Method of diagnosing bladder cancer   

Abstract: The present invention relates to a method of diagnosing cancer in a subject comprising detecting in the DNA of said subject at least one hypermethylated CpG island associated with said cancer, wherein an elevation in the level of methylation in said CpG island of said subject, relative to the level of methylation in said CpG island of a control subject, is indicative of said CpG island being hypermethylated.

FIELD OF THE INVENTION

The present invention is in the field of bladder cancer diagnosis, and in particular the methods for predicting the progression of bladder cancer tumors. The invention provides diagnostic methods and diagnostic compositions for use in such methods. The invention further provides therapeutic targets for treating specific forms of bladder cancers.

BACKGROUND OF THE INVENTION

Bladder cancer is the fifth most common cancer in the western world with an incidence of 20 new cases per year per 100,000 people in the U.S. Unfortunately, these statistics do not include superficial pTa bladder cancer, which represents the most common type of bladder cancer. In the Netherlands, the incidence of both superficial and invasive bladder cancer is estimated as about 30 new cases per year per 100,000 people. This is in accordance with data from global cancer statistics for the western world. Superficial bladder tumors are removed by transurethral resection. However, up to 70% of these patients will develop one or more recurrences, and it has been estimated that 1 in 1,450 people is under surveillance for bladder cancer in the United Kingdom. Cystoscopy is an uncomfortable, invasive, and expensive procedure, but currently remains the gold standard for detection of recurrences. Because patients have to be monitored perpetually and have a long-term survival, bladder cancer is the most expensive cancer when calculated on a per patient basis.

Hence there exists a need for an inexpensive, noninvasive, and simple procedure for the detection of bladder cancer. Cytology done on voided urine is a noninvasive procedure with up to 100% specificity. Unfortunately, this method is limited by its sensitivity, which is especially poor for low-grade tumors. Because of this limited sensitivity, alternative methods need to be developed for the detection of tumor cells in voided urine.

SUMMARY

The present inventors have found that the methylation of a number of specific CpG islands (CGIs) in the DNA of cells shaded in the urine of a subject is indicative of the present of a tumor, in particular a bladder tumor. Thus, aberrant methylation of these CpG islands in the DNA of a subject may be used as diagnostic and/or prognostic marker as well as a therapeutic target.

The present finding has been found to be particularly advantageous in the case of bladder cancer diagnostics (including disease prognosis and prediction of disease recurrence and progression), since the detection of methylation may occur in DNA (of cells) in a sample of urine obtained from the subject to be diagnosed. In particular urothelial cells present in said urine sample are used for this purpose. The skilled person will understand that diagnostic methods as indicated herein may make use of any body sample in which DNA comprising the aberrant methylations as defined herein can be detected, including biopsies of cancerous tissue, or tissue suspected of being malignant.

The present inventors have demonstrated the suitability of using methylation of specified CpG islands as diagnostic markers in bladder cancer diagnostics, such as for: detection of recurrent cancer in DNA isolated from patient urine, and detection of primary cancer in DNA isolated from patient urine.

Thus, in a first aspect, the present invention provides a method for diagnosing cancer in a subject comprising detecting in the DNA of said subject at least one hypermethylated CpG island associated with said cancer, wherein an elevation in the level of methylation in said CpG island of said subject, relative to the level of methylation in said CpG island of a control subject, is indicative of said CpG island being hypermethylated. The presence of a hypermethylated CpG island might indicate that the subject is at risk of, or suffering from, a cancer.

Preferably said CpG island is selected from the group consisting of the CpG islands listed in Table 1, Table 2, Table 3, Table 4, Table 5, Table 7, Table 9, Table 10 and Table 12.

In a preferred embodiment of methods of the invention, said cancer is bladder cancer.

In another preferred embodiment of methods of the invention, said method comprises detection of recurrent forms of cancer in DNA isolated from patient urine and wherein said at least one CpG islands methylation associated with cancer selected from the group consisting of the CpG islands listed in Table 1, Table 2, Table 3, Table 4, Table 5, Table 7, Table 9, Table 10 and Table 12.

In yet another preferred embodiment of methods of the invention, said method comprises detection of primary forms of cancer in DNA isolated from patient urine and wherein said at least one CpG islands methylation associated with cancer selected from the group consisting of the CpG islands listed in Table 1, Table 2, Table 3, Table 4, Table 5, Table 7, Table 9, Table 10 and Table 12.

In still a further preferred embodiment of methods of the invention, said DNA is obtained from a urine sample of said subject.

In another preferred embodiment of methods of the invention, said bladder cancer is non muscle-invasive bladder cancer. Alternatively, said bladder cancer is muscle-invasive bladder cancer. In a further preferred embodiment, said method provides detection of differential methylation of one or more of the genes provided in Table 7. Differential methylation of one or more of the genes provided in Table 7 is used to discriminate between subgroups of bladder cancer, such as between NMI-wt and MI and NMI-mt groups.

In a preferred embodiment of methods of the inveniton, general inflammatory cells in urine, preferably lymphocytes, are detected by methylation of at least one of the CGIs listed in Table 9. Table 9 indicates a number of CGIs methylated in blood but not in bladder cancer. The differential methylation of these CGIs, which can be detected in DNA (of cells) in a sample of urine obtained from the subject to be diagnosed, and in particular in urothelial cells present in said urine sample, are useful for the detection of lymphocytes in urine, or in general inflammatory cells in urine, which is indicative of cystitis. Positive detection of the presence of inflammatory cells in the urine can be used to diagnose infection or non-infective inflammation of the urinary tract and kidney.

In a preferred embodiment, said method comprises detection of recurrent cancer in DNA isolated from patient urine. This method entails the detection of specific CpG island methylations associated with recurrent forms of the cancer.

In another preferred embodiment, said method comprises detection of primary cancer in DNA isolated from patient urine. This method entails the detection of specific CpG island methylations associated with primary forms of the cancer.

The present inventors have further demonstrated the suitability of using methylation of specified CpG islands as prognostic markers in bladder cancer diagnostics, such as for: prediction of disease course based on analysis of tumor-derived or urine derived DNA, including: prediction of invasive potential of non-muscle invasive urothelial carcinomas; prediction of urothelial carcinoma-specific survival, and prediction of presence/absence of lymph node and distant metastases caused by urothelial carcinomas

Thus, in a second aspect, the present invention provides a method for the prediction of the recurrence, progression or prognosis of cancer, in particular bladder cancer, comprising detecting in the DNA of said subject at least one hypermethylated CpG island associated with said cancer, wherein an elevation in the level of methylation in said CpG island of said subject, relative to the level of methylation in said CpG island of a control subject, is indicative of said CpG island being hypermethylated. The presence of a hypermethylated CpG island might indicate that the subject is at risk of cancer recurrence, progression of a cancer, and/or poor prognosis. A preferred method for the prognosis of a risk of cancer recurrence, progression of a cancer, and/or poor prognosis comprises detection of one or more methylated CpGs in CGIs of the genes listed in Table 12B, whereby the CGIs are preferably chosen from GPR103, DBC1 and/or GATA2 genes. Said cancer is preferably bladder cancer.

In a preferred embodiment of said method for the prediction of the recurrence, progression or prognosis of cancer, said CpG island is selected from the group consisting of the CpG islands listed in Table 1, Table 2, Table 3, Table 4, Table 5, Table 7, Table 9, Table 10 and Table 12, preferably from Table 5 and Table 10.

In aspects of the present invention the methylation of dinucleotide in or methylation level of a CpG island may be determined by any method available to the skilled person. Preferably said method comprises methylation-specific PCR (MSP). Alternatively, or additionally, use may be made of a multiplex ligation-dependent probe amplification (MLPA).

The present inventors have further demonstrated the suitability of using methylation of specified CpG islands as markers in bladder cancer diagnostics for prediction of therapeutic response, such as for prediction of failure or success of (neo)-adjuvant therapies.

The present inventors now envision as part of their invention the use of demethylating agents capable of specifically demethylating the CpG islands associated with tumor, in particular bladder cancer, as defined herein. They may also be of use as priming therapy for chemotherapeutic regimes.

Hence, the present invention provides a method for the treatment or prevention of cancer, in particular bladder cancer, comprising administering to a subject in need of such treatment a therapeutically effective amount of a demethylating agent capable of selectively demethylating at least one of the CpG islands methylations associated with cancer as described herein.

Clinical outcome of demethylating agents may depend on specific methylation profiles.

The present invention further provides pharmaceutical compositions comprising demethylating agents capable of selectively demethylating at least one of the CpG islands methylations associated with cancer as described herein.

The present invention further provides diagnostic compositions comprising PCR primirs and reagent or probes capable of selectively hybridising under stringent conditions to hypermethylated CpG islands as defined herein.

DETAILED DESCRIPTION

As used herein the term “CpG island” refers to genomic regions that contain a high frequency of CG nucleotides. In mammalian genomes, CpG islands are typically 300-3,000 base pairs in length. They are in and near approximately 40% of promoters of mammalian genes (about 70% in human promoters). The “p” in CpG notation refers to the phosphodiester bond between the cytosine and the guanine. CpG islands are characterized by CpG dinucleotide content of at least 60% of that which would be statistically expected (˜4-6%), whereas the rest of the genome has much lower CpG frequency (˜1%), a phenomenon called CG suppression. Unlike CpG sites in the coding region of a gene, in most instances, the CpG sites in the CpG islands of promoters are unmethylated if genes are expressed.

As used herein the term “CpG island methylation” refers to a methylation of at least one CG dinucleotide in a CpG region as defined herein. Hence, the methods of the present invention include the detection of at least a single CG dinucleotide being methylated in a CpG island as defined herein.

As used herein the term “hypermethylated CpG islands” refers to a CpG island exhibiting an elevation in the level of methylation, relative to the level of methylation in the same CpG island of a control subject. Again, the level of methylation includes the presence of a single methylated CG dinucleotide in the CpG island as compared to the control situation, in which the same CpG island is unmethylated. Also, methods of the invention include embodiments wherein the methylation of a single CG dinucleotide in a CpG island as defined herein is detected among other methylated sites.

As used herein, “cancer” shall be taken to mean any one or more of a wide range of benign or malignant tumors, including those that are capable of invasive growth and metastasis through a human or animal body or a part thereof, such as, for example, via the lymphatic system and/or the blood stream. As used herein, the term “tumor” includes both benign and malignant tumors or solid growths, notwithstanding that the present invention is particularly directed to the diagnosis or detection of malignant tumors and solid cancers. Typical cancers include but are not limited to carcinomas, lymphomas, or sarcomas, such as, for example, ovarian cancer, colon cancer, breast cancer, pancreatic cancer, lung cancer, prostate cancer, urinary tract cancer, uterine cancer, acute lymphatic leukemia, Hodgkin\'s disease, small cell carcinoma of the lung, melanoma, neuroblastoma, glioma, and soft tissue sarcoma of humans; and lymphoma, melanoma, sarcoma, and adenocarcinoma of animals.

The term “bladder cancer” as used herein refers in general to urothelial cell carcinoma, i.e. carcinomas of the urinary bladder, ureter, renal pelvis and urethra. The term includes reference to the non muscle-invasive (NMI) or superficial forms, as well as to the more dangerous muscle invasive (MI) types. Also included in the term is reference to the primary forms as well as to recurrent forms of the cancer.

The NMI types may further be subdivided into FGFR3+ and FGFR3−. Mutations in the fibroblast growth factor receptor 3 (FGFR3, indicated herein as FGFR3+) occur in 50% of primary bladder tumors. It is known (e.g. Van Oers et al. 2005 Clin. Cancer Res; 11(21), pp. 7743-7748) that an FGFR3 mutation is associated with good prognosis, illustrated by a significantly lower percentage of patients with progression and disease-specific mortality. FGFR3 mutations are especially prevalent in low grade/stage tumors, with pTa tumors harboring mutations in 85% of the cases. These tumors recur in 70% of patients. Efficient FGFR3 mutation detection for prognostic purposes and for detection of recurrences in urine is an important clinical issue. Thus, in preferred embodiments of the present invention the method of diagnosis includes further the step of detecting an FGRF3 gene mutation. This additional step may be performed prior to, during or after the step of detecting the hypermethylated CpG island as indicated herein. The detection of the FGFR3 gene mutation as indicated in Van Oers et al (this reference is expressly referred to and incorporated herein by reference in its entirety for the methods and mutations to be detected as described therein) indicates the cancer is very likely of the non invasive type.

“Subject” as used herein includes, but is not limited to, mammals, including, e.g., a human, a non-human primate, a mouse, a pig, a cow, a goat, a cat, a rabbit, a rat, a guinea pig, a hamster, a degu, a horse, a monkey, a sheep, or other non-human mammal; and non-mammal animals, including, e.g., a non-mammalian vertebrate, such as a bird (e.g., a chicken or duck) or a fish, and an invertebrate.

A method of the invention can be performed on any suitable body fluid, such as for instance on abdominal fluid, pleural fluid, bronchial fluid, pericardial fluid, blood, serum, milk, plasma, sweat, tears, urine, peritoneal fluid, lymph, vaginal secretion, semen, spinal fluid, cerebrospinal fluid, ascitic fluid, saliva, stool, sputum, mucus or breast exudate. Preferably, a method of the invention is performed on blood, serum, plasma or ascitic fluid, more preferably serum. Depending on the methods employed, the skilled person will be capable of establishing the amount of sample required to perform the various steps of the method of the present invention. Generally, such amounts will comprise a volume ranging from 0.01 μl to 100 ml or more. Preferred samples are urine samples.

In even more preferred embodiments of aspects of the invention the cell fraction of urine, preferably tumor cell fraction, is used. Urine cell fractions may be obtained by filtration or centrifugation. The cellular DNA may subsequently be analyzed, for instance upon extraction of the DNA from the cells, although in situ methods performed on whole cells are also envisioned.

The skilled physician or biologist will be familiar with the various ways of providing a sample of a body fluid from a subject, in particular an urine sample. Urine collection and preparation of the sample for CpG island methylation analysis suitably comprises for instance the collection of a urine sample were collected into a 50 ml centrifuge tube. The sample may optionally be used for additional tests, such as dip stick tests for leucocytes, erythrocytes and nitrite as routinely performed in the art. The cells in the urine are suitably spun down for 10 min @ 3000 rpm; 4° C. An amount of supernatant is suitably stored at −80° C. for later use. The cell pellet may then be washed, for instance by adding a suitable amount of PBS (phosphate-buffered saline), such as 10 ml, to the cell pellet. After mixing and centrifugation (e.g. 10 min @ 3000 rpm; 4° C.), the PBS may be discarded. The cell pellet may then be resuspended in PBS (e.g. 1 ml) and transferred to a microcentrifuge tube. The suspension is then suitably centrifuged (e.g. 5 min @ 6000 rpm; 4° C.). The supernatant can then be carefully removed and the cell pellet may be stored in a −80° C. freezer until DNA extraction.

Commercial systems for DNA isolation from blood, urine and tissue are available form various suppliers of molecular biological reagents. Special reference is made to the DNeasy® Blood & Tissue Kit and DNeasy® 96 Blood & Tissue Kit available from QIAGEN GmbH, Hilden, Germany.

The term “therapeutically effective amount” as used herein refers to an amount of a therapeutic agent to treat, ameliorate, or prevent a desired disease or condition, or to exhibit a detectable therapeutic or preventative effect. The effect can be detected by, for example, chemical markers or antigen levels. Therapeutic effects also include reduction in physical symptoms. The precise effective amount for a subject will depend upon the subject\'s size and health, the nature and extent of the condition, and the therapeutics or combination of therapeutics selected for administration. Thus, it is not useful to specify an exact effective amount in advance. However, the effective amount for a given situation can be determined by routine experimentation and is within the judgment of the clinician.

For purposes of the present invention, an effective dose will be from about 0.01 mg/kg to 50 mg/kg or 0.05 mg/kg to about 10 mg/kg of the polynucleotide or polypeptide compositions in the individual to which it is administered.

The present invention also pertains to pharmaceutical compositions comprising demethylating agents as defined herein.

A pharmaceutical composition can also contain a pharmaceutically acceptable carrier. The term “pharmaceutically acceptable carrier” refers to a carrier for administration of a therapeutic agent, such as a polypeptide, polynucleotide, and other therapeutic agents. The term refers to any pharmaceutical carrier that does not itself induce the production of antibodies harmful to the individual receiving the composition, and which may be administered without undue toxicity. Suitable carriers may be large, slowly metabolized macromolecules such as proteins, polysaccharides, polylactic acids, polyglycolic acids, polymeric amino acids, amino acid copolymers, and inactive virus particles. Such carriers are well known to those of ordinary skill in the art.

Pharmaceutically acceptable salts can be used therein, for example, mineral acid salts such as hydrochlorides, hydrobromides, phosphates, sulfates, and the like; and the salts of organic acids such as acetates, propionates, malonates, benzoates, and the like. A thorough discussion of pharmaceutically acceptable excipients is available in Remington\'s Pharmaceutical Sciences (Mack Pub. Co., N.J. 1991).

Pharmaceutically acceptable carriers in therapeutic compositions may contain liquids such as water, saline, glycerol and ethanol. Additionally, auxiliary substances, such as wetting or emulsifying agents, pH buffering substances, and the like, may be present in such vehicles. Typically, the therapeutic compositions are prepared as injectables, either as liquid solutions or suspensions; solid forms suitable for solution in, or suspension in, liquid vehicles prior to injection may also be prepared. Liposomes are included within the definition of a pharmaceutically acceptable carrier.

Once formulated, the pharmaceutical compositions of the invention can be (1) administered directly to the subject; (2) delivered ex vivo, to cells derived from the subject; or (3) delivered in vitro for expression of recombinant proteins.

Direct delivery of the compositions will generally be accomplished by injection, either subcutaneously, intraperitoneally, intravenously or intramuscularly, or delivered to the interstitial space of a tissue. The compositions can also be administered into the nervous system. Other modes of administration include topical, oral, suppositories, and transdermal applications, needles, and particle guns or hyposprays. Dosage treatment may be a single dose schedule or a multiple dose schedule.

Specific aspects of the present invention relate to the CpG islands indicative of certain forms of cancer emerging for instance from the following comparisons:

A) CpG islands hypermethylated in non muscle-invasive (NMI) bladder cancer (BC) that are FGFR3 wild type, herein referred to as NMI-BC wt, vs. muscle-invasive (MI) bladder cancer herein referred to as MI-BC (n=31)

B) CpG islands hypermethylated in MI-BC vs. NMI-BC wt (n=11)

C) CpG islands hypermethylated in all bladder cancers (n=62)

D) CpG islands hypermethylated in NMI-BC-FGFR3 wild type vs. NMI-BC-FGFR3 mutant (n=31), and

E) Hypermethylated CpG islands predicting progression of disease or death of disease (resp. n=3 and n=11)).

The methods of the invention comprise the detection of hypermethylated CpG islands in the DNA of a subject. As indicated, hypermethylation is a relative term indicating that the methylation level of the respective CpG island is higher than or elevated with respect to the methylation level of the corresponding CpG island in a healthy control subject.

The methods of the invention comprise the detection of at least one hypermethylated CpG island in the DNA of a subject. Since there are many CpG island indicated herein whose hypermethylation is indicative of cancer, in particular bladder cancer, the method preferably entails the detection of at least 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29, 30, or more, such as 35, 40, 45, 50, 55, 60, 65 or more hypermethylations in the DNA of a subject. In such instances, it is possible to speak of a CpG island methylation profile. In such a profile, the percentage of positively dectected CpG islands is preferably at least 50%, more preferably at least 70%, more preferably at least 90%.

The CpG island methylation profiles may comprise of between 2-25 CpG islands for diagnostic purpose, such as determining whether a bladder cancer is present, and/or whether it is an NMI or MI type.

The CpG island methylation profiles preferably comprise of between 2-25, more preferably more, such as between 50 and 150, for instance about 100 CpG islands for diagnostic purpose, such as determining the prognosis of an NMI to develop into a more aggressive MI type of tumor. Thus, the present invention provides for a prognostic method for determining whether an NMI type bladder cancer can develop into an MI type.

It is also possible to use a method of the present invention to distinguish between a primary or recurrent form of the tumor.

The skilled person is well aware of the various methods that have been developed to analyze DNA methylation. Amongst these methods are restriction enzyme- and sodium bisulfite based approaches, as well as multiplex ligation-dependent probe amplification (MLPA) approches.

Restriction-enzyme based methods are based on the inability of methylation sensitive restriction enzymes to cleave methylated cytosines in their recognition site. The identification of the methylation status relies on Southern hybridization techniques or PCR and is based on the length of the digested DNA fragment. The inability to digest methylated sequences results in longer fragments, indicating a methylated CpG dinucleotide. Restriction-enzyme based methods are simple, rapid and highly sensitive and are suitable for genome-wide methylation analyses as well as marker discovery techniques.

Preferred methods for application in aspects of the present invention is sodium bisulfite (NaHSO3) based detection of DNA methylation. Such methods are essentially based on the fact that treatment of single-stranded DNA with sodium bisulfite results in sequence differences due to deamination of unmethylated cytosines to uracil under conditions whereby methylated cytosines remain unchanged. The difference in methylation status marked by bisulfite reactivity can accurately be determined and quantified by PCR-based technology. Bisulfite sequencing techniques (such as described in Frommer et al. Proc. Natl. Acad. Sci. USA 89 (1992), 1827-1831) provide qualitative data on the methylation status of 5-methylcytosines in the amplicon between the sequence primers and thus requires primers specific for bisulfite converted, but not specific for unmethylated or methylated DNA. This approach provides detailed information on the methylation status of all CpG-sites.

A methylation-specific PCR (MSP) assay for determining the methylation status of CpG islands may be used. Such methods are for instance described in Herman et al. 1996 (Proc. Natl. Acad. Sci. USA 93 (1996), 9821-9826) and Herman and Baylin (Current Protocols in Human Genetics 10 (1998), 10.16.11-10.16.10). The MSP assay is based on the use of two distinct methylation-specific primer sets for the sequence of interest. The unmethylated (U) primer only amplifies sodium bisulfite converted DNA in unmethylated condition, while the methylated (M) primer is specific for sodium bisulfite converted methylated DNA. Using MSP, 1 methylated allele may be detected in a background of 1000 unmethylated alleles. MSP is very suitable for analyzing the methylation status of CpG dinucleotides in a CpG-island. The method may also be applied for high-throughput analysis of clinical samples. The most critical parameters determining the success and specificity of MSP, i.e. bisulfite conversion, primer design and PCR as well as several post PCR validation approaches are discussed in Derks et al. 2004 (Cellular Oncology 26 (2004) 291-299). Methylation Specific PCR (MSP) is described in great detail in U.S. Pat. No. 5,786,146, U.S. Pat. No. 6,017,704, U.S. Pat. No. 6,200,756 and U.S. Pat. No. 6,265,171 and International Patent WO 97/46705.

Commercial systems for DNA methylation analysis using MSP are available form various suppliers of molecular biological reagents. Special reference is made to the EZ DNA Methylation-Startup™ Kit and EZ DNA Methylation-Direct™ Kit available from Zymo Research Corp. Orange, Calif., U.S.A.

Use can also be made, alone, or in combination with any of the above, of the MLPA technique. The MLPA technique is for instance described in great detail in Schouten et al., 2002 (Nucleic Acids Research 3(12) e57, 13 pp.).

Also, use can be made of a microarray chip to which DNA of a subject is hybridized. Such arrays for CpG islands are for instance commercially available from Agilent Technologies Inc., Santa Clara, USA.

Herein below are provided the following Tables:

Table 1. Coordinates of selected regions containing relevant CpG islands based on Homo sapiens full genome as provided by UCSC (hg18, March 2006). These CpG islands are aspect of the present invention as hypermethylation of these regions is associated with cancer, preferably bladder cancer and/or certain forms of said cancer.

Table 2. CpG islands differentially methylated in NMI-BC wt vs. invasive BC. These 42 CpG islands are aspect of the present invention as hypermethylation of these regions is associated with either NMI or more aggressive MI forms of the cancer. Hence, these regions are particularly indicated for use in diagnostic methods wherein typing of the cancer is relevant. The table provides data on CpG islands hypermethylated in non muscle-invasive (NMI) bladder cancer (BC) that are FGFR3 wild type, herein referred to as NMI-BC wt, vs. muscle-invasive (MI) bladder cancer herein referred to as MI-BC (n=31) as well as CpG islands hypermethylated in MI-BC vs. NMI-BC wt (n=11).

Table 3. CpG islands hypermethylated in (bladder) cancer. These 62 CpG islands are aspect of the present invention as hypermethylation of these CpG islands is associated with (bladder) cancer.

Table 4. CpG islands hypermethylated in NMI-BC FGFR3 wt vs NMI-BC FGFR3 mut. These 31 CpG islands are aspect of the present invention diagnostic markers for typing of (bladder) cancers and in particular indicate the relevance of FGFR3 mutations in bladder cancer. These 31 CpG islands may be used for diagnosis of FGFR3 wt primary and recurrent tumors in for instance urine. These 31 CpG islands may also be used for detection of FGFR3 wt tumors in patients with a FGFR3 ml (mutant) primary tumor. Alternatively, these 31 CpG islands may be used for the identification of recurrences that progressed to muscle-invasive disease or to stage pT1 or to high grade (WHO 2004 grading system) or G3(WHO grading system 1973). These 31 CpG islands may also be used to present specific targets for therapy in NMI-BC tumors that are FGFR3 wt.

Table 5. CpG islands potentially involved in progression and death of disease. These 14 CpG islands are aspect of the present invention as hypermethylation of these regions is associated with prediction of the recurrence, progression or prognosis of cancer of cancer, in particular bladder cancer.

Table 7 (including Tables 7A and 7B) indicates differentially labeled CGIs between subgroups of bladder cancer and/or between subgroups of bladder cancer and a reference sample (i.e. blood).

Table 9 indicates a number of CGIs methylated in blood but not in bladder cancer. The differential methylation of these CGIs, which can be detected in DNA (of cells) in a sample of urine obtained from the subject to be diagnosed, and in particular in urothelial cells present in said urine sample, are—apart from the purpose indicated herein for diagnosing bladder cancer—also useful for the detection of lymphocytes in urine, or in general inflammatory cells in urine, which is indicative of cystitis. Positive detection of the presence of inflammatory cells in the urine can be used to diagnose infection or non-infective inflammation of the urinary tract and kidney.

Table 10 provides a list of hypermethylated CGIs that show 3 or more CpG dinucleotides highly methylated in a specific CGI. This list comprises 82 CGIs representing 71 genes and 11 CGIs not directly associated with a gene. A preferred gene from Table 10 is MEIS1, showing the highest degree of methylation with a fold change of 4.8 and an average fold change of 2.2 across the 10 probes that were present on the array for this CGI.

Table 12 (including Tables 12A and 12B) provides a list of CGIs that are differentially methylated between tumors and urine from non-bladder cancer control. These genes represent potential biomarkers for urine tests.

FIG. 1. Methylation pattern and expression of selected genes. (a) MEIS1, (b) NR4A2 and (c) HOXA9. (d), (e), (f) are Box plots representing the expression profiles which were taken from oncomine

FIG. 2. Comparison of differential methylation between subgroups. (a) Unsupervised analysis performed on all probes present on the 244K array without selection: PCA showing the distinct bladder tumor groups cluster separately (Red-MI, Blue-NMI-mt and Green NMI-wt), (b) Venn diagram showing the number of CGIs that are differentially methylated

FIG. 3. Semi-supervised analyses between bladder tumor subgroups involving hierarchical clustering and PCA. (a) Clustering and PCA of NMI-mt and NMI-wt tumors, (b) Clustering and PCA of MI and NMI-wt tumors, (c) Clustering and PCA of NMI-mt and MI tumors.

FIG. 4. Most methylated gene-associated CGIs are targets of polycomb complexes. (a) Overrepresentation of PcG genes in BC methylated CGIs. (b), Venn diagram showing the overlap in PcG target genes between bladder cancer subgroups.

FIG. 5. A. Hierarchical clustering of GGMA data of all the investigated samples. B. Heat map showing the probes which are methylated in all tumor subgroups vs. blood and urine; C) Methylation of two CpGs in the MEIS1 CGI (black peaks: methylated CpG, red: not methylated. IM, in vitro methylated DNA; RT112, T24, J82: bladder cancer cell lines; PU: patient urine; NU: normal urine; NB: blood), D) KM curve for progression to muscle-invasive disease based on a combination of methylation of GRP103, DBC1 and GATA2.

TABLE 1 Coordinates of selected regions containing relevant CpG islands based on Homo sapiens full genome as provided by UCSC (hg18, March 2006) chr1: 119333484-119333719 chr1: 149638545-149639227 chr1: 160220156-160220709 chr1: 178464743-178471598 chr1: 2072175-2072389 chr1: 2106293-2106715 chr1: 232106869-232108183 chr1: 33385564-33385979 chr1: 41122328-41122880 chr1: 47672249-47672972 chr1: 68288825-68289104 chr1: 71284766-71286392 chr10: 21828640-21829645 chr10: 22804715-22807056 chr10: 73437163-73438385 chr10: 7449476-7449790 chr10: 7489383-7495345 chr12: 113657930-113659205 chr12: 118612357-118612674 chr12: 94776044-94776377 chr13: 113930978-113931584 chr13: 34950488-34951119 chr13: 49595986-49600287 chr13: 94152191-94153185 chr14: 36205192-36206099 chr14: 37746906-37747538 chr14: 53488428-53488700 chr15: 94688798-94689131 chr15: 94696311-94696840 chr15: 94705727-94706054 chr15: 94712480-94712812 chr16: 52873104-52882105 chr16: 52873104-52882105 chr16: 85098883-85102729 chr16: 86294154-86294408 chr16: 87372445-87372729 chr17: 24303411-24303889 chr17: 34157398-34159854 chr17: 44074280-44075233 chr17: 56827843-56838048 chr17: 58865328-58865618 chr17: 73932992-73933361 chr17: 75377960-75381951 chr17: 75531280-75531546 chr18: 5186244-5187389 chr18: 68359955-68362770 chr19: 4059891-4060207 chr19: 42586165-42586705 chr19: 63420090-63420541 chr19: 63784504-63785085 chr2: 104835284-104839920 chr2: 105864220-105865009 chr2: 111591678-111597436 chr2: 115635091-115637285 chr2: 124498611-124499725 chr2: 156892636-156892878 chr2: 156893736-156894685 chr2: 171384729-171385226 chr2: 176737610-176738187 chr2: 19424445-19425131

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