Classifications

• • C—CHEMISTRY; METALLURGY
  • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
  • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
  • C12Q1/00—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions
  • C12Q1/68—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions involving nucleic acids
  • C12Q1/6813—Hybridisation assays
  • C12Q1/6827—Hybridisation assays for detection of mutation or polymorphism
• • Y—GENERAL TAGGING OF NEW TECHNOLOGICAL DEVELOPMENTS; GENERAL TAGGING OF CROSS-SECTIONAL TECHNOLOGIES SPANNING OVER SEVERAL SECTIONS OF THE IPC; TECHNICAL SUBJECTS COVERED BY FORMER USPC CROSS-REFERENCE ART COLLECTIONS [XRACs] AND DIGESTS
  • Y10—TECHNICAL SUBJECTS COVERED BY FORMER USPC
  • Y10T—TECHNICAL SUBJECTS COVERED BY FORMER US CLASSIFICATION
  • Y10T436/00—Chemistry: analytical and immunological testing
  • Y10T436/14—Heterocyclic carbon compound [i.e., O, S, N, Se, Te, as only ring hetero atom]
  • Y10T436/142222—Hetero-O [e.g., ascorbic acid, etc.]
  • Y10T436/143333—Saccharide [e.g., DNA, etc.]

Definitions

• chromosomal aneuploidies Various genetic disorders, such as chromosomal aneuploidies, are detectable during pregnancy according to a variety of methods currently in use by hospitals and medical professionals. Most of these methods, however, are invasive and carry a risk of unintended loss of fetus or miscarriage. Noninvasive prenatal diagnosis of chromosomal aneuploidies using fetal DNA in maternal plasma is an actively researched area, and there exists a clear need for new and more reliable methods for early detection.
• This invention provides a novel method for detecting chromosomal aneuploidies such as trisomy 21 by the combination of fetal -specific epigenetic and genetic markers.
• the present inventors searched for fetal DNA markers on
• chromosomes 21, 18, and 13 that were differentially methylated in the placenta and maternal blood cells using methods including combined bisulfite restriction analysis and
• Chromosome dosage analysis was performed by comparing the dosage of these epigenetic markers to a genetic marker, a DNA sequence that is derived from a fetus and can be distinguished from a maternal DNA sequence by virtue of its distinct polynucleotide sequence.
• a genetic marker a DNA sequence that is derived from a fetus and can be distinguished from a maternal DNA sequence by virtue of its distinct polynucleotide sequence.
• ZFY zinc finger protein
• HLCS holocarboxylase synthetase
• This invention provides a method for detecting a chromosomal aneuploidy in a fetus carried by a pregnant woman.
• the method comprises the steps of: (a) determining in a biological sample taken from the pregnant woman the amount of a methylation marker of fetal origin, wherein the methylation marker is located on a chromosome relevant to the chromosomal aneuploidy or within a section of a chromosome relevant to the chromosomal aneuploidy, and wherein the methylation marker of fetal origin is distinguished from its counterpart of maternal origin due to differential DNA methylation; (b) determining the amount of a genetic marker of fetal origin in the sample, wherein the genetic marker is located on a reference chromosome, and wherein the genetic marker of fetal origin is distinguished from its counterpart of maternal origin in the sample due to difference in polynucleotide sequence, or the genetic marker does not exist in the maternal genome; (c) determining the ratio of the amounts
• the standard control value approximates the expected gene or chromosome dosage or ratio in the human genome, although slight variations may exist depending on the specific methodology used in the detection method. For example, there are two copies of chromosome 21 and one copy of chromosome Y in a euploid male genome. Hence, the ratio of dosage between an epigenetic marker on chromosome 21 to a genetic marker on chromosome Y would be approximately 2.
• the methylation marker of fetal origin is from the placenta.
• the counterpart of maternal origin is from the pregnant woman's blood cells.
• the methylation marker of fetal origin may be more methylated than its counterpart of maternal origin, or it may be less methylated than its counterpart of maternal origin.
• the sample is maternal whole blood, serum, plasma, urine, amniotic fluid, genital tract lavage fluid, placental-tissue sample, chorionic villus sample, or a sample containing fetal cells isolated from maternal blood.
• the sample is any sample that contains fetal nucleic acids.
• the methylation marker is part of, or in proximity to, the
• HLCS Holocorb ⁇ xylase Synthetase gene.
• regions of the HLCS gene including the putative promoter region) as shown in Table 2 may be used as methylation markers.
• Other methylation markers include Marker 18A and Marker 13 A.
• Additional methylation markers are defined as follows: a region of about 15 to 450 nucleotides and comprises one cytosine, the region being (1) a genomic locus selected from the group consisting of MAT.18.0094, MAT.13.0023, MAT.13.0020, MAT.13.0038, MAT.18.0071, MAT.18.0097, MAT.21.0178, and TAS.21.1175; or (2) no more than 10 kb upstream and/or downstream from the locus.
• markers on chromosome 21 are defined as follows: a region of about 15 to 450 nucleotides on chromosome 21 and comprises one cytosine, the region being (1) a genomic locus selected from the group consisting of CGIl 37, phosphodiesterase 9 A (PDE9A), Homo sapiens protein phosphatase 1, regulatory
• methylation markers are intended for use in accordance with the detection method of this invention in combination with any one or more of the genetic markers described herein.
• step (a) comprises treating the sample with a reagent that differentially modifies methylated and unmethylated DNA.
• a reagent that differentially modifies methylated and unmethylated DNA.
• Such reagent may comprise bisulfite or a protein or chemical that binds to DNA based on methylation status; or the reagent may comprise an enzyme that either preferentially cleaves methylated DNA or preferentially cleaves unmethylated DNA.
• the genetic marker does not exist in the maternal genome. In other cases, the genetic marker is located on the Y chromosome. Frequently, the genetic marker of fetal origin is distinguished from the genetic marker of maternal origin based on genetic polymorphism, which includes a single nucleotide polymorphism (SNP), simple tandem repeat polymorphism, and insertion-deletion polymorphism.
• the genetic marker is the Zinc-Finger protein, Y-linked (ZFY) gene.
• the genetic marker is a genomic sequence comprising SNP rs6636 in TMED8 gene, e.g., SEQ ID NO:1 or SEQ ID NO:2.
• step (a) or step (b) may include the process of amplification of the methylation marker and/or the genetic marker, especially the methylation marker and the genetic marker of the fetal origin.
• the amplification is by a polymerase chain reaction (PCR), such as a methylation-specific PCR; or the amplification may be a nucleic acid sequence-specific amplification.
• PCR polymerase chain reaction
• step (a) or (b) is performed by molecular counting.
• step (a) or (b) comprises digital polymerase chain reaction, real-time quantitative polymerase chain reaction, array capture, a nucleic acid sequence-based detection, massively parallel genomic sequencing, single molecule sequencing, or multiplexed detection of polynucleotide with color-coded probe pairs.
• step (a) or (b) comprises mass
• spectrometry or hybridization to a microarray, fluorescence probe, or molecular beacon.
• the chromosome relevant to the chromosomal aneuploidy is chromosome 13, 18, 21 , or X.
• the ratio is higher or lower than the standard control by at least 1 standard deviation, it indicates the presence of the chromosomal aneuploidy in the fetus, whereas in other cases, the presence of the chromosomal aneuploidy in the fetus is indicated when the ratio is higher or lower than the standard control by at least 2 or even 3 standard deviations.
• the above described methods can be used in a non-diagnostic context for assessing any potential change in the amount of a particular chromosome of interest in relation to another chromosome, a reference chromosome that is not suspected to have any change in its relative amount.
• the present invention can also be embodied in a device or a system comprising one or more such devices, which is capable of carrying out all or some of the method steps described herein.
• the device or system performs the following steps upon receiving a biological sample taken from the pregnant woman: (a) determining in sample the amount of a fetus derived methylation marker relevant to a chromosomal aneuploidy; (b) determining in the sample the amount of a fetus derived genetic marker on a reference chromosome; (c) determining the ratio of the amounts from (a) and (b); and (d) comparing the ratio with a standard control and providing an output indicating whether the chromosomal aneuploidy is present in the fetus.
• the device or system of the invention performs the task of steps (c) and (d), after steps (a) and (b) have been performed and the amounts from (a) and (b) have been entered into the device.
• the device or system is partially or fully automated.
• the first CpG site (-232) corresponds to chr21 : 37275031 (reverse strand) of the Human March 2006 (hgl8) assembly of the UCSC Genome Browser.
• Each subsequent row depicts the methylation status across the CpG sites in a single DNA molecule studied by cloning. Filled and unfilled circles represent methylated and unmethylated CpG sites, respectively.
• Clones from trisomy 21, normal first-trimester and normal third-trimester placental tissue samples are labeled with the prefix "T21 PLN,” “Normal PLN 1st,” and “Normal PLN 3rd,” respectively, while those from maternal blood cells are labeled with the prefix "MBC.”
• Placenta and maternal blood cells from different pregnant individuals are identified by sample numbers following the prefix.
• RASSFlA assays were run as monoplex, while the ZFX/Y assays were run in a duplex fashion. Each chip is divided into 12 panels with each panel being compartmentalized into 765 reaction wells. Reaction wells with the target molecules are shown as red or blue colored dots, while reaction wells with no amplification are shown as grey-colored dots. HLCS, RASSFlA and ZFY are shown in red. ZFX is shown in blue.
• A Illustration of the digital PCR results for enzyme-digested euploid placental DNA samples. Four panels were counted for each sample, hence each chip could accommodate three samples.
• B Illustration of the digital PCR results for an enzyme-digested maternal plasma DNA sample. DNA from the sample was evenly distributed in all 12 panels. It is noted that for maternal plasma analysis, the copy number of ZFY (fetal DNA) was much less than that of ZFX (fetal plus maternal DNA).
• FIG. 1 Gene dosage comparison in euploid and trisomy 21 placental tissue DNA samples.
• A Ratios of HLCS to RASSFlA.
• B Ratios of HLCS to ZFY. The normal reference range is depicted by the dotted lines.
• Figure 4 Gene dosage comparison in euploid and trisomy 21 maternal plasma DNA samples. The ratios of HLCS to ZFY were plotted for each sample. The normal reference range is depicted by the dotted lines.
• FIG. Genomic sequences of the four digital PCR assays ⁇ HLCS, RASSFlA, ZFY and ZFX).
• the chromosomal location on the March 2006 human reference sequence (NCBI Build 36.1) of the UCSC Genome Browser is indicated.
• the underlined nucleotides represent the enzyme recognition sites.
• the bold nucleotides in capital letters represent the forward and reverse primers.
• the bold nucleotides in small letters represent the minor groove binding (MGB) probe sequence.
• FIG. Gel electrophoresis of COBRA results for (A) HLCS region B2, and (B) C21or ⁇ l.
• Two trisomy 21 placentas T21 PLN
• Two first-trimester normal placentas Normal PLN 1 st
• two third-trimester normal placentas Normal PLN 3 rd
• two first- trimester maternal blood cells MCC
• PCR products were incubated with (+) or without (-) the BstUI enzyme. DNA methylation was detected by the appearance of the smaller size digestion products.
• One kb ladder (Invitrogen Carlsbad, CA) (M) was used in gel electrophoresis.
• Figure 7 Quantification of HLCS DNA from four placental tissues and eight maternal blood cells. The methylation index of a sample was calculated by dividing the copy number of HLCS after enzyme digestion by that obtained from mock digestion.
• Normal PLN represents placental DNA and "MBC” represents maternal blood cell DNA.
• Figure 8 Postpartum clearance in plasma. Detection of HLCS in maternal plasma samples (A) with (+), or (B) without (-) restriction enzyme digestion. "Pre” represents pre-delivery plasma samples and "Post” represents post-delivery plasma samples. Paired samples from the same subject are depicted by identical symbols connected by a line.
• FIG. 9 Chromosome dosage comparison in euploid and trisomy 21 placental tissue DNA samples by determining the ratio of (A) HLCS to TMED8-C with mock digestion, and (B) HLCS to TMED8-C with BsflJl digestion. The normal reference range is depicted by dotted lines.
• FIG. 1 Chromosome dosage comparison in euploid and trisomy 21 placental tissue DNA samples by determining the ratio of (A) HLCS to TMED8-G with mock digestion, and (B) HLCS to TMED8-G with BstUl digestion. The normal reference range is depicted by dotted lines.
• FIG. 11 Chromosome dosage comparison in ifartJI-digested, euploid and trisomy 21 maternal plasma DNA samples by determining the ratio of (A) hypermethylated HLCS to TMED8-C allele, and (B) hypermethylated HLCS to TMED8-G allele.
• the normal reference range is depicted by dotted lines.
• the positions of the recognition sites of the methylation-sensitive restriction endonuclesae are marked next to each genomic location of the CpG site.
• the genomic locations were defined according to the Human Genome March 2006 Assembly (hgl8) of the UCSC Genome Browser (genome.ucsc.edu).
• FIG. 14 Characterization of digestion-resistant Marker 18A sequences in maternal plasma
• A Concentrations of digestion-resistant Marker 18 A DNA in maternal plasma before and after delivery of the fetus.
• B Correlation between concentrations of digestion-resistant Marker 18A DNA against the concentrations of an established fetal genetic marker, ZFY, in pregnancies bearing male fetuses.
• the normal reference range (mean ⁇ 1.96SD) is depicted by the dotted lines.
• Figure 17 DNA methylation levels of a region on the beta-actin gene in 3 pairs of first-trimester euploid placentas and maternal blood cells determined by cloned bisulfite sequencing. For legends of the bisulfite sequencing data, refer to Figure 12. This region was used for the development of a control assay to check the efficiency of enzyme digestion.
• MI methylation index
• the positions of the recognition sites of the methylation-sensitive restriction endonucleases are marked next to each genomic location of the CpG site.
• the genomic locations were mapped according to the Human Genome March 2006 Assembly (hgl8) of the UCSC Genome Browser (genome.ucsc.edu).
• Tl 3 trisomy 13
• AU AU of the euploid placentas were obtained from the first trimester.
• the MIs of the euploid cases were compared with the Tl 3 cases at each CpG unit using Mann Whitney Rank Sum Test.
• pregnancy-associated disorder refers to any condition or disease that may affect a pregnant woman, the fetus the woman is carrying, or both the woman and the fetus. Such a condition or disease may manifest its symptoms during a limited time period, e.g. , during pregnancy or delivery, or may last the entire life span of the fetus following its birth.
• a "pregnancy-associated disorder” is necessarily accompanied by pregnancy and is not merely a condition that is incidentally occurring to a pregnant woman. In other words, the disorder is not one that can occur to a non-pregnant woman.
• Some examples of a pregnancy-associated disorder include ectopic pregnancy, preeclampsia, preterm labor, and fetal chromosomal abnormalities such as trisomy 13, 18, or 21.
• chromosomal aneuploidy encompasses any genetic defect exhibiting an abnormal number of chromosomes, including having more or fewer than normal number of any one chromosome, as well as having an extra portion of any one chromosome in addition to the normal pair, or missing a portion of any one chromosome in the normal pair.
• the abnormality can involve more than one chromosome, or more than one portion of one or more chromosomes.
• the most common chromosome aneuploidy is trisomy, e.g., trisomy 21, where the genome of an afflicted patient has three rather than the normal two (i.e. , a pair) chromosome 21.
• reference chromosome There are also cases where the number of a relevant chromosome is less than the normal number of 2. Turner syndrome is one example of a chromosomal aneuploidy where the number of X chromosome in a female subject has been reduced from two to one.
• alleles e.g., alleles from two different individuals, such as alleles from a fetus v. alleles from the pregnant woman
• a "methylation marker" located on a chromosome relevant to the chromosomal aneuploidy refers to a genomic polynucleotide sequence on a chromosome having an abnormal number; or in the case where there is an extra piece of the chromosome or a portion of the chromosome is missing, the "methylation marker” is located within the piece or portion of the relevant chromosome. Difference in methylation profiles of the methylation marker allows distinction of the corresponding methylation marker from two different individuals, e.g., a fetus and the pregnant woman.
• epigenetic state refers to any structural feature at the molecular level of a nucleic acid (e.g., DNA or RNA) other than the primary nucleotide sequence.
• the epigenetic state of a genomic DNA may include its secondary or tertiary structure determined or influenced by, e.g., its methylation pattern or its association with cellular proteins, e.g. , histones and the modifications of such proteins, e.g., acetylation, deacetylation, and methylation.
• methylation profile or "methylation status,” when used in this application to describe the state of methylation of a genomic sequence, refers to the characteristics of a DNA fragment at a particular genetic locus relevant to methylation. Such characteristics include, but are not limited to, whether any of the cytosine (C) residues within this DNA sequence are methylated, location of methylated C residue(s), percentage of methylated C at any particular stretch of residues, and allelic differences in methylation due to, e.g., difference in the origin of the alleles.
• C cytosine
• the term “methylation profile” or “methylation status” may also refer to the relative or absolute concentration of methylated C or
• single nucleotide polymorphism refers to the polynucleotide sequence variation present at a single nucleotide residue among different alleles of the same gene, which may be the same gene located on the two copies of the same chromosome from the same individual ⁇ e.g. , two alleles from a fetus) or may be the same gene from two different individuals (e.g., fetus and pregnant woman). This variation may occur within the coding region or non-coding region (e.g., the promoter region or its proximity, or the intron) of a gene, or in the intergenic region. Detection of one or more SNP allows differentiation of different alleles of a single gene.
• chromosome from the same individual e.g. , fetus
• may be the same gene from two different individuals e.g. , fetus and pregnant woman.
• This variation often occurs within the non-coding region (e.g. , the promoter region or its proximity, or intron) of a gene, or in the intergenic region. Detection of difference in tandem repeat numbers allows differentiation of different alleles of a single gene.
• insertion-deletion polymorphism refers to the polynucleotide sequence variation demonstrated in the presence or absence of a short nucleotide sequence (e.g., 1-3 nucleotides) among different alleles of the same gene, which may be the same gene located on two copies of the same chromosome from the same individual (e.g., fetus) or may be the same gene from two different individuals (e.g., fetus and pregnant woman).
• This variation can occurs within both the coding region and the non- coding region (e.g. , the promoter region or its proximity, or intron) of a gene, or in the intergenic region.
• blood refers to a blood sample or preparation from a pregnant woman or a woman being tested for possible pregnancy.
• the term encompasses whole blood or any fractions of blood, such as serum and plasma as conventionally defined.
• bisulfite encompasses all types of bisulfites, such as sodium bisulfite, that are capable of chemically converting a cytosine (C) to a uracil (U) without chemically modifying a methylated cytosine and therefore can be used to
• a reagent that "differentially modifies" methylated or non- methylated DNA encompasses any reagent that reacts differentially with methylated and unmethylated DNA in a process through which distinguishable products or quantitatively distinguishable results (e.g. degree of binding or precipitation) are generated from methylated and non-methylated DNA, thereby allowing the identification of the DNA methylation status.
• Such processes may include, but are not limited to, chemical reactions (such as an
• a reagent that "differentially modifies" methylated and unmethylated DNA also refers to any reagent that exhibit differential ability in its binding to DNA sequences or precipitation of DNA sequences depending on their methylation status.
• One class of such reagents consists of methylated DNA binding proteins.
• nucleic acid or “polynucleotide” refers to deoxyribonucleic acids (DNA) or ribonucleic acids (RNA) and polymers thereof in either single- or double-stranded form. Unless specifically limited, the term encompasses nucleic acids containing known analogs of natural nucleotides that have similar binding properties as the reference nucleic acid and are metabolized in a manner similar to naturally occurring nucleotides. Unless otherwise indicated, a particular nucleic acid sequence also implicitly encompasses conservatively modified variants thereof (e.
• nucleic acid is used
• gene cDNA, and mRNA encoded by a gene.
• gene means the segment of DNA involved in producing a polypeptide chain; it includes regions preceding and following the coding region (leader and trailer) involved in the transcription/translation of the gene product and the regulation of the transcription/translation, as well as intervening sequences (introns) between individual coding segments (exons).
• locus means the segment of DNA defined by a start nucleotide position to an end nucleotide position on a chromosome (L e. , a genomic location, or a chromosomal location) of a reference genome assembly (e.g., the Human Genome March 2006 assembly (hgl8) on the UCSC Genome Browser).
• a locus may or may not overlap with the genomic location of a gene, a CpG island, or any product of transcription/translation.
• a locus usually refers to a continuous segment of DNA identified by
• a locus may contain one or more CpG sites.
• a locus may be sub-divided into shorter segments (e.g., CpG-containing genomic sequences, fragments or regions) that are amenable to analysis (e.g., Epityper assay, bisulfite sequencing, polynucleotide amplification and determination).
• a locus may be developed into one or more fetal epigenetic markers. In some context of this application, a locus also refers to a continuous segment of DNA identified by certain bioinformatics criteria.
• polypeptide polypeptide
• peptide protein
• protein protein
• amino acid polymers in which one or more amino acid residue is an artificial chemical mimetic of a corresponding naturally occurring amino acid, as well as to naturally occurring amino acid polymers and non-naturally occurring amino acid polymers.
• the terms encompass amino acid chains of any length, including full-length proteins (i.e. , antigens), wherein the amino acid residues are linked by covalent peptide bonds.
• amino acid refers to naturally occurring and synthetic amino acids, as well as amino acid analogs and amino acid mimetics that function in a manner similar to the naturally occurring amino acids.
• Naturally occurring amino acids are those encoded by the genetic code, as well as those amino acids that are later modified, e.g., hydroxyproline, ⁇ - carboxyglutamate, and O-phosphoserine.
• Amino acids may be referred to herein by either the commonly known three letter symbols or by the one-letter symbols recommended by the IUPAC-IUB Biochemical Nomenclature Commission. Nucleotides, likewise, may be referred to by their commonly accepted single-letter codes.
• an “increase” or a “decrease” refers to a detectable positive or negative change in quantity from an established standard control.
• An increase is a positive change by at least 10% or 20% or by at least 50%, 80%, or 100% of the standard control value; in some case, an increase can be at least about 1.5-fold, at least about 2-fold, or at least about 3 -fold of the control value.
• a decrease is a negative change by at least 1/10, 1/6, 1/5, or by at least 1/3 or even 1/2 of the control value.
• a "polynucleotide hybridization method” as used herein refers to a method for detecting the presence and/or quantity of a polynucleotide based on its ability to form
• Watson-Crick base-pairing under appropriate hybridization conditions, with a polynucleotide probe of a known sequence.
• hybridization methods include Southern blotting and Northern blotting.
• digital polymerase chain reaction refers to a refined version of conventional polymerase chain reaction (PCR) methods that can be used to directly quantify and clonally amplify nucleic acids including DNA, cDNA or RNA, such that the amount of target nucleic acid can be directly quantitatively measured.
• Digital PCR achieves this direct quantitative measurement by capturing or isolating each individual nucleic acid molecule present in a sample within many separate reaction chambers that are able to localize and concentrate the amplification product to detectable levels. After PCR amplification, a count of chambers containing the PCR end-product is a direct measure of the absolute nucleic acid quantity.
• the capture or isolation of individual nucleic acid molecules may be effected in capillaries, microemulsions, arrays of miniaturized chambers, or on nucleic acid binding surfaces.
• the basic methodology of digital PCR is described in, e.g., Sykes et al. , Biotechniques 13 (3): 444-449, 1992; and Vogelstein and Kiiizler, Proc ⁇ f ⁇ / ⁇ c ⁇ Sc/ USA 1999;96:9236-41.
• molecular counting refers to any method that allows quantitative measurement of the number of a molecule or molecular complex, often the relative number in the context of other co-existing molecules or complexes of distinct characteristics.
• Various methods of molecular counting are described in, e.g., Leaner et al., Analytical Chemistry 69:2115-2121, 1997; Hirano and Fukami, Nucleic Acids Symposium Series No. 44:157-158, 2000; Chiu et al, Trends in Genetics 25:324-331, 2009; and U.S. Patent No. 7,537,897.
• Standard control refers to a value reflective of the ratio, or the amount or concentration of a fetal genomic sequence located on a chromosome relevant to a particular chromosomal aneuploidy (e.g., trisomy 13, 18, or 21) over the amount or concentration of a fetal genetic marker located on a reference chromosome, as the amounts or concentrations are found in a biological sample (e.g., blood, plasma, or serum) from an average, healthy pregnant woman carrying a chromosomally normal fetus.
• a "standard control” may be determined differently and represent different value depending on the context in which it is used.
• the "standard control” is a value reflective of the ratio, or the amount or concentration of a fetal genomic sequence located on a chromosome relevant to a particular chromosomal aneuploidy (e.g., trisomy 13, 18, or 21) over the amount or concentration of a fetal genetic marker located on a reference chromosome, as the amounts or concentrations are found in a biological sample (e.g., blood, plasma, or serum) from an average, healthy pregnant woman carrying a chromosomally normal fetus.
• a standard control is determined based on an average healthy pregnant woman at a certain gestational age, whereas in other cases, no distinction is made with regard to the gestational age.
• the selected group of women generally have a similar gestational age to that of a woman whose blood is tested for indication of a potential pregnancy-associated disorder.
• the preferred gestational age for practicing the present invention may vary depending on the disorder that is being screened for. For example, fetal chromosomal aneuploidy is preferably screened for and diagnosed as early as possible.
• the preferred gestational age for testing may also depend on the gene of interest in testing.
• polynucleotide sequence of interest e.g., a genetic marker or an epigenetic/methylation marker of fetal origin
• quantity may be expressed in the absolute terms, i.e., the total quantity (e.g. in mass, or in number of molecules) of the polynucleotide sequence in the sample, or in the relative terms (e.g. a ratio, or relative to other markers), or as the concentration (e.g. mass per unit volume, or number of molecules per unit volume) of the polynucleotide sequence in the sample.
• T21 trisomy 21
• the screening for trisomies constitutes an important component in modern obstetrics care in many countries.
• the common screening methods that are routinely available in prenatal clinics target the epiphenomena associated with the chromosomal aneuploidy, rather than directly targeting the actual chromosome dosage in the fetus (Wapner etal, N EnglJ Med 2003;349.T405-13; Malone et al, N Engl J Med
• the first group involves allelic ratio analysis of single nucleotide polymorphisms (SNPs) present in a fetal-specific nucleic acid marker (Lo and Chiu, Nat Rev Genet 2007;8:71-7).
• SNPs single nucleotide polymorphisms
• Examples of the latter include circulating placental mRNA (the so-called RNA-SNP approach) (Lo etal, Nat Med 2007; 13:218-23) and DNA methylation markers (the so-called epigenetic allelic ratio approach) (Tong et al., Clin Chem 2006;52:2194-202).
• the main disadvantage of this approach is that these methods are only applicable to fetuses that are heterozygous for the analyzed SNP. Furthermore, there is a finite number of SNPs with sufficiently high heterozygosity rates within a particular locus so population coverage is a major challenge for this approach.
• the second group of approaches involves the use of single molecule counting approaches such as digital PCR (Lo et al, Proc NatlAcad Sci USA 2007;104:13116-21) and massively parallel genomic sequencing (Chiu et al., Proc Natl Acad Sci USA 2008;105:20458-63; Fm et al, Proc Natl Acad Sci USA 2008; 105:16266-71 ). In these approaches, individual plasma DNA molecules are counted.
• This application describes a new approach for the noninvasive prenatal detection of chromosomal aneuploidies (e.g., trisomy 21) from maternal plasma that is based on the determination of the ratio of the concentrations of a fetal-specific DNA methylation marker on chromosome potentially involved in the aneuploidy (e.g., chromosome 21) and a fetal- specific DNA marker on a reference chromosome. This is called the epigenetic-genetic
• EGG epigenetic chromosome dosage approach.
• the EGG approach does not require the fetal-specific DNA methylation marker and the SNP to be present within a short stretch of DNA and thus population coverage would be much easier to be achieved.
• the EGG approach is more precise than an approach based purely on epigenetic markers, the latter being typically performed with one on chromosome 21 and one on a reference chromosome.
• fetal-specific DNA methylation marker on the relevant chromosome, such as chromosome 21, 18, or 13.
• One preferred type of markers would be one that is hypermethylated in the fetus and hypomethylated in maternal blood cells, so that one can use methylation-sensitive restriction enzyme to digest away the maternal sequences.
• the promoter of the RASSFlA gene is one such marker, except that it is on chromosome 3 (Chan et al, CHn Chem 2006;52:2211-8; Chiu et al, Am J Pathol 2007;170:941-50).
• a number fetal DNA methylation markers on chromosome 21 has been reported (Chim et al, Clin Chem 2008;54:500-ll; Old et al, Reprod Biomed Online 2007;15:227-35;
• nucleic acids sizes are given in either kilobases (kb) or base pairs (bp). These are estimates derived from agarose or acrylamide gel electrophoresis, from sequenced nucleic acids, or from published DNA sequences.
• kb kilobases
• bp base pairs
• proteins sizes are given in kilodaltons (kDa) or amino acid residue numbers. Protein sizes are estimated from gel electrophoresis, from sequenced proteins, from derived amino acid sequences, or from published protein sequences.
• oligonucleotides are synthesized, e.g., according to the solid phase phosphoramidite triester method first described by Beaucage and Caruthers, Tetrahedron Lett. 22:1859-1862 (1981), using an automated synthesizer, as described in Van Devanter et. al, Nucleic Acids Res. 12:6159-6168 (1984). Purification of oligonucleotides is performed using any art-recognized strategy, e.g., native acrylamide gel electrophoresis or anion-exchange high performance liquid chromatography (HPLC) as described in Pearson and Reanier, J Chrom. 255: 137-149 (1983).
• HPLC high performance liquid chromatography
• the present invention relates to analyzing the epigenetic- genetic chromosome dosage of appropriate fetal chromosomal DNA found in maternal blood as a non-invasive means to detect the presence and/or to monitor the progress of a pregnancy-associated condition or disorder.
• the first steps of practicing this invention are to obtain a blood sample from a pregnant woman and extract DNA from the sample.
• a blood sample is obtained from a pregnant woman at a gestational age suitable for testing using a method of the present invention.
• the suitable gestational age may vary depending on the disorder tested, as discussed below. Collection of blood from a woman is performed in accordance with the standard protocol hospitals or clinics generally follow. An appropriate amount of peripheral blood, e.g., typically between 5-50 mL, is collected and maybe stored according to standard procedure prior to further preparation.
• DNA may also be recovered from the cellular fraction, enriched in the buffy coat portion, which can be obtained following centrifugation of a whole blood sample from the woman and removal of the plasma.
• the cellular fraction can also be previously enriched for fetal nucleated cells circulating in maternal blood.
• enrichment procedures may include a sorting or selection procedure involving one or more antibodies against fetal cells or a procedure targeting physical, chemical, biochemical or other characteristics which can differentiate fetal from maternal cells.
• the sorting procedure can involve technologies such as the fluorescence activated cell sorter, magnetic activated cell sorting or microfluidics.
• the selection procedure can involve micromanipulation, or laser-captured microdissection, manipulation with optical tweezers or any other single cell manipulation procedure.
• Fetal cell types that can be targeted include nucleated red blood cells, lymphocytes, mononuclear cells, trophoblasts, or cellular remnants, e.g., apoptotic fetal cells.
• reagents or kits such as the QIAamp DNA Mini Kit or QIAamp DNA Blood Mini Kit (Qiagen, Hilden, Germany), GenomicPrepTM Blood DNA Isolation Kit (Promega, Madison, WI), and GFXTM Genomic Blood DNA Purification Kit (Amersham, Piscataway, NJ), may also be used to obtain DNA from a blood sample from a pregnant woman. Combinations of more than one of these methods may also be used.
• Such a reagent reacts with the unmethylated C residue(s) in a DNA molecule and converts each unmethylated C residue to a uracil (U) residue, whereas the methylated C residues remain unchanged.
• This C ⁇ U conversion allows detection and comparison of methylation status based on changes in the primary sequence of the nucleic acid.
• An exemplary reagent suitable for this purpose is bisulfite, such as sodium bisulfite. Methods for using bisulfite for chemical modification of DNA are well known in the art (see, e.g., Herman et al, Proc. Natl. Acad. ScL USA 93:9821-9826, 1996) and will not be discussed in detail here.
• any other reagents that are unnamed here but have the same property of chemically (or through any other mechanism) modifying methylated and unmethylated DNA differentially can be used for practicing the present invention.
• methylation-specific modification of DNA may also be used for practicing the present invention.
• methylation-sensitive restriction enzymes some of which typically cleave an unmethylated DNA fragment but not a methylated DNA fragment, while others (e.g., methylation-dependent endonuclease McrBC) cleave DNA containing methylated cytosines but not unmethylated DNA.
• McrBC methylation-dependent endonuclease
• a combination of chemical modification and restriction enzyme treatment e.g. , combined bisulfite restriction analysis (COBRA) may be used for practicing the present invention.
• COBRA combined bisulfite restriction analysis
• An amplification reaction is optional prior to the epigenetic marker's sequence analysis after methylation specific modification.
• the amplification is performed to preferentially amplify a portion of the marker that has a particular methylation pattern, such that only the marker from one particular source, e.g., from the placenta or other tissues of the fetus, is detected and analyzed for its quantity or concentration.
• the amplification of a genetic marker on a reference chromosome that allows determination of fetal or maternal origin based on differences in polynucleotide sequence is carried out using known amplification methods that selectively amplify the fetal version of the marker sequence.
• preferential amplification is achieved by careful primer design.
• PCR reagents and protocols are also available from commercial vendors, such as Roche Molecular Systems.
• PCR is most usually carried out as an automated process with a thermostable enzyme. In this process, the temperature of the reaction mixture is cycled through a denaturing region, a primer annealing region, and an extension reaction region automatically. Machines specifically adapted for this purpose are commercially available. Improved and more sensitive PCR methods such as real-time PCR and digital PCR are also useful in certain embodiments of the present invention.
• PCR amplification of a target polynucleotide sequence e.g. , a portion of the epigenetic marker where the fetal and maternal sequence is differentially methylated
• amplification of the HLCS gene sequence found in a maternal blood sample may be accomplished by any known method, such as the ligase chain reaction (LCR), transcription- mediated amplification, and self-sustained sequence replication or nucleic acid sequence- based amplification (NASBA), each of which provides sufficient amplification.
• LCR ligase chain reaction
• transcription- mediated amplification transcription- mediated amplification
• NASBA nucleic acid sequence- based amplification
• Branched- DNA technology may also be used to qualitatively demonstrate the presence of a particular marker sequence (which represents a particular methylation pattern or a particular polynucleotide sequence), or to quantitatively determine the amount or concentration of a particular marker sequence in the maternal blood.
• a particular marker sequence which represents a particular methylation pattern or a particular polynucleotide sequence
• Branched-DNA signal amplification for direct quantitation of nucleic acid sequences in clinical samples, see Nolte, Adv. Clin. Chem. 33:201-235, 1998.
• a group of healthy pregnant women carrying healthy fetuses is first selected. These women are within the appropriate time period of pregnancy for the purpose of screening for pregnancy- associated conditions such as fetal chromosomal aneuploidy and others using the methods of the present invention. Optionally, the women are of similar gestational age, e.g., within the same trimester of pregnancy, such as in the first or second trimester.
• the selected number of healthy pregnant women carrying healthy fetuses must be of a reasonable size, such that the average amount/concentration of fetal genetic and epigenetic markers in the maternal blood, the amount/concentration ratio, and the methylation profile of one or more of the epigenetic markers in the maternal blood obtained from the group can be reasonably regarded as representative of the normal or average level or methylation profile among the general population of healthy women carrying healthy fetuses.
• the selected group comprises at least 10 women.
• a fetal epigenetic marker methylation profile may reflect multiple different and separable aspects of the methylation status of this gene.
• one aspect of a methylation profile is whether the C residue is methylated or not; another aspect is the number of methylated C bases within a particular region of the marker; a further aspect of the profile is the percentage(s) of methylated C at any given locations in a number of analyzed DNA molecules. Additional aspects of a methylation profile may include, but are not limited to, the allelic difference in methylation, the ratio of differentially methylated alleles, and the like. Fetal epigenetic marker methylation profile may also vary depending on the tissue type, e.g. , placental or other fetal tissue. Thus, separate standard controls may be established for different fetal tissues used in testing.
• COBRA Xiong and Laird, Nucleic Acids Res 1997;25:2532-4
• COBRA Xiong and Laird, Nucleic Acids Res 1997;25:2532-4
• the loci for an epigenetic-genetic comparison were HLCS on chromosome 21 and ZFY on chromosome Y from pregnancies with a male fetus.
• the sequences of primers and probes with the PCR thermal cycle conditions for all the assays are listed in Table 1.
• CVS Chorionic villus samples
• Placental tissue samples were collected from euploid third-trimester pregnancies after delivery and from euploid and trisomy 21 pregnancies after termination of pregnancy. The fetal chromosomal status was confirmed by full karyotyping.
• Maternal peripheral blood samples (12 - 20 mL EDTA) were collected from all subjects. An additional 12 mL of blood was collected into EDTA tubes from the third trimester pregnancies after delivery.
• Gestational ages of the first-, second- and third- trimester samples were 12 - 14 weeks, 17 - 21 weeks and 38 - 40 weeks, respectively.
• PCR was performed in a 20 ⁇ L reaction with Ix PCR Buffer, MgCl 2 , 50 ⁇ M of each dNTP, forward and reverse primers, HotStar Taq polymerase, and with or without 2X PCRx Enhancer (Invitrogen, Carlsbad, CA).
• the thermal profile was 95 °C for 15 min, followed by 45-55 cycles of 95 °C for 20 s, appropriate annealing temperature for 30 s, 72 °C for 1.5 min, and a final extension of 72 °C for 3 min.
• PCR products were then subjected to restriction enzyme digestion.
• the restriction enzyme to be used for each respective locus was chosen for its ability to distinguish between the methylated and unmethylated sequences after bisulfite conversion.
• restriction sites were only present in either the methylated or unmethylated sequence but not both, so that one of the sequences would be digested while the other would remain intact. Restriction enzyme digestions were performed in 20 ⁇ L reactions with 5 ⁇ L PCR products, Ix appropriate buffer, and 10 U restriction enzyme (or none for mock digestion) under the manufacturer's recommended temperatures for 2 h. AU enzymes were purchased from New England Biolabs (Ipswich, MA). Digested products were then analyzed by agarose gel electrophoresis.
• MSRE digestion For each placental and maternal blood cell DNA sample, 100 ng DNA was subjected to MSRE digestion. Restriction enzyme digestion was performed in a 50 ⁇ L reaction with Ix appropriate buffer, 25 U of Hp ⁇ ll and 50 U of BstUI (or none for mock digestion) (New England Biolabs) under the manufacturer's recommended temperatures for at least 16 h. For each maternal plasma sample, 1.6 mL plasma was used for DNA extraction, and was eluted in 50 ⁇ L of deionized water, 21 ⁇ L of which was subjected to restriction enzyme digestion.
• Enzyme digestion was performed in a 30 ⁇ L reaction with Ix appropriate buffer, 20 U of Hpall and 30 U of Bsi ⁇ l (or none for mock digestion) under the manufacturer's recommended temperatures for at least 16 h.
• Digested products were then analyzed by real-time quantitative PCR.
• the selected restriction enzymes only digested the unmethylated DNA but not the methylated DNA. Since the data from the COBRA analysis have shown that HLCS is hypermethylated in placental tissues and unmethylated in maternal blood cells, it was expected that a proportion of DNA from placental tissues would remain detectable while most DNA from maternal blood cells would be digested, thus becoming undetectable after restriction enzyme treatment. [0099] Real-time quantitative PCR analysis.
• MSRE digestion The MSRE, BstOI (New England Biolabs), was used to digest the hypomethylated DNA. Extracted DNA was digested with the BstUl enzyme at 60 °C for 16 h. For CVS, placental tissues and maternal blood cells, 40 U of BstlJl enzyme was used to digest 200 ng of DNA for the microfluidics digital PCR assays. A mock-digested aliquot was included as the digestion control. For mock-digestion, an equal amount of DNA was subjected to the same digestion condition without the addition of enzyme. For the plasma samples, 20 U of the Bst ⁇ l enzyme was used to digest the DNA from 3.4 - 4.8 mL plasma in the third-trimester samples.
• Microfluidics digital PCR analysis Microfluidics digital PCR assays were designed for the HLCS, RASSFlA and ZFY loci ( Figure 5), representing the dosage of chromosome 21, chromosome 3 and chromosome Y, respectively.
• the ZFX/Y assay and the basis of the digital PCR analysis have been described previously (Lun et al, Clin Chem 2008;54: 1664-72).
• the sequences of the primers and probes are listed in Table 1.
• the digital experiments were carried out on the BioMark System (Fluidigm, South San Francisco, CA) using the 12.765 Digital Arrays (Fluidigm).
• the Digital Array consists of 12 panels, and each panel is further partitioned into 765 reaction wells.
• the reaction was set up as a 10 ⁇ L mixture at a final concentration of Ix TaqMan Universal PCR Master Mix (Applied Biosystems), 125 nM TaqMan probe (Applied Biosystems), and 900 nM forward and reverse primers (Integrated DNA Technologies) diluted with the assay loading buffer and sample loading buffer according to the manufacturer's protocol.
• the input DNA volume was 3.5 ⁇ L for each of the 10 ⁇ L reaction mixture.
• the thermal profile was 50 °C for 2 min, 95 °C for 10 min, followed by 50 cycles of 95 0 C for 15 or 30 s, and 57 0 C or 60 °C for 1 min.
• the thermal cycle condition for each assay is specified in Table 1.
• the HLCS and RASSFlA assays were performed as a monoplex assay.
• the ZFX/Y assays were performed as a duplex reaction.
• DNA samples from the CVS 5 placenta, and maternal blood cells were subjected to the HLCS, RASSFlA, and ZFX/Y digital PCR analysis after Bst ⁇ l digestion. After enzyme digestion, the DNA was diluted to a concentration of 1 - 2 ng/ ⁇ L for loading into the reaction mixture for digital PCR analysis.
• DNA samples from the CVS and placenta constituted enzyme digestion-resistant HLCS and RASSFlA molecules, thus signals should be detected after restriction enzyme digestion. On the other hand, we would expect no or low level of detection in the blood cells as they are hypomethylated at these two loci.
• the ZFX/Y loci did not contain any BstUl enzyme digestion sites, thus restriction enzyme treatment should not confer any effects on the DNA molecules.
• the ZFY molecules constituted the fetal-derived sequences from a male fetus for the ratio comparison.
• Bioinformatics Database (website: www.genome.ucsc.edu/) (NCBI Build 36.1), and designed 51 COBRA assays to compare the methylation patterns between placental tissues and maternal blood cells (Table 2).
• the methylation profiles of the promoter regions between placental tissues collected from the first- and third-trimesters and maternal blood cells were compared. At least one placental tissue and one maternal blood cell sample from normal pregnancies were used for the COBRA screening (Table 2). Among the screened regions, the putative promoter regions of HLCS and C21orf81 (GenBank accession AF326257) were identified by COBRA to be differentially-methylated between placental tissues and maternal blood cells.
• COBRA results are illustrated in Figure 6 A for HLCS region B2, in which the placenta was hypermethylated when compared to maternal blood cells; and 6B for C21orf81, in which the maternal blood cells were slightly methylated when compared to placental tissues.
• Target -ln [E/N] x N, where Target is the Poisson-corrected counts of the target molecules, In is the natural logarithm, E is the number of negative (empty) wells, and N is the total number of digital PCR wells in the reaction.
• Results from the fe/UI-digested placental DNA samples showed that about 60% - 70% of the HLCS and RASSFlA molecules remained detectable when compared to the mock- digested samples.
• the hypomethylated RASSFlA molecules were completely digested by Bs(Ul enzyme treatment, while a few HLCS molecules remained detectable in the samples.
• ZFY and ZFX assays there was no change in the copy number counted from the mock- or i&/UI-digested DNA samples (Table 3A).
• the heterogeneity in the methylation density of the two loci across different samples may contribute to the large inter-individual variation in the HLCS to RASSFlA ratio. To solve this precision problem, a more stable baseline would be required for the dosage comparison between the euploid and T21 DNA samples.
• the EGG technique was then applied to maternal plasma DNA samples from euploid and T21 pregnancies to determine whether the EGG approach can be applied for noninvasive prenatal detection of fetal trisomy 21. It was reasoned that while the maternal HLCS molecules in the maternal plasma was restriction digested by the Bsi ⁇ l enzyme, leaving the fetal-derived hypermethylated HLCS molecules intact for analysis, the fetal- derived ZFY locus would not be affected as there was no Bsf ⁇ l enzyme recognition site located within the PCR amplicon, thus providing a stable baseline for gene dosage comparison.
• a normal reference range of 1.49 - 2.88 was calculated from the 24 maternal plasma samples with euploid pregnancies. The ratio of one euploid DNA sample fell out of the normal reference range. This sample dried up during Speedvac concentration, and was reconstituted with water during sample preparation, which might explain the inaccuracy. All five maternal plasma samples from T21 pregnancies had a higher ratio of HLCS to ZFF than the reference range ( Figure 4). The data showed that with the EGG approach, fetal trisomy 21 can be detected noninvasively in maternal plasma samples.
• the present inventors have successfully validated a hypermethylated fetal DNA marker on chromosome 21 , namely, the promoter region of the HLCS gene (US Patent Application Publication No. 2007/0275402).
• the hypermethylated nature of this marker allows it to be detected relatively easily in maternal plasma through the use of methylation-sensitive restriction enzyme digestion and PCR amplification.
• HLCS was then used to demonstrate that the novel EGG approach is a feasible method for fetal chromosome dosage analysis.
• the main advantage of the EGG method over the previously epigenetic allelic ratio analysis is that using this method one has bypassed the requirement of the latter method for the epigenetic target and the genetic target (i.e., the SNP) to be present in the same locus and within a short distance from one another.
• the ZFY gene on the Y chromosome was used as a model for the fetal-specific genetic target.
• any fetal- specific genetic target e.g., an SNP allele that the fetus has inherited from the father but absent in the pregnant mother, can be used.
• a panel of such markers would be relatively easily developed to ensure a broad population coverage of this approach.
• microfluidics digital PCR was used as the detection and measurement platform because previous results have shown it to be a highly precise analytical method (Lun et al., CHn Chem 2008;54: 1664-72; Lun et ai, Proc Natl Acad Sci USA
• the EGG approach can also be implemented in other variation of this molecular counting theme, e.g. , by targeted sequencing using a 'next-generation' sequencer.
• fetal epigenetic markers on the other chromosomes important for prenatal screening e.g., chromosomes 18 and 13
• a fetal epigenetic marker is the SERPINB5 gene, coding for maspin, on chromosome 18 (Chim et al, Proc Natl Acad Sd USA 2005;102:14753-8).
• Other examples of fetal epigenetic markers on chromosome 18 and 13 are described by Papageorgiou et al (Papageorgiou et al, Am J Pathol 2009; 174: 1609-18).
• Chromosome dosage comparison of the chromosome 21 and the reference marker in placental tissue and maternal plasma DNA samples was analyzed by real-time quantitative polymerase chain reaction (qPCR) and digital PCR (Vogelstein and Kinzler Proc Natl Acad Sci USA 1999;96:9236-41), respectively. Chromosome dosage analysis was performed by comparing the amount of hypermethylated HLCS to that of a SNP allele (rs6636, a C/G SNP) that the fetus has inherited from the father but absent in the pregnant mother.
• qPCR real-time quantitative polymerase chain reaction
• digital PCR Vogelstein and Kinzler Proc Natl Acad Sci USA 1999;96:9236-41
• a methylation-sensitive restriction endonuclease BstUI (New England Biolabs) was used to digest the hypomethylated DNA. Extracted DNA was digested with the BstUI enzyme at 60 °C for 16 hours. For CVS, placental tissues and maternal and normal control blood cells, 40 U of BstUI enzyme was used to digest 100 ng of DNA for the PCR assays. A mock-digested aliquot was included as the digestion control. For mock-digestion, an equal amount of DNA was subjected to the same digestion condition without the addition of enzyme. For the plasma samples, 20 U to 40 U of the BstUI enzyme was used to digest the DNA from 1.6 - 5.2 mL plasma. Assay design and reaction conditions for conventional real-time qPCR analysis
• HLCS oligonucleotide sequences for real-time PCR analysis
• TMED8-C/G SNP digital PCR analysis Table 5
• the HLCS assay was performed as a duplex reaction with each of the TMED8-CIG SNP assays.
• the fluorescent probes were labeled as HLCS(VlC) duplex with TMEDS-C(FAM) and HICS(FAM) duplex with IMEDa-G(VIC).
• Genomic DNA extracted from placental tissues with known TMED8 genotypes were subjected to the HLCS and TMED8 duplex assays. Samples that were homozygous for one allele were tested with the TMED8-C/G SNP assay for the other allele. A sample homo2ygous for the C allele should not show any signals for the TMED8 assay detecting the G allele, and vice versa.
• the HLCS and TMED8-C/G SNP assays were applied to a total of 20 euploid and nine T21 placental tissue samples with the heterozygous C/G genotype. Six euploid and four T21 samples were analyzed by using the HLCS to TMEDZ-C ratio, and the remaining 14 euploid and five T21 samples were analyzed by the HLCS to TMED8-G ratio. A calibration curve constructed by serially-diluted genomic DNA extracted from adult male blood cells with concentration ranging from 10000 GE to 3 GE per reaction was used to determine the absolute copy number of the two loci in the tested samples.
• the HLCS to TMED8-G ratio was first determined in mock-digested placental DNA samples. A normal reference range was calculated from the 14 euploid samples as 1.36 - 3.03. One sample from each of the euploid and T21 groups was misclassified (Table 7A) ( Figure 10A).
• Beta-actin as a digestion control
• the BstUl enzyme digestion efficiency was evaluated by applying the beta-actin assay to the same mock- and ZfcrtJI-digested placental DNA samples as those used for HLCS to TMED8 chromosome dosage analysis.
• the same calibration standard was used to quantify the amount of beta-actin sequences in the samples.
• the slope of the calibration curve was - 3.41 , whereas the y-intercept showed threshold cycle value of 37.97. Results showed that over 96% of the DNA was digested in all tested samples (Table 8 A and 8B).
• homozygous G/G genotypes were tested with the HLCS and TMED8 duplex assay to ascertain the specificity for detecting either one of the SNP alleles. Two samples were used for each of the three groups. A sample homozygous for the C allele should not show any signals for the TMED8 assay detecting the G allele, and vice versa.
• Maternal plasma DNA analysis was performed by comparing the ratio of digestion- resistant HLCS to fetal- specific TMED8 SNP allele in informative samples.
• An informative sample was defined as one in which the fetus was heterozygous and the mother was homozygous, being the TMED8-C/G SNP in the current example.
• the extra allele that the fetus had inherited from the father was used as the reference baseline for chromosome 21 dosage determination.
• the HLCS and TMED8-C duplex assay was applied to a total of 16 euploid and two T21 pregnancies.
• the fetal and maternal genotypes for the TMED8 SNP were C/G and G/G, respectively.
• the fetal-specific SNP allele was the C allele.
• Maternal plasma DNA samples were analyzed by digital PCR after BstUl enzyme digestion. Each sample was analyzed in at least one 384-well plate. The total number of positive wells was used to calculate the ratio of HLCS to TMED8-C allele in each sample.
• a normal reference range of 2.12 - 3.65 was calculated from the euploid maternal plasma samples. Eight samples were collected from the third-trimester, and four samples were collected from each of the second- and first- trimester pregnancies. Among these 16 euploid samples, ten were from pregnancies carrying a female fetus, and six from those carrying a male fetus. The HIGS to TMED8-C allele ratios of all euploid samples fell within the reference range. The T21 samples collected from the second- and first-trimester pregnancies showed a higher ratio than the reference range ( Figure 7A). Both T21 cases carried a female fetus.
• the fetal and maternal genotypes for the TMED8 SNP were C/G and C/C, respectively.
• the fetal-specific SNP allele was the G allele.
• the HLCS and TMED8-G duplex digital PCR assay was applied to 5.?tUI-digested maternal plasma DNA samples from nine euploid pregnancies and one T21 pregnancy. Each sample was analyzed in at least one 384-wellplate. The total number of positive wells was used to calculate the ratio of HLCS to TMED8-G allele in each sample.
• a normal reference range of 2.06— 3.68 was calculated from euploid maternal plasma samples. Among the nine euploid samples, five, three and one cases were collected from the third-, second- and first-trimester pregnancies, respectively. They included four pregnancies with a female fetus, and five with a male fetus. The HLCS to TMED8-G allele ratios of all euploid samples fell within the reference range. The first-trimester T21 pregnancy with a female fetus showed a higher HLCS to TMED8-G ratio than the reference range ( Figure 7B).
• Beta-actin as a digestion control
• the BstXJl enzyme digestion efficiency was evaluated by applying the beta-actin digital PCR assay to the same ifr/UI-digested maternal plasma DNA samples as those used for HLCS to TMED8 chromosome dosage analysis. An aliquot of the digested DNA samples (1/50 of the total digestion mixture) was confirmed to show no more than one positive well for the beta-actin assay before subjected to chromosome dosage analysis.
• the inventors have demonstrated in principle that the EGG approach was a feasible method for fetal chromosome dosage analysis in maternal plasma DNA samples.
• the hypermethylated HLCS locus was used as the epigenetic component, which represented a class of fetal-specific molecules, and the ZFY locus was a genetic marker which was specific to a male fetus.
• the chromosome 21 dosage could be deduced.
• epigenetic-genetic chromosome dosage approach can be applied to the prenatal diagnosis of trisomy 21 using a fetal-specific SNP allele as a genetic reference baseline in place of a chromosome Y marker derived from a male fetus.
• SNP rs6636 located within the TMED8 locus on chromosome 14 was used as an example.
• the chromosome 21 dosage could be deduced. It was demonstrated that both SNP alleles could serve as such a genetic reference baseline.
• the EGG chromosome dosage approach can be applied to the prenatal diagnosis of trisomy 21 for both male and female fetuses. Furthermore, development of a panel of such markers will ensure a broad population coverage of this approach. As previously described (Chow et al.
• a maternal buffy coat sample which comprises of mostly maternal DNA, to ascertain the maternal genotypes for the panel of SNPs.
• SNPs where the mother was shown to be homozygous, one could then aim to detect the allele that is not represented in the maternal genotype in maternal plasma. If the plasma sample is positive for the non-maternal allele, it suggests that the fetus has inherited that allele from the father. The quantification of that paternally inherited fetal-specific allele in maternal plasma could then be used as the reference for gene dosage assessment using the peigenetic-genetic approach.
• EXAMPLE 3 Epigenetic-genetic chromosome dosage approach for the detection of fetal trisomy 18
• fetal trisomy 18 This example of the EGG approach involved a fetal epigenetic marker located on chromosome 18 and a fetal genetic marker located on a reference chromosome, respectively, in maternal plasma.
• the fetal epigenetic marker is, preferably, Marker 18A [genomic location chrl 8: 10022533- 10022724, defined according to the Human Genome March 2006 Assembly (hgl8)], which is a 146-bp intergenic region located 75 kb downstream of the gene VAPA (vesicle-associated membrane protein) -associated protein A) and 421 kb upstream of the gene APCDDl
• this fetal epigenetic marker can also be any cytosine-containing DNA genomic region located within 100 kb upstream or downstream of the above locus, i.e., chrl8: 10022533-10022724.
• this fetal epigenetic marker can also be any cytosine-containing DNA genomic region with different epigenetic signature (DNA methylation levels) that distinguishes the fetal from the maternal chromosome 18 in maternal plasma.
• the fetal genetic marker in maternal plasma is, preferably, a region located in the zinc-finger Y -linked (ZFY) gene on chromosome Y.
• ZFY zinc-finger Y -linked gene on chromosome Y.
• this fetal genetic marker can also be any genetic differences between the fetus and its mother, including single-nucleotide polymorphism (SNP) and insertion/deletion (indel) polymorphism.
• the inventors adopted the EGG approach to compare the concentrations of Marker 18A on chromosome 18 with those of a fetal genetic marker, the zinc finger protein, Y-linked (ZFY) gene on chromosome Y for the noninvasive prenatal detection of Tl 8.
• CVS Chorionic villus samples
• Peripheral blood samples were processed by a double centrifugation protocol as previously described (Chiu et al. Clin Chem 2001; 47:1607-13). The blood cell portion was recentrifuged at 2,500 g, and any residual plasma was removed.
• DNA from the peripheral blood cells and that from maternal plasma was extracted with the blood and body fluid protocol of the QIAamp DNA Blood Mini Kit and the QIAamp DSP DNA Blood Mini Kit, respectively (Qiagen).
• DNA from the CVS and placentas was extracted with the QIAamp DNA Mini Kit (Qiagen) according to the manufacturer's tissue protocol.
• the methylation status of Marker ISA were analyzed in six pairs of placental tissues and maternal blood cells by cloning and bisulfite sequencing. Briefly, extracted DNA was bisulfite-converted using the EZ DNA Methylation Kit (ZymoResearch) according to the manufacturer's instructions. Bisulfite-converted DNA was subjected to PCR amplification by primers targeting the Marker ISA region. The primer sequences for the PCR are listed in Table 10. The PCR conditions are summarized in Table 1 IA. The PCR product was subsequently TA-cloned into a plasmid vector with the pGEM T-Easy Cloning Kit (Promega) according to manufacturer's instructions.
• the MI at each CpG site was calculated by the number of methylated clones divided by the total number of clones for each sample. The average MI of the two biological replicates was calculated for each CpG site. The methylated site frequency was given by the number of methylated clones across each sample over the total number of clones scored.
• the Epiryper assay was performed with the standard MassCLEAVE protocol (Sequenom) (Ehrich et al Proc Natl Acad Sci USA 2005; 102:15785-90) (Details of the conditions for individual reactions involved in the protocol are summarized in Table 1 IB). Briefly, the bisulfite-converted DNA was subjected to PCR amplification with the Epityper assay targeting Marker 18A. The primer sequences were listed in Table 10. A T7 promoter tag was added to the 3' end of the reverse primer, and a 10-base tag was added to the 5' end of the primer to equalize the melting temperature between the forward and reverse primers.
• Extracted DNA was subjected to bisulfite conversion with an EZ DNA Methylation Kit (ZymoResearch) according to the manufacturer's instruction and amplified with PCR.
• the PCR products were then in vitro transcribed as RNA using the T7 DNA polymerase and T7 RNA polymerase, and cleaved specifically at bases with A- or G-residues by RNase A.
• the cleavage reaction generated CpG-containing fragments, or CpG unit, whose sizes would be dependent on the methylation status of the CpG sites (i.e. , CpG or TpG for methylated and unmethylated CpGs, respectively, after bisulfite conversion).
• the products were then cleaned up, and resolved with a matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrophotometer (MassARRAY Analyzer Compact).
• MALDI-TOF matrix-assisted laser desorption/ionization time-of-flight
• MassARRAY Analyzer Compact MassARRAY Analyzer Compact
• Quantitative real-time PCR (qPCR) assays were designed to target Marker 18A.
• the primer and probes were strategically positioned such that the unmethylated CpG sites in maternal DNA, but not the methylated CpG sites in the fetal DNA, would be specifically cleaved by the relevant restriction endonucleases.
• MSRE Methylation-sensitive restriction endonuclesae
• Hpal ⁇ and HinPll Two types of MSRE, namely Hpal ⁇ and HinPll (New England Bio labs), were used to digest the plasma DNA.
• DNA was extracted from 0.8 mL - 3.2 mL plasma and eluted in 50 ⁇ L water. 35 ⁇ L of the eluted DNA was then incubated with 20 U each of HpaII and HinPl I (New England Biolabs) in IX NEBuffer 1 at 37 0 C for 2 hours.
• the probe was labeled with VIC on its 5' end as reporter.
• the thermal profile was 50 0 C for 2 min, 95 °C for 10 min, 40 cycles of 95 °C for 15 s, and 60 °C for 1 minute.
• the primer and probe sequences are listed in Table 12.
• a calibration curve was derived by serial dilutions of known concentrations of genomic DNA extracted from a male peripheral blood cell sample, which was quantified by NanoDrop ND- 1000 (Thermo Fisher Scientific).
• the inventors adopted the EGG approach to compare the relative dosage of the fetal epigenetic marker, Marker 18A, on chromosome 18, and that of a fetal genetic marker, ZFY, on chromosome Y, in placental tissues (CVS) and maternal plasma samples obtained from euploid and T 18 pregnancies.
• the digestion protocol for the EGG analysis involving Marker 18A was the same as that used for qPCR analysis.
• 50 ng of DNA was subjected to digestion. All of the placental tissues were obtained from the first trimester.
• DNA was extracted from 1.6 mL - 3.2 mL plasma obtained from first, second and third trimester of euploid or Tl 8 pregnancies. Extracted DNA from each case was eluted into 50 ⁇ L water, of which 35 ⁇ L was subjected to digestion.
• a duplex digital PCR assay was developed to amplify digestion-resistant Marker 18A and ZFY sequences. The basis of the digital PCR analysis have been described previously (Lo et al. Proc Natl Acad Sci USA 2007; 104:13116-21; Tong et al. Clin Chem 2010; 56: 90-8).
• the reaction volume was 5 ⁇ L per well at a final concentration of Ix TaqMan® Universal PCR Master Mix (Applied Biosystems) with the respective primers and probes concentrations for each target.
• Marker 18A the reaction involved 250 nM TaqMan® probe (Integrated DNA Technologies) and 1500 nM of each of the forward and reverse primers (Integrated DNA Technologies).
• ZFY the reaction involved 100 nM TaqMan® probe (Applied Biosystems), and 300 nM of each of the forward and reverse primers (Integrated DNA Technologies).
• the probe for Marker 18A was labeled with the reporter FAM while that for ZFY was labeled with the reported VIC (Table 12).
• the total number of digital PCR reactions for each target was 384.
• the primer and probe sequences are the same as those for qPCR.
• the reaction volume was 5 ⁇ L per well at a final concentration of Ix TaqMan® Universal PCR Master Mix (Applied Biosystems) with 250 nM TaqMan® probe (Applied Biosystems) and 900 nM of each of the forward and reverse primers (Integrated DNA Technologies).
• the probe was labeled with the reporter VIC at its 5' end (Table 10).
• the assay was carried out on the 7900HT Sequence Detection System (Applied Biosystems). The reaction was initiated at 50°C for 2 min and continued at 95 0 C for 10 min, followed by 55 cycles of 95°C for 15 s, and 60°C for 1 min. The total number of digital PCR reactions for each target was 96.
• Marker 18A is a potential fetal epigenetic marker
• Beta-actin as a digestion control
• the enzyme digestion efficiency was evaluated by analyzing the enzyme-digested maternal plasma samples with the beta-actin assay that targeted at a region completely unmethylated in placentas and maternal blood cells while containing similar MSRE restriction sites as the Marker 18A amplicon ( Figure 17). Beta-actin sequences were not detectable in all the digested plasma samples.
• the noninvasive prenatal detection of trisomy 18 using this EGG approach could be extended to cover more fetuses in the general population by replacing the Y-specific fetal genetic marker, which was used in this example as an illustration, with other fetal genetic marker, such as paternally-inherited SNP on a reference chromosome, to specifically measure the dosage of the fetal reference chromosome in maternal plasma.
• Peripheral blood samples were processed by a double centrifugation protocol as previously described (Chiu et al. CHn Chem 2001 ; 47: 1607-13). The blood cell portion was recentrifuged at 2,500 g, and any residual plasma was removed. DNA from the peripheral blood cells was extracted with the blood and body fluid protocol of the QIAamp DNA Blood Mini Kit (Qiagen).
• DNA from the CVS and placentas was extracted with the QIAamp DNA Mini Kit (Qiagen) according to the manufacturer' s tissue protocol.
• the PCR product was then subjected to sequencing reaction with the BigDye Terminator Cycle Sequencing v 1.1 kit (Applied Biosystems) according to the manufacturer's instructions (Reaction conditions are summarized under the sub-title sequencing reaction in Table 13A).
• DNA was then precipitated with ethanol and resuspended in 10 ⁇ L of Hi-Di formamide and sequenced on a 3100 DNA Analyzer (Applied Biosystems).
• the sequencing data were analyzed using the SeqScape v2.5 software (Applied Biosystems). The inventors ensured > 99% bisulfite conversion of each clone by examining the conversion rate at non-CpG cytosine residues.
• the Epityper assay was performed with the standard MassCLEA VE protocol (Sequenom) (Ehrich et al. Proc Natl Acad Sci USA 2005; 102:15785-90) (Details of the conditions for individual reactions involved in the protocol are summarized in Table 13B). Briefly, the bisulfite-con verted DNA was subjected to PCR amplification with the forward primer '5 - aggaagagagGGAGG ATAGG AGGAGGGAGTTATAGT - 3' and reverse primer '5 - cagtaatacgactcactatagggagaaggctAAAATTACACACAATACACACCAAAAAAT - 3' targeting Marker 13 A region.
• a T7 promoter tag was added to the 3' end of the reverse primer, and a 10-base tag was added to the 5' end of the primer to equalize the melting temperature between the forward and reverse primers.
• Extracted DNA was subjected to bisulfite conversion with an EZ DNA Methylation Kit (ZymoResearch) according to the manufacturer's instruction and amplified with PCR.
• the PCR products were then in vitro transcribed as RNA using the T7 DNA polymerase and T7 RNA polymerase, and cleaved specifically at bases with A- or G-residues by RNase A.
• MSRE Fermentas Life Sciences
• the probe for Marker ISA was labeled with the reporter FAM while that for ZFY was labeled with the reporter VIC (Table 14).
• the total number of digital PCR reactions for each target was 192.
• Marker ISA is a potential fetal epigenetic marker
• Placental DNA samples (5 for Tl 3 and 10 for euploid) from pregnancies with male fetuses were analyzed with the respective monoplex digital PCR assays for Marker 13 A and ZFY.
• a normal reference range, defined as the mean ratio of Marker 13A to ZFY ⁇ 1.96SD, of the euploid samples was 1.40 - 2.10. All except one of the Tl 3 cases had a ratio greater than the upper reference limit ( Figure 20).
• Placenta 1 mock 295 287 158 171 Placenta l Bs(Ul 196 187 164 177
• Table 9 Specificity of the TMED8-CIG SNP assays. Genotypes of the placentas are indicated after the sample number. The copy numbers were corrected for Poisson distribution.
• A HLCS and TMED8-C duplex assay.
• B HLCS and TMED8-G duplex assay.
• Marker 18A Bisulfite Forward 5' - aggaagagagGGTTATTTGGGGGTAGTAGG - 3 1
• This mixture is added to the product of the PCR amplification
• Reverse primer 5 1 - CACTCGCTGAGCGTCCCC -3'
• Reverse primer 5 1 TGAAGTAATGTCAGAAGCTAAAACATCA - 3 1
• VIC TaqMan probe
• VIC TaqMan probe
• FAM 6-carboxyfluorescein
• VIC Applied Biosystems proprietary dye
• BHQl Black-hole quencher 1
• MGB minor groove
• This mixture is added to the product of the PCR amplification
• FAM 6-carboxyfluorescein
• VIC Applied B iosystems ® proprietary dye
• BHQl Black-hole quencher 1
• MGB minor groove binding.

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