Human Methylation450 ip Array data analysis: Genome wide methylation is
was performed using the Illumina Infinium Methylation 450K beadchip (Illumina Inc USA, WG1003). The raw
data processing and quality control was performed in R/Bioconductor (versions 2.15.0/2.11) (Ref. S5) using minfi
(Ref. S6) and BMIQ (Ref. S7) packages. fication of differentially methylated regions (DMRs) was carried out
using Genedata Expressionist® for Genomic Profiling as described below.
40 [223] To correct for the dual probe to probe variation in the affinity/sensitivity to unnmethylated vs.
methylated DNA we used fully methylated (SssI treated) and unmethylated (whole genome amplified; WGA) genomic
DNA from WBC samples of different individuals. These cal controls were used for both filtering out probes that
do not show sufficient specificity (i.e. cannot discriminate between methylated vs. unmethylated state) and to
perform array-wide recalibration of the biological sample data to normalize for the probe to probe variation in
background and c range, respectively. The removal of the non-specific probes was achieved by doing a T-test
with 5551 vs WGA samples (using M-values) and removing the probe sets that have p-value <0.01 and effect size
below <5 i.e. cannot discriminate between fully methylated and unmethylated DNA. The normalization was done for
each sample individually for each probe set with the formula Mme: (Mmeasured- MWGA)/ (M5551. MWGA); M5551 and MWGA
values used were average (arithmetic mean) values of the respective sample groups. For the ream analyses
the individual sample $551 and WGA data were also normalized with the same formula. This leads to efficient
removal of background noise from the probe to probe variation and increases the power to detect homogenously
methylated or unmethylated genomic regions. T-test and normalization were performed in Genedata Expressionist®
for Genomic Profiling software.
[224] The control sample set was selected to identify DMRs that are cancer specific and would also be specific in a
serum based clinical assay. Therefore, in addition to the ovarian (including Fallopian Tube and endometrium) control
tissues we used a large panel of tissues that are likely to shed DNA into the serum [i.e. white blood cells ,
lung, liver, rectum and , with WBCs being the most abundant source of normal germline DNA in serum
samples. Two statistical approaches were used to identify DMRs from the 450K data: (1) a tical test to fy
single probes showing differential methylation between n cancer and WBC s, and (2) a sliding window
ANOVA approach that scans the whole genome and identifies sets of neighboring probes (Ranges) showing
correlated methylation differences between ovarian cancer and WBC samples. Only the DMRs showing no
methylation in WBCs were considered for downstream analysis steps. The identified DMRs where ranked and scored
based on the following criteria: (1) Differences in methylation levels between ovarian cancer and the control tissues
(with WBC difference being ized). (2) ility of designing a clinical assay (number of Cst in the region
to allow ing an assay with sufficient sensitivity/specificity). (3) For ranges only: ility of the DMRs
(number of probes within the Range).
In the sliding window approach, the algorithm performs a pooling of all features in a given sliding window
(120bp) before it calculates an ANOVA p-value between sample groups. The pooling increases statistical robustness
and also results in smoother ANOVA p-Values. The smoothed ANOVA p-Values are then used to detect regions
containing one or more p-values ing the given Maximum P-Value threshold (1e-5). If a gap of more than
1000bp is detected between similar ation differences, two different regions are reported. Note, that the
algorithm also reports single probes g significant methylation difference (if no ouring similar
methylation difference is present), but groups of probes with similar profile do get lower es and are therefore
preferentially reported. The sliding window ch was used for CC vs WBC samples to detect cancer DMRs (using
normalized M-values) and arithmetic mean M-values of the probes per detected DMR (here after referred as “Range")
were reported for all the relevant samples for downstream analysis. The Range discovery was performed in Genedata
Expressionist® for Genomic ing v8.0 software. The Ranges varied in size between 1 and 45432bp, with average
(arithmetic mean) size being 368bp. The Ranges showing methylation in WBC were removed by a T-test with WBC
vs. WGA samples (p-value <1e-6 and/or directed effect >0.15; i.e. M(WBC) > M(WGA)+0.15). Next, a T-test for CC
vs WBC was used and Ranges showing significant difference (p-value <1e-6) and difference (directed effect) of WBC
upper quartile vs OC lower quartile >0.15 were selected as entially methylated regions. For different control
tissue samples the methylation values were calculated for the same OC vs WBC Ranges metic mean M-values of
the probes per ed DMR).
40 [226] For ranking of the DMRs the effect sizes of methylation of cancer samples versus different relevant controls
tissues were calculated. In addition to “direct” control tissues (fimbrial/endometrial/benign ovarian tissues) also large
tissues with high turnover (liver, lung, rectum and colon) were included; data were download from TCGA data portal
(https://tcga-data.nci.nih.gov/tcga/) as level 3 data as detP ed alues; data normalization was carried out
as described above. The effect sizes were always calculated with cancer lower quartile vs control tissue upper
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quartile values (based on SssI/WGA normalized M-values).
Two different scoring methods were used for the effect sizes. In Method 1 the OC vs WBC effect size gets
the weight 6x, and all the control tissue 1/4x. In Method 2 the OC vs WBC effect size gets the weight 6x, and all the
control tissue 1x. The Method 2 takes more into account the data from all the control tissues s Method 1
maximises the effect of the difference between WBC and cancers samples. However, for both methods only DMRs
prefiltered for low methylation in WBCs were used (as described above). The final scores are the sum of the tissue
scores and the feasibility and confidence scores (see next paragraph). If data were not ble for a certain probe
for a certain tissue (i.e. was filtered out due to high detection p-value), the score for the tissue was 0.
For further ranking of the DMRs ility (for designing a functional clinical assay) and confidence (for
ranges) scores were calculated. The feasibility score is based on number of CpG dinucleotides within (or close by; +/-
60bp) a probe/range. If the number of Cst is <5, the score is -0.5, if the number of Cst is between 5 and 9 the
score is 0 and if the number of Cst is >=10 the score is 0.5. The number of Cst per range was calculated using
EMBOSS ort tool in Galaxy (Refs. 58-510) using the range genomic coordinates as input. The confidence score
for ranges is 0.5 if 2 or more probes are within the range, if only one probe the score is 0.
[229] Reduced Representation Bisulfite Sequencing (RRBS):
w: RRBS libraries were ed by GATC Biotech AG using INVIEW RRBS-Seq according to etary
SOPs. In brief, DNA was digested with the restriction endonuclease MspI that is specific for the CpG containing motif
CCGG; a subsequent size selection provides enhanced coverage for the CpG-rich regions including CpG islands,
promoters and enhancer elements (Refs. $11, $12). The digested DNA is then adapter ligated, ite modified and
PCR—amplified. The ies were ced on Illumina’s HiSeq 2500 with 50 bp or 100 bp paired-end mode.
After sequencing raw data was trimmed using Trimmomatic (0.32) to remove r sequences and low
quality bases at the beginning and end of reads. Subsequently, reads were trimmed with lore (0.3.3) to
remove cytosines derived from library preparation which must not be included in the methylation analysis. Read pairs
were mapped to the human genome (hg19) in Genedata Expressionist® for Genomic Profiling 8.0 applying Bisulfite
Mapper based on BOWTIE v2.1.0 (Ref. 513) with the settings --no-discordant der -p 8 --end-to-end --no-mixed
-D 50 -k 2 --fr --norc -X 400 -I 0 --phred33. Further analysis was done using Genedata Expressionist® for Genomic
Profiling v9.1.
Computation of RRBS-determined methylation pattern frequencies: In order to allow the sensitive detection
of methylation patterns with low abundance, the read data available for each sample type (e.g. breast cancer,
ovarian cancer and white blood cells) were pooled across patients and sequencing runs. Candidate genomic regions
for methylation pattern analysis were defined based on bundles of at least 10 paired-end reads covering at least 4
consecutive CpG sites which are located within a genomic range of at most 150bp. As illustrated in FIGURE 5, our
algorithm first determines sets of consecutive CpG sites of maximum size, from which multiple potentially overlapping
subsets are derived, which still meet the selection criteria. CpG sites located in the gap between the mate reads are
d. For each d set of CpG sites, the absolute and relative frequencies of all methylation patterns observed
in the corresponding reads are determined. The methylation patterns are represented in terms of binary strings in
which the methylation state of each CpG site is denoted by 1 if methylated or 0 if unmethylated. The thm for
selecting candidate regions and calculating methylation pattern frequencies was ented in our software
rm Genedata Expressionist® for c Profiling.
40 [233] Procedure for the selection of tumour-specific RRBS-determined ation patterns: In order to ensure
that the pattern exclusively occurs in tumour samples, all patterns present in white blood cells were excluded. A
score for assessing the relevance of each n was determined by integrating multiple subordinate scores which
quantitatively capture desired properties of candidate biomarker patterns. First, for each pattern a Tumour Specificity
Score Sp = DL - TP - TE - AF was calculated, which consists of the four components Dilution Factor DL, Tumour
ence TP, Tumour Enrichment Factor TE and Avoiding Factor AF. The formal definitions of the score components
are given in the following:
#total reads 1
DL 2—_*WBC
#reads with pattern 103
#reads with pattern in tumor
TP =—*10tumor
#total reads in tumor
#observed reads with pattern in tumor
TE =+tumor
#expected reads wrth pattern Ln tumor
#expected reads with n in WBC
AF 2—WBC
#observed reads with pattern in WBC
The Dilution Factor DL and Tumour Prevalence TP favour patterns which are supported by a high proportion
of reads in tumour and low proportion of reads in WBC, respectively. A pattern observed in 1 out of 10 reads in
tumour and in 1 out of 1000 reads in WBC scores 1 for both s. The Tumour Enrichment Factor TE and Avoiding
Factor AF were ed to assess the overrepresentation of the pattern in tumour samples and its
underrepresentation in WBC samples, respectively, relative to an expected number of pattern reads which is based
on the observed overall methylation level in those tissues. In order to estimate the number of expected reads
supporting the pattern, the methylation ncies are calculated for each CpG site individually. Next, the number of
expected reads with a specific pattern is calculated as the product of the relative frequencies of the tumour specific
methylation states observed for each CpG site in the pattern times the number of reads stretching across the
pattern. A TE >1 indicates that a pattern is more frequent in tumour than expected when randomly distributing the
observed methylation levels across reads. Besides favouring tumour icity our scoring procedure was also
designed to make patterns with high variance of the highest priority (i.e., patterns for which a high number of
transitions in the methylation state is observed between consecutive CpG sites). Such ns may be a product of
the epigenetic reprogramming of tumour cells and in order to account for the potentially increased biological
relevance of these patterns another score component was introduced. The normalized variance VP of a n p is
defined as the pattern variance divided by the maximum variance, i.e., the pattern length minus 1. The scores for
the tumour specificity SP and pattern ce VP were combined in the tumor-specific variance score SVP 2
VP -10g(5p). In order to facilitate the ranking of each candidate genomic region r based on the relevance of patterns
p1,..., pN observed in the region the aggregation score A5, was calculated based on the following formula:
A5,=Zn 1
i=1 1
[235] The aggregation score A5, corresponds to a weighted sum of the tumour-specific variance scores of the
observed patterns. The weighting was included since an ordinary sum would introduce a bias towards regions, in
which a high number of patterns have been observed due to a high read coverage and/or high CpG site density. All
of the presented statistics for assessing the nce of methylation patterns and genomic regions were
ented in ta Expressionist® for Genomic Profiling and R, respectively.
[236] DNA methylation analyses in serum samples:
Serum separation: For Serum Sets 1-3 and the NACT Serum Set, women ing the hospitals in London
and Prague have been invited, consented and 20-40 mL blood has been obtained (VACUE'I'I'E® 2 Serum Sep Clot
Activator tubes, Cat 455071, Greiner Bio One ational GmbH), centrifuged at pm for 10 minutes and
serum collected and stored at -80°C. We have applied non-stringent measures (i.e. allowed for up to 12 hours
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between blood draw and centrifugation) purposely in order to mimic the situation of UKCTOCS s which could
be used to compare the results presented herein, which samples had been sent from the recruiting centre to UCL
within 24-48 hours before centrifugation.
Serum DNA isolation and bisulfite modification: DNA was isolated using the DNeasy Blood and Tissue Kit
(Qiagen Ltd, UK, 69506) at GATC Biotech (Constance, Germany). Serum DNA was quantified using the Fragment
Analyzer and the High Sensitivity Large Fragment Analysis Kit (AATI, USA). DNA was bisulfite converted using the
EZ-96 DNA ation Kit (Zymo Research Inc, USA, D5004/8) at GATC Biotech.
Targeted ultra-high coverage bisulfite sequencing: Targeted bisulfite sequencing was performed at GATC.
To this end, a two-step PCR approach was used similar to the recently published BisPCR2 (Ref. S14). Bisulfite
modification was performed with 1mL serum equivalent. For each batch of samples, positive and non-template
controls were processed in parallel. Bisulfite converted DNA was used to test up to three different markers using
automated workflows. After ite modification the target regions were amplified using primers carrying the target
specific sequence and a linker sequence. Amplicons were purified and quantified. All amplicons of the same sample
were pooled equimolarly. In a second PCR, primers specific to the linker region were used to add sequences
necessary for the sequencing and multiplexing of samples. Libraries were purified and quality controlled. Sequencing
was performed on Illumina’s MiSeq or HiSeq 2500 with 75 bp or 125 bp paired-end mode. Trimming of adapter
sequences and low quality bases was performed with matic as described for the RRBS data.
Assessment of RRBS-determined methylation pattern frequency in serum DNA: After sequencing, raw data
were d using Trimmomatic (0.32) to remove adapter sequences and low quality bases at the beginning and
end of reads. uently, reads were d with TrimGalore (0.3.3) to remove cytosines derived from library
preparation which must not be included in the methylation analysis. r analysis was done using Genedata
Expressionist® for Genomic Profiling 9.1. Read pairs were mapped to the human genome (hg19) applying Bisulfite
Mapper based on BOWTIE v2.2.5 (13) with the settings --no-discordant -p 8 --norc --reorder -D 50 --fr --end-to-end -
X 500 -I 0 d33 -k 2 ixed. Coverage was calculated per sample and target region using c Data
Feature Quantification activity by calculating the arithmetic mean of the coverage in each region. As part of the data
quality control, efficiency of the bisulfite conversion was estimated in each sample by quantifying the methylation
levels of CpHpG and CpHpH sites (where H is Any Nucleotide Except G), with minimum ge of 10, within the
target s. The median bisulfite conversion efficiency was 99.4%, with efficiency for no sample being lower than
97.7%. Methylation pattern frequencies in serum samples for target regions were determined as described above.
Relative pattern frequencies were calculated by dividing the number of reads containing the pattern by the total
number of reads covering the pattern region.
DISCUSSION:
Circulating tumour DNA analysis — using cancer—specific DNAme markers and/or patterns of the present
invention - shows independent sensitivity/specificity to that of CA125 and has a greater dynamic range correlating
with s in tumour burden and response to treatment.
Consistent with hed data (Ref. 8), CA125 change after 2 cycles of chemotherapy was not able to
indicate responsiveness to chemotherapy (in this case carboplatin alone or in combination with paclitaxel). The fact
that serum DNAme-dynamics — as analysed using a method of the present invention - correctly identified 7/9 and 6/7
neoadjuvant chemotherapy ders and non-responders, respectively, provides a proof of principle and a basis for
40 prospective clinical trials to dualise pre-operative systemic treatment in ed n cancer.
In healthy individuals, cell-free DNA is present at concentrations between 0 and 100 ng/mL and an e
of 30 ng/mL (Ref. 32). DNA d from tumour cells is shorter than that from non-malignant cells in the plasma of
cancer patients (Ref. 33). One m to be solved is the development of DNAme based markers (and an assay) for
ovarian cancer detection, in particular early detection of n cancer. Samples available in order to carry out this
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task are from large population based ing studies. For example, the largest of such studies being UKCTOCS.
Serum samples from ~100,000 women need to be collected in order to secure sufficient numbers (i.e. between 40-
50) of women who develop ovarian cancer within 2 years of sample on. Within the S setting whole
blood samples were cou riered to the central laboratory with median time to spin of 22 hours. Prospectively collected
blood samples were spun down between 2-12 hours after collection in order to mimic the collection-setting typically
used for large studies like UKCTOCS. It is expected for such an analysis of UKCTOCS samples that, and as has been
already seen for other prospectively collected sets including UKCTOCS (Anjum et al, 2014), samples from such
prospectively collected sets contain higher than average amounts of cell-free DNA and fragments being longer on
average. Both factors are likely to reflect the leakage of WBC DNA into serum. e these complicating factors the
three-DNAme marker panel can outperform CA125 in detecting ovarian , also for detecting ovarian cancer
early.
False CA125-positivity can usually be explained by a CA125 producing benign condition (Ref. 34). The fact
that in Serum Set 3 there was no overlap at all between false CA125 and false DNAme positive samples tes that
the DNAme-false positivity is largely triggered by technical cts as a result of extremely low thresholds down to
a pattern frequency of 0.000003 (i.e. 3 cancer patterns in the background of 1.000.000 DNA nts with a non-
cancer pattern).
Based on the UKCTOCS ence screen (Ref. 23), the Risk of Ovarian Cancer Algorithm (ROCA) identified
0.65% of women at an elevated risk of which 13% (42/327) have eventually been diagnosed after having been
assessed by ultrasound, additional imaging and clinical assessment. Applying the three-marker DNAme test of the
present invention with a conservative estimate of specificity and sensitivity of 90% and 60%, respectively, in ROCA-
elevated risk women would immediately enable sis and treatment of the 0.05% of women within a population
with an ovarian cancer with a positive predictive value of 44% (Le. only 2.3 ions are necessary to
diagnose/treat 1 n cancer patient).
At the UKCTOCS prevalence screen (Ref. 22), the Risk of Ovarian Cancer Algorithm (ROCA) identified
elevated risk in 0.65% of women of whom 13% (42/327) were diagnosed after repeat CA125 testing, ultrasound,
additional imaging and al assessment. Applying the three-marker DNAme test of the present invention with a
vative estimate (i.e. excessive background DNA will not be an issue in prospective samples) of specificity and
sensitivity of 90% and 60%, as a second line test to ROCA-elevated risk women could substantially decrease time to
diagnosis in at least half the women with ovarian cancer.
[248] Overall and for the first time, the present invention provides serum DNAme markers and assays (and other
means and methods) that can diagnose ovarian cancers (or are useful for such diagnosis), and it is likely that they
are able to detect/diagnose OC up to two years in advance of tional methods of diagnosis, and are able to
individualise ovarian cancer treatment. The recent advance of e-made blood collection tubes (such as those
from Streck as described above) that stabilise ating DNA and prevent leakage of DNA from blood cells (Ref. 35)
will facilitate al implementation of DNAme pattern detection in cell free DNA as a clinical tool in cancer medicine.
Note: The work leading to this invention has ed funding from the European Union Seventh Framework
Programme (FP7/2007-2013) under Grant Agreement Number 305428 (Project EpiFemCare).
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Claims (1)
- CLAIMS A method of determining the presence or absence of, or response to therapy against, an ovarian cancer in a woman, said method comprising the steps: 0 providing a biological sample from said woman, said sample sing ree DNA of said woman; and - determining, in at least one molecule of said cell-free DNA, the ation status at one or more Cst located within one or more of the nucleotide sequences independently selected from the group consisting of: SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31, or a nucleotide sequence present within about 2,000bp 5’ or 3’ thereof, or an allelic 10 variant and/or complementary sequence of said nucleotide sequence(s), wherein, the presence in at least one of said cell-free DNA molecules of one or more: (i) methylated Cst associated with one or more of said nucleotide ces independently selected from: SEQ ID NOs: 1, 2, 3, 4, 10, 12, 14, 15, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29 and 30; and/or (ii) un-methylated Cst associated with one or more of said nucleotide sequences independently ed from: SEQ ID NOs: 5, 6, 7, 8, 9, 11, 13, 15 16, 17, 22 and 31, indicates the presence of, or a reduced response to therapy against, an ovarian cancer in said woman. The method of claim 1, wherein said biological sample is liquid biological sample ed from the group consisting of: a blood sample, a plasma sample and a serum sample. The method of claim 1 or 2, wherein said Cst for a given nucleotide sequence are fiable by a genome position for the ne (C) thereof, independently selected from the list of genome positions corresponding to said nucleotide sequence set forth in TABLE 1C. 25 The method of any one or claims 1 to 3, wherein the methylation status is determined at a number being two, three, four, five, six, seven, eight, nine, ten, about 12, about 15, about 20, about 25 or more of said Cst located within said nucleotide sequence; wherein, the presence in at least one of said cell-free DNA molecules of at least one, such as up to said number, of: (i) methylated Cst associated with one or more of said nucleotide sequences independently selected from: SEQ ID NOs: 1, 2, 3, 4, 10, 12, 14, 15, 18, 19, 20, 21, 23, 30 24, 25, 26, 27, 28, 29 and 30; and/or (ii) un-methylated Cst associated with one or more of said tide sequences independently selected from: SEQ ID NOs: 5, 6, 7, 8, 9, 11, 13, 16, 17, 22 and 31, indicates the presence of, or a reduced response to therapy t, an ovarian cancer in said woman. The method of any one of claims 1 to 4, wherein the presence in at least one of said cell-free DNA les 35 of one or more pattern of methylation and/or un-methylation as set forth in TABLE 23 for the respective nucleotide sequence(s), indicates the presence of, or a reduced response to therapy against, an ovarian cancer in said woman. The method of any one of claims 1 to 5, wherein the methylation status at one or more Cst located within a 40 number of two, three, four or more of said nucleotide sequences is ined; wherein, the presence in at least one of said cell-free DNA molecules of one or more: (i) methylated Cst associated with one or more of said tide sequences independently selected from: SEQ ID NOs: 1, 2, 3, 4, 10, 12, 14, 15, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29 and 30; and/or (ii) un-methylated Cst associated with one or more of said nucleotide sequences independently selected from: SEQ ID NOs: 5, 6, 7, 8, 9, 11, 13, 16, 17, 22 and 31, indicates the presence of, or a reduced response to therapy, t an ovarian cancer in said woman. The method of any one of claims 1 to 6, wherein said nucleotide sequence(s) is/are associated with DMR(s) #141 and/or #204 and/or #228 (eg, SEQ ID NOs: 1, 2 and/or 3), or an allelic variant and/or complementary sequence of said nucleotide sequence(s). The method of claim 7, wherein the methylation status is determined at one or more of said Cst located within each of said three nucleotide sequences; wherein, the presence in at least one of said cell-free DNA molecules of one or more methylated Cst, and/or of one or more pattern of methylation and/or un- 10 methylation as set forth in TABLE 2B for the tive nucleotide sequence(s), located within any one of said nucleotide sequences tes the presence of, or a reduced response to therapy against, an ovarian cancer in said woman. The method of claim 7 or 8, wherein the methylation status is determined at a number of between about 5 15 and about 18 of said Cst located within said nucleotide sequence(s); wherein, the presence in at least one of said cell-free DNA molecules of at least said number of methylated Cst, and/or of one or more pattern of methylation and/or un-methylation as set forth in TABLE 2B for the respective nucleotide sequence(s), located within any one of said nucleotide sequences indicates the presence of, or a reduced response to therapy against, an ovarian cancer in said woman. 10. The method of any one of claims 7 to 9, wherein the methylation status is determined at about 7 Cst located within nucleotide sequence SEQ ID NO 1 and/or at about 16 to 18 Cst located within nucleotide sequence SEQ ID NO 2 and/or at about 7 to 9 Cst located within tide sequence SEQ ID NO 3. 25 11. The method of any one of claims 7 to 10, wherein the methylation status is determined at about 7 Cst located within nucleotide sequence SEQ ID NO 1 and at about 16 to 18 Cst located within nucleotide sequence SEQ ID NO 2 and about 7 to 9 Cst located within tide sequence SEQ ID NO 3; wherein, the presence in at least one of said ree DNA molecules of at least said number of methylated said Cst, and/or of one or more n of methylation and/or un-methylation as set forth in TABLE 2B for the 30 respective nucleotide sequence(s), located within any one of said nucleotide ces indicates the presence of, or a reduced se to y against, an ovarian cancer in said woman. 12. The method of any one of claims 1 to 11, comprising the step of isolating said cell-free DNA from said biological sample. 13. The method of any one of claims 1 to 12, comprising the step of treating said cell-free DNA with an agent that differentially modifies said cell-free DNA based on the methylation status of one or more Cst located within; ably a methylation sensitive restriction enzyme and/or bisulphite. 40 14. The method of claim 13, n said agent is bisulphite and said determining step comprises the detection of at least one hite-converted un-methylated cytosine within one or more of the nucleotide sequences independently ed from those set forth in TABLE 2A (eg, independently selected the group consisting of: SEQ ID N05 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61 and 62), wherein one or more of the bases identified by “Y” therein is a U or T and, WO 09212 preferably, where one or more of the bases identified by “Y” in a CpG therein is a C, or an allelic variant and/or complementary sequence of said nucleotide sequence(s). 15. The method of claim 13 or 14, wherein said agent is bisulphite and said determining step ses the detection of at least one bisulphite-converted un-methylated cytosine within a nucleotide sequence having a length of at least 50bp comprised in SEQ ID NO 32 and/or SEQ ID NO 33 and/or SEQ ID NO 34, wherein one or more of the bases identified by “Y” therein is a U or T and, preferably, where one or more of the bases identified by “Y” in a CpG therein is a C, or an allelic variant and/or complementary sequence of said nucleotide sequence(s). 16. The method of any one of claims 1 to 15, comprising the step of amplifying one or more s of said cell- free DNA to produce DNA prior to or as part of said ining step, and; preferably after said treating step. 17. The method of claim 16, n said amplified region(s) comprises at least one of said nucleotide sequences. 18. The method of claim 17, wherein said amplification comprises PCR using the primer-pair(s) for the respective nucleotide sequence(s) as independently selected from the group of primer-pairs set forth in each row of TABLE 3. 20 19. The method of any one of claims 1 to 18, n the methylation status of said Cst is determined by a technology ed from the group consisting of: methylation specific PCR/MethylLight, Epityper, nucleic acid chip-hybridisation, nucleic acid mass-spectrometry, Methylated DNA immunoprecipitation (MeDIP), Raindance and nucleic acid sequencing, preferably, e) strand sequencing, nanopore sequencing, bisulphite sequencing, such as targeted bisulphite sequencing; preferably wherein said determination step is conducted 25 as a pool when in respect of two, three, four or more of said nucleotide sequences. 20. The method of any one of claims 1 to 19, wherein the methylation status of said CpG(s) is determined in multiple molecules of said cell-free DNA and/or amplified DNA representing each of said nucleotide sequences. 30 21. The method of claim 20, wherein the presence in at least a plurality of said cell-free DNA molecules of one or more methylated and/or un-methylated Cst (as applicable), and/or the presence in at least a plurality of said cell-free DNA molecules of one or more pattern of methylation and/or un-methylation as set forth in TABLE 2B for the tive nucleotide sequence(s), located within one or more of said nucleotide sequences, indicates the ce of, or a reduced response to therapy against, an ovarian cancer in said woman. 22. The method of claim 20 or 21, wherein said plurality of cell-free DNA molecules with one or more of said ated and/or hylated Cst (as applicable), and/or the presence in at least a plurality of said cell- free DNA molecules of one or more pattern of methylation and/or un-methylation as set forth in TABLE 2B for the respective tide sequence(s), located is at least 2, 3, 4, 5, 6, 7, 18, 9 or 10, or at least about 15, 20, 40 25, 30, 35, 40, 45, 50, 55, 60, 70, 80, 90, 100, 125, 150, 175 or 200, or a greater number such as greater than about 500, 1,000, 5,000, 7,500, 1,000, 2,500, 5,000 or greater than 5,000 les. 23. The method of any one of claims 20 to 22, wherein the methylation status of said CpG(s) is determined in a number of molecules of said cell-free DNA and/or amplified DNA representing each of said nucleotide sequences selected from the group consisting of at least about: 1,000, 5,000, 10,000, 50,000, 100,000, 200,000, 500,000, 1,000,000, 1,500,000, 2,000,000, 2,500,000, 3,000,000, 3,500,000, 000 and 5,000,000 molecules, or more than 5,000,000 molecules. 24. The method of any one of claims 20 to 23, wherein a fraction or ratio of, or an absolute number of, cell-free DNA molecules in said sample having said methylated and/or un-methylated CpG(s) (as applicable) located within said tide sequence(s), and/or having said n of methylation and/or hylation as set forth in TABLE 23 for the respective nucleotide sequence(s), is estimated. 10 25. The method of claim 24, further comprising a step of comparing said fraction or ratio with a standard or cut- off value; wherein a fraction or ratio greater than the standard or cut-off value indicates the presence of or a reduced response to therapy against, an ovarian cancer in said woman. 26. The method of claim 25, wherein said standard or cut-off value is about 0.0008 for said methylated/un- 15 methylated CpG or said n of methylation and/or un-methylation associated with nucleotide sequence SEQ ID NO 1 and/or about 0.00003 for said methylated/un-methylated CpG or said n of ation and/or hylation associated with nucleotide sequence SEQ ID NO 2 and/or about 0.00001 for said ated/un-methylated CpG or said pattern of methylation and/or un-methylation associated with tide sequence SEQ ID NO 3. 27. The method of claim 25 or 26, wherein a fraction or ratio of cell-free DNA molecules with said methylated and/or un-methylated CpG(s) (as applicable) located within each of said nucleotide sequence(s), and/or with said pattern of ation and/or un-methylation as set forth in TABLE 23 for the respective nucleotide sequence(s), is estimated and compared to a respective standard or cut-off value; wherein any one of such 25 fraction or ratios being greater than its respective standard or cut-off value tes the presence of, or a reduced response to therapy against, an ovarian cancer in said woman. 28. The method of any one of claims 25 to 27, wherein said rd or cut-off value(s) is/are modified for a given sample based on: 30 o the amount or concentration of total cell-free DNA present in said sample; and/or 0 a baseline value of said fraction or ratio previously determined for said woman; and/or 0 a value of said fraction or ratio determined from multiple samples from a population of women representative of said woman; and/or 0 the specificity and/or sensitivity desired for said method of determination. 29. The method of claim 28, wherein said standard or cut-off value is/are reduced for a given sample that has an amount or concentration of total ree DNA present in said sample that is greater than a standard or cut-off value. 40 30. The method of any one of claims 1 to 29, which is practiced on multiple samples; wherein each sample is ted from the same woman at different time points. 31. The method of claim 30, wherein said multiple samples are collected from said woman with an interval between them selected from the group consisting of about: 2 days, 3 days, 4 days, 5 days, 7 days, 10, days, 14 days, 21 days, 24 days, 3weeks, 4 weeks, 5 weeks, 6 weeks, 6, weeks, 8 weeks, 3 months, 4 months, 5 months, 6 months, 8 months, 12 months, 18 months, 2 years, 3 years and 5 years. 32. The method of claim 30 or 31, wherein in comparison to a previous sample, the presence of, or an se in the te number of, or an increase in the on or ratio of, cell-free DNA molecules in said sample having said methylated and/or un-methylated CpG(s) (as able) located within said nucleotide sequence(s), and/or having said pattern of methylation and/or un-methylation as set forth in TABLE 23 for the respective nucleotide sequence(s), indicates the presence of, or a reduced response to therapy against, an ovarian cancer in said woman. 33. The method of any one of claims 1 to 32, comprising the step of determining tro), from a blood sample from said woman, the amount present therein of one or more proteins independently selected from the group consisting of: CA—125, HE4, transthyretin, apolipoprotein A1, -microglobin and transferrin; wherein, either or both of: 15 o the presence in at least one of said cell-free DNA molecules of one or more methylated and/or un- methylated Cst (as able) located within one or more of said nucleotide sequences, and/or the presence in at least one of said cell-free DNA molecules of one or more pattern of methylation and/or un- methylation as set forth in TABLE 23 for the respective nucleotide sequence(s); - an amount of said protein(s) present in said blood sample is greater than a standard or f value for 20 such amount or protein, tes the presence of, or a reduced response to therapy against, an ovarian cancer in said woman. 34. The method of claim 33, wherein said protein is ined by a ROCA, a ROMA and/or an OVA1 diagnostic test. 35. The method of any one of claims 1 to 34, wherein said ovarian cancer is an invasive ovarian cancer, such as an invasive epithelial ovarian cancer; in particular one selected from the group consisting of: high grade serious (HGS), endometroid, cell-cell and mucinous n cancers; and/or is a peritoneal cancer or a Fallopian tube . 36. The method of any one of claims 1 to 35, for distinguishing the presence of ovarian cancer from the presence of a benign pelvic mass. 37. The method of any one of claims 1 to 36, for determining the response of a woman suffering from ovarian 35 cancer to a therapy comprising chemotherapeutic agent(s) against said ovarian cancer. 38. The method of claim 37, wherein the risk of death of said woman is predicted. 39. The method of claim 37 or 38, ced on said woman after one, two, three, four and/or five cycles of said 40 (chemo)therapy. 40. The method of any one of claims 37 to 39, wherein said sample is obtained from said woman within a period after completion of said cycle or (chemo)therapy that is selected from the group consisting of about: 2 hours, 4 hours, 6 hours, 12 hours, 18 hours, 24 hours, 36 hours, 48 hours, 3 days, 4 days, 5 days, 6, days, 7 days, 8 days, 10 days, 12 days, 14 days, 16, days, 18 days, 21 days, 24 days, 4 weeks, 5 weeks, 6 weeks, and 8 weeks. 41. The method of any one of claims 37 to 40, wherein said (chemo)therapy includes one or more chemotherapeutic agent(s) independently selected from the group consisting of: a platinum-based antineoplastic and a taxane. 42. The method of claim 41, wherein at least one of said chemotherapeutic agents is carboplatin, cisplatin, paclitaxel or xel 43. The method of any one of claims 37 to 42, wherein said therapy is a uvant (chemo)therapy. 44. The method of any one of claims 37 to 43, wherein if said woman is determined to respond to said (chemo)therapy, then said woman is designated as being eligible for tumour de-baulking surgery. 45. The method of any one of claims 37 to 43, wherein if said woman is determined to not respond to said (chemo)therapy, then said woman is ated as eligible for therapy with one or more second-line chemotherapeutic agent(s) against said ovarian . 20 46. The method of claim 45, wherein said second-line (chemo)therapy es one or more chemotherapeutic agent(s) independently selected from the list consisting of: paclitaxel, carboplatin, cisplatin, liposomal doxorubicin, gemcitabine, trabectedin, etoposide, cyclophosphamide, an angiogenesis inhibitor and a PARP inhibitor. 25 47. A chemotherapeutic agent, such as one ed from the list consisting of: carboplatin, paclitaxel, docetaxel, cisplatin, liposomal doxorubicin, gemcitabine, tedin, etoposide, cyclophosphamide an angiogenesis inhibitor and a PARP inhibitor; for use in a method of therapy of ovarian cancer in a woman, n said chemotherapeutic agent is administered to a woman within about 3 months of said woman having been determined, using a method of any one of claims 37 to 43, to not respond to a therapy against 30 ovarian . 48. A nucleic acid comprising at least 10 (preferable at least about 15, such as at least 50, for any SEQ ID other than SEQ ID NO:58) contiguous bases comprised in a ce selected from the group consisting of: SEQ ID N05 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 35 59, 60, 61 and 62, wherein said nucleic acid sequence includes one or more of the bases identified by “Y” therein is a U or T and, preferably, where one or more of the bases identified by “Y” therein is a C, or an allelic variant and/or complementary sequence of said nucleotide ce. 49. The nucleic acid ce of claim 48, comprising at least 50 contiguous bases comprised in a sequence of 40 SEQ ID NO 32, SEQ ID NO 33 or SEQ ID NO 34, wherein said nucleic acid sequence includes one or more of the bases identified by “Y” therein is a U or T and, preferably, where one or more of the bases identified by “Y” therein is a C, or an allelic variant and/or complementary sequence of said nucleotide sequence. 50. The nucleic acid ce of claim 48 or 49, which is comprised in a sequence as set forth in TABLE 23 (eg, a sequence selected from the group consisting of: SEQ ID N05 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92 and 93. 51. A nucleic acid probe complementary to a nucleic acid sequence recited in any one of claims 48 to 50, preferably for detection of said nucleic acid. 52. The nucleic acid probe of claim 51, that differentially binds to said nucleic acid sequence depending on the methylation status of one or more Cst within said nucleic acid sequence. 10 53. The nucleic acid probe of claim 51 or 52, comprising a label, preferably a label being a detectable scent moiety. 54. A nucleic acid primer pair for amplifying a nucleic acid sequence consisting of at least 10 (preferable at least about 15, such as at least 50, for any SEQ ID other than SEQ ID NO:89) uous bases comprised in 15 a sequence) selected from the group consisting of: SEQ ID NOs: SEQ ID N05 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92 and 93, or a nucleotide sequence present within about 2,000 bp 5’ or 3’ thereof, or an allelic variant and/or complementary sequence said nucleotide sequence(s), preferably wherein at least one primer of said pair includes a sequence corresponding to at least one bisulphite-converted CpG present in said nucleotide sequence(s). 55. The primer pair of claim 54, selected from the group of primer-pairs set forth in each row of TABLE 3. 56. A plurality of nucleic acids comprising at least two or three nucleic acid sequences of any one of claims 48 to 50 and/or at least two or three nucleic acid probes of any one of claims 51 to 53 and/or at least two or 25 three primer pairs of claim 54 or 55. 57. The plurality of nucleic acids of claim 56, as an admixture or array of said nucleic acid sequences and/or nucleic acid probes and/or primer pairs. 30 58. A kit, preferably for determining the presence or absence of, or response to therapy against, an ovarian cancer in a woman, said kit comprising: 0 one or more nucleic acid sequences of any one of claims 48 to 50 and/or nucleic acid probes of any one of claims 51 to 53 and/or primer pairs of claim 54 or 55 and/or the plurality of nucleic acids of claim 56 or 57; and 35 - optionally, said kit further comprising: (i) a printed manual or er readable memory comprising instructions to use said nucleic acid ce(s), nucleic acid s), primer pair(s) and/or plurality of nucleic acids to ce a method of any one of claims 1 to 46 and/or to produce or detect the nucleic acid sequence(s) of any one of any one of claims 48 to 50; and/or 40 (ii) one or more other claim, component or reagent useful for the practice of a method of any one of claims 1 to 46 and and/or the tion or detection of the nucleic acid ce(s) of any one of claims 48 to 50, ing any such item, component or reagent disclosed herein useful for such practice, production or detection. 59. The kit of claim 58, further comprising one or more of the following components. 0 means to collect and/or store a biological sample, such as blood, to be taken from said woman, preferably wherein said means is a blood collection tube; and/or 0 means to extract DNA, preferably cell-free DNA, from the sample to be taken from said woman, preferably wherein said means is a cell-free DNA extraction kit; and/or 0 an agent to differentially modify DNA based on the methylation status of one or more Cst located within said DNA, preferably wherein said agent is bisulphite; and/or 0 one or more reagents to detect a nucleic acid sequence, preferably for detecting the sequence of a bisulphite-converted nucleotide sequence; and/or 10 0 a printed manual or computer readable memory comprising instructions to identify, obtain and/or use one or more of said means, agent or reagent(s) in the context of a method of any one of claims 1 to 46. 60. A computer program product comprising: a computer readable medium encoded with a plurality of instructions for controlling a ing system to perform and/or manage an operation for determining the 15 presence or absence of, or response to therapy against, an ovarian cancer in a woman, from a biological sample from said woman, said sample comprising cell-free DNA of said woman, and determining, in at least one le of said cell-free DNA, the methylation status at one or more Cst located within one or more nucleotide sequences in accordance with a method as set forth in any one of claims 1 to 46; said operation comprising the steps of: 20 0 ing a first signal representing the number of les of said cell-free DNA sing one or more methylated and/or un-methylated Cst (as applicable), and/or comprising one or more pattern of methylation and/or un-methylation as set forth in TABLE 23 for the respective tide sequence(s), located within one or more of the tide sequences independently selected from the group consisting of: SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 25 27, 28, 29, 30 and 31, or a nucleotide sequence present within about 2,000bp 5’ or 3’ f, or an allelic variant and/or mentary ce of said nucleotide sequence(s); and - determining a classification of the presence or absence of, or response to therapy against, an ovarian cancer in said woman based on their being at least one molecules of said ree DNA comprising one or more said methylated and/or un-methylated Cst (as applicable), and/or comprising one or more said 30 pattern of methylation and/or un-methylation, located within one or more of said nucleotide sequences. 61. The computer program product of claim 60, wherein said operation r comprising the steps of: 0 receiving a second signal representing the number of les of said cell-free DNA comprising said nucleotide sequence(s); and 35 - estimating a fraction or ratio of molecules of said cell-free DNA comprising one or more said methylated and/or un-methylated Cst (as applicable), and/or comprising one or more said pattern of methylation or un-methylation, located within one or more of the nucleotide sequences within all of said nucleotide SEQUGHCGS. 40 62. The computer program t of claim 61, wherein said classification is determined by comparing said a fraction or ratio to a standard or cut-off value. 63. The computer program product of claim 62, n said operation further comprising the steps of: 0 ing a third signal representing: (i) the amount or concentration of total ree DNA present in said sample; and/or (ii) a baseline value of said fraction or ratio previously determined for said woman; and - ing said standard or cut-off value for a given sample based on said third signal. 64. The computer program t of any one of claims 60 to 63, wherein said first signal, and optional second signal, is determined from nucleotide sequence and/or methylation status ation of a plurality of said les of said cell-free DNA and/or ied DNA representing each of said nucleotide sequences, preferably wherein said plurality is a number selected from the group consisting of at least about: 1,000, 5,000, 10,000, 50,000, 100,000, 200,000, 500,000, 1,000,000, 1,500,000, 2,000,000, 2,500,000, 3,000,000, 3,500,000, 4,000,000 and 5,000,000 molecules, or more than 5,000,000 molecules. 65. The computer program product of claim 64, wherein said operation further comprises the steps of: o for each of said molecule’s sequence and/or methylation status information, determining if said molecule comprises none, one or more methylated and/or un-methylated Cst (as applicable), and/or comprises none, one or more pattern of ation or un-methylation as set forth in TABLE 23 for the respective 15 nucleotide sequence(s), located within one or more of the nucleotide ces ndently selected from the group consisting of: SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31, or a nucleotide sequence present within about 2,000bp 5’ or 3’ thereof, or an allelic variant and/or complementary sequence of said nucleotide sequence(s); and - calculating said first signal, and optional second signal, based on said determination for all or a portion of 20 said plurality of molecules. 66. The computer program product of any one of claims 60 to 65, n said operation further comprises the steps of: 0 receiving a signal representing the amount present, in a sample of blood taken from said women, of one 25 or more proteins ndently selected from the group consisting of: CA—125, HE4, transthyretin, apolipoprotein A1, -microglobin and transferrin; and - comparing said a fraction or ratio to a standard or cut-off value for said protein; and - determining a classification of the presence or absence of, or response to therapy against, an ovarian cancer in said woman based on their being either or both of: (i) at least one molecules of said cell-free 30 DNA comprising one or more said methylated and/or un-methylated Cst (as applicable), and/or comprising one or more said pattern of methylation or hylation, located within one or more of said nucleotide sequences; and/or (ii) an amount of said protein(s) present in said blood sample is greater than said standard or f value for such amount or protein. 35 67. A use of a nucleic acid sequences of any one of claims 48 to 50 and/or a nucleic acid probes of any one of claims 51 to 53 and/or a primer pair of claim 54 or 55 and/or a plurality of nucleic acids of claim 56 or 57 and/or a kit of claim 58 or 59 and/or a computer program t of any one of claims 60 to 66, in each case for determining the presence or absence of, or response to therapy t, an ovarian cancer in a woman. Ezhmm £2 3% mfiafi E mmgfimm m £ng gnwmmg $83“. “WEE” Egg gaxu mmmgcw sagas": cymimm Emma; 3 “imam 3% Ruiz “mm w fiég 3%, 393m m 3%. fifiwm gnaw 339$. mmfigau fimfimumam ”3&5 «55%? gamma «$5 figmfigwm mzmfimfizugfi ymmmé E E33 m 33$ WW 33$ mmgfi magi flags, 3» ”Em ”Egg 3%: gas, §§$ “wag ”33% Emmfiawéez flfigfia Emigm 33% Ma»; 53mm E m E33 m 5 Shmm Em Kwaé fignggg fig Emfié gwwhgfl fiaéggfigm fimfifi Exam?” £3212“? 9?me 3% an: figfiafi hamnmuwmu m www-mm wmmi “33%”ng 3““ch wmfiwgu mfifizm :9 3&3”,ng mmgm gawkmbfl «$3 fig 3 Em w Egg fix ,» gag Ewfimm 3» wwm ymw 3W ”afifimm Eu. fi, :wvmé fimmmmm «53a Eghwm 3mm 3% figmfi Smumfiwam «Ema. gags figs.» $3 “mm $33 fifii a, mg... mmmx mg: cwgm twggmfiéaz figé gumbmggm gag mmmg géfig "fig figgw fifififim £333 ”3me 5. igaumfi Eucmu mmEQ “g mafia ma mmfiga ammumam v.33 £5334 wymwmgmgzm Mmfimfi “35$ 35E; $5 F .3th Eggfi ME, “Em 3&3”;me mmmgg 3% cmmfifi Eéamfiencw mmmxg fig, gmiw wmxcxug $33me .9"— taughfi 8”ng $3, $3 xmmwé €me 3n: figgm SUBSTITUTE SHEET (RULE 26) :rz'r‘éé‘!"»'2=:w game‘s m’ylivmmg m, . ., .wfifi’s,‘~,’r§ Uneag‘gifiptvsfém: wwimga KGWCGWCCEWCG RRBS reads White Bland Celts (W8C) wag,“ :zahéiigiEEE‘,‘‘ ficwfalh .‘ ‘ meme - ‘"'~’~'~::-=n Mam azarzatvmzrw: . . , mmmmwmmmwwmmwmmmmwwmW Fatima,_ memy FWCWWW g QC WM: E 0105003 0%7 ‘ 0%“ ‘E “(300001? 49% 0% i ”HUN? (3% pvity 84 specifiaity filtering and ranking Fig.2 22.55 WWHEWW ymi‘mmg WW 5}; Wm {55% W " WW1; WWWWWW iW flfl’fiflgfid WWW EiWWW KNEW WWWW M5 5 WWWWWW 53W?WWW 3W “:2: "I? {3% W? WWWWW QWWWWW Q‘WWKW r-WWWW £55 WWt‘iWWW W5 QMWWWE WWWWWMKWWWWEK WWWWWW‘WWWWY‘W 3%: 5‘ atgg‘g W ”*2Vita 1*; fiafiwm Wmmww 00 93% M:x~4--rw.v/wfl~w¢ WmmwmammwinVWRWWWmtmmm»mWmmMWxmummmfimmwmvmwuwwmmmw»mkmwmwammvmmmm mmmm Pattam date-mm arid quantifimfim A B 0.100 *** *** ** ns * HS 0030 *** *** *** n5 * n5 E 3'3033. g g-ggg 0'025 E 0'01"" 02015“ e E a.» 4 E _ 0.010? 4% 0.000- E ‘3; e % s "-006 g 3 ‘6 5 “ 0.005.: % 0.004~ 0 a; ,4 a E m; .5 ‘— 'T' , = 0.002 a ‘ Vs . v a; S « a: V 0.000 ‘_ _"'"'" 1970‘: IE 0.000 ‘ ~ “291"” 4 ‘ H BPM BOT NET 00M NHGS HGS H BPM BOT NET OCM NHGS HGS (n=119lln=27) (5) (n=37) (n=121 ("=29) (n=21)(n=119)(n=27) (5) (n=37) (n=12)(n=29) C D 0.04}0.06- * ns ns ns ns sooo *** *** '15 ** *** "S g 7000] 3 1 g 0.003 4 ‘g i E 3000 E § . W “ 0% 0.002 ":5 5 2000 - N __ 4 < % i U 1 "'0‘" E. 1000 9 4 .__. m g , a“ I. J; _ I. ,“ .9 H BPM BOT NET 00M NHGS HGS H BPM BOT NET 0cm NHGS HGS ("=21)(n=119)(n=27l (5) (FM ln=12)(n=29l (n=21)(n=119)(n=27) (5) (n=37) (n=29) Specificity Sensitivity CA125(cut-off35|UImL) 122/140 (87.1%:95%C| 00.1-92.0%) 24129 (82.8%:95%C| 63.5-93.5%) Three DNAme-Marker Panel (thresholds based on Sets 1 & 2) 127/140 (90.7%:95%C| 84.3—94.8%) 12I29 (41 .4%:95%C| 24.1—60.9%) Three Marker Panel “Set 2 & 3 173/194 (91.8%:95%Cl Bar—95.1%) 28I48 (58.3%:95%C| 43.2—72.1%) (thresholds based on Sets 1, 2 & 3) H & BPM HGS CA125 negative CA125 positive CA125 negative CA125 positive Three DNAme-Marker negative 108 13 4 9 Panel (new thresholds) positive 14 0 1 15
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