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• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/74—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving hormones or other non-cytokine intercellular protein regulatory factors such as growth factors, including receptors to hormones and growth factors
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/53—Immunoassay; Biospecific binding assay; Materials therefor
  • G01N33/575—Immunoassay; Biospecific binding assay; Materials therefor for cancer
  • G01N33/57525—Immunoassay; Biospecific binding assay; Materials therefor for cancer of the liver or pancreas
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/53—Immunoassay; Biospecific binding assay; Materials therefor
  • G01N33/577—Immunoassay; Biospecific binding assay; Materials therefor involving monoclonal antibodies binding reaction mechanisms characterised by the use of monoclonal antibodies
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/58—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving labelled substances
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/68—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids
  • G01N33/6863—Cytokines, i.e. immune system proteins modifying a biological response such as cell growth proliferation or differentiation, e.g. TNF, CNF, GM-CSF, lymphotoxin, MIF or their receptors
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/68—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids
  • G01N33/6863—Cytokines, i.e. immune system proteins modifying a biological response such as cell growth proliferation or differentiation, e.g. TNF, CNF, GM-CSF, lymphotoxin, MIF or their receptors
  • G01N33/6869—Interleukin
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2800/00—Detection or diagnosis of diseases
  • G01N2800/06—Gastro-intestinal diseases
  • G01N2800/067—Pancreatitis or colitis

Definitions

• pancreatic cancer i.e. pancreatic ductal adenocarcinoma,‘PDAC’] or pancreatitis in a cohort of patients selected for an increased risk of developing PDAC which is associated with diabetes mellitus (DM).
• PDAC pancreatic ductal adenocarcinoma
• the pancreas has a complex anatomical and cellular composition comprising endocrine cells that release several important hormones into the blood (such as insulin, glucagon and somatostatin) and exocrine cells that secrete lipases and proteases into the intestine to aid digestion. It is the exocrine pancreas that is believed to be the tissue of origin of PDAC.
• PDAC typically has vague symptoms or is considered asymptomatic until a late stage often allowing the disease to metastasize to other organs before its diagnosis.
• Untreated metastatic PDAC has a median survival of 3-5 months. Survival for locally advanced disease is 6-10 months. However, the majority of cases are diagnosed in the advanced stages, too late for potentially curative resection.
• chemotherapy is not curative, such that rates of mortality of PDAC approach incidence rates.
• US9863960 discloses a method for diagnosing pancreatic cancer by measuring the presence of lnterleukin-1 receptor antagonist (I L-1 Ra).
• W02017109518 discloses methods of determining the protein glycosylation signature of target proteins to determine if a subject has pancreatic cancer. Hyper-glycosylation of CA- 19-9 and CEA was shown to be associated with pancreatic cancer.
• US20170003294 and WO2015157557 disclose diagnostic tests for the detection of diseases such as pancreatic cancer or pancreatic inflammatory conditions comprising determining the presence or absence of a numerous range of biomarkers.
• T2DM type 2 DM
• PDAC pancreatic disease
• This disclosure relates to the characterisation of a highly specific test for the detection of PDAC or pancreatitis in an individual with new-onset diabetes which measures the levels of adiponectin and IL-1 Ra in a biological sample to distinguish diabetes of the exocrine pancreas (Type 3c, including PDAC and pancreatitis-associated DM) from T2DM, allowing the former to enter screening for PDAC.
• Type 3c including PDAC and pancreatitis-associated DM
• an immunoassay to determine whether a subject has elevated levels of an adiponectin polypeptide and an IL-1 Ra polypeptide comprising the steps: i) obtaining a biological sample from a subject to be tested; ii) forming a preparation comprising said sample and an antibody or antibodies that bind adiponectin and an antibody or antibodies that bind IL-1 Ra to form an antibody/adiponectin polypeptide complex and an antibody/I L-1 Ra polypeptide complex;
• a relevant matched control could be a subject that has or is suspected of having new-onset DM without associated pancreatic cancer.
• an immunoassay to determine whether a subject is suspected of having early stage pancreatic ductal adenocarcinoma or pancreatitis comprising the steps: i) obtaining a biological sample from a subject to be tested; ii) forming a preparation comprising said sample and an antibody or antibodies that bind an adiponectin and an antibody or antibodies that bind IL-1 Ra to form an antibody/adiponectin polypeptide complex and an antibody/I L-1 Ra polypeptide complex;
• pancreatitis is the inflammation of the pancreas which can be acute or chronic. In acute pancreatitis the pancreas becomes inflamed for a short period of time often without lasting damage; in chronic pancreatitis the pancreas is permanently damaged and is unable to produce any or enough amounts of digestive fluids. The symptoms of chronic pancreatitis are often very similar to pancreatic cancer.
• pancreatitis is acute or chronic pancreatitis, preferably chronic pancreatitis.
• the adiponectin polypeptide comprises the amino acid sequence set forth in SEQ ID NO: 1 , or a polymorphic sequence variant thereof.
• the level of the adiponectin polypeptide is increased at least 2-fold compared to said normal matched control.
• the IL-1 Ra polypeptide comprises the amino acid sequence set forth in SEQ ID NO: 2, or a polymorphic sequence variant thereof.
• the level of the IL-1 Ra polypeptide is increased at least 2-fold compared to said normal matched control.
• said subject is pre-screened to determine whether the subject is pre-diabetic or has early stage T2DM.
• Diabetes mellitus can vary but include excessive thirst, frequent urination, tiredness, weight loss and loss of muscle bulk, frequent episodes of thrush, cuts or wounds that heal slowly and blurred vision. Diabetes mellitus is typically diagnosed by measuring blood sugar in the blood.
• said subject is tested for diabetes mellitus
• the level of CA19-9 is determined as a measure of whether the subject has or is predisposed to PDAC.
• the level of CA19-9 is determined as a measure of whether the subject has or is predisposed to pancreatitis.
• pancreatitis is acute or chronic pancreatitis, preferably chronic pancreatitis.
• Sialyl Lewis A is synthesized by glycosyltransferases that sequentially link the monosaccharide precursors onto both N-linked and O-linked glycans.
• the level of CA19-9 is determined by an immunoassay.
• said immunoassay is an ELISA or bead-based immunoassay.
• said biological sample is selected from the group consisting of: urine, blood, blood plasma or serum.
• Urine is an important source of biomarkers and can be collected continuously, in a non- invasive fashion and is typically preferred over blood sampling.
• IL-1 Ra detection in urine is a standard procedure (21) and commercially available kits for the detection of IL-1 Ra in urine are widely available (Table 1).
• Adiponectin can be detected in urine from healthy subjects with commercially available kits such as Luminex assay kit.
• said biological sample is urine.
• said antibody is polyclonal serum.
• said antibody is a monoclonal antibody.
• the subject is imaged, for example by tomography or magnetic resonance imaging, to determine whether the subject has early stage pancreatic ductal adenocarcinoma or pancreatitis.
• a treatment regimen for early stage pancreatic ductal adenocarcinoma or pancreatitis comprising: i) conducting the method according to the invention on a subject suspected of having early stage pancreatic ductal adenocarcinoma or pancreatitis; and ii) treating the subject for early stage pancreatic ductal adenocarcinoma or pancreatitis if the method determines said subject has or is susceptible to early stage pancreatic ductal adenocarcinoma or pancreatitis.
• said treatment is the resection of tumour tissue.
• said treatment is the administration of one or more chemotherapeutic agents.
• said therapeutic agent is selected from the group consisting of FOLFIRINOX (oxaliplatin, leucovirin, irinotecan and fluorouracil), Gemcitabine, GemCap (gemcitabine and capecitabine), FOLFOX (oxaliplatin, fluorouracil and folinic acid) and Nab-paclitaxel with gemcitabine.
• a solid support comprising immobilised antibodies that specifically bind adiponectin and/or IL-1 Ra.
• said solid support further comprises an immobilised antibody that specifically binds CA19-9.
• antibodies that specifically bind adiponectin, IL-1 Ra and CA19-9 are monoclonal antibodies.
• a point of care device comprising a solid support according to the invention.
• kits comprising or consisting of: an antibody that specifically binds an adiponectin polypeptide; an antibody that specifically binds an IL-1 Ra polypeptide; and secondary antibodies that bind said monoclonal antibody that binds an adiponectin polypeptide and a secondary antibody that binds an IL-1 Ra polypeptide wherein said secondary antibodies comprise separate detectable labels.
• an antibody that binds CA-19 and a secondary antibody that binds CA19-9 comprising a separately detectable label.
• said antibodies that specifically bind adiponectin, IL-1 Ra and CA19-9 are monoclonal antibodies.
• a method to determine whether a subject should be imaged for early stage pancreatic ductal adenocarcinoma or pancreatitis comprising or consisting of the steps: i) obtaining a biological sample from a subject to be tested; ii) forming a preparation comprising said sample and an antibody or antibodies that bind an adiponectin and an antibody or antibodies that bind IL-1 Ra to form an antibody/adiponectin polypeptide complex and an antibody/I L-1 Ra polypeptide complex;
• the subject is imaged, for example by tomography or magnetic resonance imaging, to determine whether the subject has early stage pancreatic ductal adenocarcinoma or pancreatitis.
• FIG. 1 -10% of all individuals who are newly diagnosed with T2DM actually have T3cDM.
• PDAC-associated DM accounts for 8 to 10% of T3cDM.
• T3cDM type 3c diabetes mellitus
• T2DM type 2 diabetes mellitus;
• FIG. 2 Serum adiponectin measured in three independent cohorts shows that levels of this adipokine are higher in PDAC-DM patients compared to DM controls and can distinguish PDAC from long-standing and new-onset T2DM.
• PC Pancreatic cancer
• PDAC-DM pancreatic cancer-associated diabetes
• DM longstanding diabetes
• NOD new-onset diabetes
• HC healthy controls
• FIG. 3 Circulating levels of IL-1 Ra measured in two independent cohorts.
• IL-1 Ra is up regulated in patients with PDAC and PDAC-DM compared to those with T2DM, regardless of duration (A, B).
• PDAC Pancreatic cancer
• PDAC-DM pancreatic cancer-associated diabetes
• DM long-standing diabetes
• NOD new-onset diabetes.
• FIG. 4 Serum levels of adiponectin (A) and plasma levels of IL-1 Ra (B) are significantly elevated in patients with T3cDM (PDAC- and chronic pancreatitis-associated) compared to those with T2DM.
• T3cDM type 3c diabetes mellitus
• T2DM type 2 diabetes mellitus.
• Figure 5 In combination, serum adiponectin and plasma IL-1 Ra showed good performance in the discrimination of type 3c diabetes from type 2 diabetes, regardless of diabetes duration (A) or compared to new-onset alone (B) (T3cDM, type 3c diabetes mellitus; T2DM, type 2 diabetes mellitus; NOD, new-onset diabetes mellitus).
• FIG 6 Biomarker-mediated identification of PDAC (black individual) amongst new-onset DM individuals (all colours) and pathway to diagnosis. Distinguishing T3cDM (dark grey and black individuals) from T2DM (grey individuals) will identify a PDAC-enriched population, making screening of this subpopulation feasible. All T3cDM patients require management that differs from that typically offered to T2DM patient. Our focus is on the detection of PDAC. PDAC accounts for 10% of cases in the T3cDM group.
• Figure 7 Calibration curve obtained from Plate 1 of Luminex analysis displaying the measured adiponectin concentration (pg/mL) in each standard and sample against fluorescence intensity. Optimal dilutions of urine are placed on the linear section of the curve between S2 and S4 (circled in red).
• Figure 8 Calibration curve obtained from Plate 2 of Luminex analysis displaying the measured adiponectin concentration (pg/mL) in each standard and sample against fluorescence intensity. Optimal dilutions of urine are placed on the linear section of the curve between S2 and S4 (circled in red).
• Serum and plasma samples from individuals with pancreatic cancer (pre-surgical) and healthy subjects were obtained from the University of Liverpool GCP Laboratory Facility Biobank. Serum and plasma samples from individuals with diabetes were collected at the Royal Liverpool University Hospital after referral from diabetes clinics and primary care centres. All participants gave written informed consent using approved ethics protocols, at the Royal Liverpool University Hospital (Ethics Identifier: 11/NW/0083 and 16/LO/1630).
• the validation set consisted of 78 individuals with histologically confirmed PDAC (37 with diagnosed diabetes and 41 with a negative diabetes diagnosis), 39 individuals with chronic pancreatitis (19 with diagnosed diabetes and 20 with a negative diabetes diagnosis), 20 individuals with long-standing (>3 years post-diagnosis) type 2 diabetes mellitus, 18 individuals with new-onset (£3 years post-diagnosis) type 2 diabetes mellitus and 20 healthy subjects.
• a list of significantly altered proteins generated from our iTRAQ data was uploaded into Ingenuity Pathway Analysis (I PA) software (http://www.ingenuity.com). Both a Core Analysis and Biomarker Filter were performed to identify those proteins associated with metabolic disease pathways and diabetes.
• Serum adiponectin and plasma IL-1 Ra levels were measured using commercially available Luminex (Bio-Plex Pro Diabetes Adiponectin Assay and Bio-Plex Pro Human Cytokine 27- Plex Assay, respectively; Bio-Rad, UK) on a Bio-Plex 200 System (Bio-Rad, UK). All samples were measured in duplicate following the manufacturers’ instructions with inter plate variability assessed using 3 quality controls per plate.
• Biomarker concentrations were determined from standard curves of positive control proteins using four- or five-parameter logistic regression models. Inter-plate variation of less than or equal to 15% was considered acceptable; any plate falling outside of this was repeated. Quantified biomarkers with concentrations falling outside of the linear range and those with duplicate measurements having a coefficient of variance (CV) >20%, were removed from the dataset.
• CV coefficient of variance
• Blood glucose (HbA1c mmol/mol) was measured by the Royal Liverpool University Hospital Clinical Biochemistry Department, using an International Federation of Clinical Chemistry- approved method.
• Urine samples were obtained from two healthy subjects and processed with- and without the inclusion of protease inhibitors. Urine samples were subjected to the following dilutions: (1 :1), (1 :2), (1 :4), (1 :5), (1 :10), (1 :20), (1 :100). Plasma controls were obtained from one healthy subject and one pancreatic cancer patient and were prepared to a (1 :400) dilution. Adiponectin levels were measured using the Bio-Plex Pro Human Diabetes Adiponectin Assay (Bio-Rad, #171A7003M).
• a quality control check was also carried out using the adiponectin concentrations of the plasma controls where CV values ⁇ 15% were considered acceptable.
• Table 1 commercially available kits for the detection of IL-1 Ra in urine
• T2DM type 2 DM
• T3cDM type 3c DM
• PDAC-associated DM accounts for 8-10% of cases of misdiagnosed new-onset T3cDM (equivalent of 0.8-1% of new diagnoses of T2DM).
• Identifying the 0.8-1% of individuals with new-onset diabetes who have underlying PDAC- associated DM is not feasible using current screening modalities. Distinguishing T3cDM from T2DM would identify a PDAC-enriched population, making screening of this subpopulation feasible. Screening would be facilitated if diagnostic biomarkers were established that would, in combination with other clinical features, aid in the identification of these high-risk individuals.
• Interleukin-1 receptor antagonist reduces the endogenous activity of the IL-1 family of pro-inflammatory cytokines, protects b-cells from the destructive effects of high glucose exposure, and while the b-cell expression of IL-1 Ra is reduced in patients with T2DM 19 , blood levels are increased.
• IL-1 Ra expression was unaffected by jaundice and elevated in PDAC compared to healthy controls in both serum and plasma in a Luminex based discovery program (p ⁇ 0.05, data not shown 20 ).
• Adiponectin was successfully detected in urine using a Luminex assay (Table 2), with concentrations measurable in line with generated calibration curves (Fig 7 and Fig 8). Optimal dilutions of urine were (1 :1) and (1 :2) as these samples lay between the linear section of the standard curve. Little variance in adiponectin concentrations were observed for urine processed with- and without protease inhibitors. Adiponectin levels are measurable in urine. Urine is thus suitable for the measurement of adiponectin and IL-1 RA.
• Table 2 Table displaying average adiponectin concentration in patient urine samples with and without protease inhibitors and their corresponding CV values.
• pancreas 2013;42:198-201 Pancreas 2013;42:198-201.
• Tonack S, Jenkinson C, Cox T, et al. iTRAG reveals candidate pancreatic cancer serum biomarkers: influence of obstructive jaundice on their performance. Br J Cancer 2013;108:1846-53.
• Herder C Carstensen M, Ouwens DM. Anti-inflammatory cytokines and risk of type 2 diabetes. Diabetes Obesity & Metabolism 2013;15:39-50.
• Zwiech R Predictive value of conjointly examined IL-1 ra, TNF-R I, TNF-R II, and

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