U.S. patent application number 13/188350 was filed with the patent office on 2012-01-19 for gene and gene expressed protein targets depicting biomarker patterns and signature sets by tumor type.
Invention is credited to Robert Penny, Daniel D. Von Hoff.
Application Number | 20120015843 13/188350 |
Document ID | / |
Family ID | 42107198 |
Filed Date | 2012-01-19 |
United States Patent
Application |
20120015843 |
Kind Code |
A1 |
Von Hoff; Daniel D. ; et
al. |
January 19, 2012 |
GENE AND GENE EXPRESSED PROTEIN TARGETS DEPICTING BIOMARKER
PATTERNS AND SIGNATURE SETS BY TUMOR TYPE
Abstract
Provided herein are methods and systems for identifying a
therapeutic for an individual, such as a therapeutic not previously
identified for treating the individual. The therapeutic can be
identified by molecular profiling, such as determining the
biomarker patterns or signature sets of a biological sample of an
individual.
Inventors: |
Von Hoff; Daniel D.;
(Scottsdale, AZ) ; Penny; Robert; (Lebanon,
IN) |
Family ID: |
42107198 |
Appl. No.: |
13/188350 |
Filed: |
July 21, 2011 |
Related U.S. Patent Documents
|
|
|
|
|
|
Application
Number |
Filing Date |
Patent Number |
|
|
12579241 |
Oct 14, 2009 |
|
|
|
13188350 |
|
|
|
|
11750721 |
May 18, 2007 |
|
|
|
12579241 |
|
|
|
|
61105335 |
Oct 14, 2008 |
|
|
|
61106921 |
Oct 20, 2008 |
|
|
|
60747645 |
May 18, 2006 |
|
|
|
Current U.S.
Class: |
506/9 ; 435/6.11;
435/6.12; 435/7.1; 506/7 |
Current CPC
Class: |
G01N 33/57484 20130101;
G01N 2800/52 20130101; G16H 15/00 20180101; G16B 50/00 20190201;
G01N 33/57492 20130101; G16H 50/20 20180101; C12Q 1/6886 20130101;
C12Q 2600/158 20130101; C12Q 2600/106 20130101 |
Class at
Publication: |
506/9 ; 435/7.1;
435/6.11; 435/6.12; 506/7 |
International
Class: |
C40B 30/04 20060101
C40B030/04; C12Q 1/68 20060101 C12Q001/68; C40B 30/00 20060101
C40B030/00; G01N 33/566 20060101 G01N033/566 |
Claims
1. A method for identifying one or more therapeutic agent for an
individual with a cancer comprising: (a) determining an expression
level of two or more markers from a biological sample of said
individual, wherein said markers are selected from the group
consisting of SPARC, TOP2A, PTEN, CD52, HSP90, Survivin, RRM1,
SSTR3, DNMT3B, VEGFA, SSTR4, RRM2, SRC, RRM2B, HSP90AA1, SSTR2,
FLT1, SSTR5, YES1, BRCA1, RRM1, DHFR, KDR, EPHA2, RXRG, and LCK;
(b) comparing said expression level to a predetermined reference
level; and (c) identifying one or more therapeutic agent specific
for one or more of said two or more markers based on said
comparison, wherein said individual has not been previously treated
with said one or more therapeutic agent, thereby identifying the
one or more therapeutic agent for treating the individual.
2. The method of claim 1, wherein said expression level for at
least two of said two or more markers is determined by analysis of
mRNA and protein.
3. The method of claim 1, wherein said determining an expression
level is by immunohistochemistry (IHC) analysis, microarray
analysis, in-situ hybridization (ISH), real-time PCR, or a
combination thereof.
4. The method of claim 1, wherein determining an expression level
of at least two of said two or more genes is by IHC and
microarray.
5. The method of claim 3, wherein said microarray analysis
comprises using an expression microarray, a comparative genomic
hybridization (CGH) microarray, a single nucleotide polymorphism
(SNP) microarray, a proteomic array or an antibody array.
6. The method of claim 3, wherein said microarray analysis
comprises identifying whether said gene is up-regulated or
down-regulated relative to a reference with a significance of
p<0.001.
7. The method of claim 3, wherein said IHC analysis comprises
determining whether 30% or more of said sample are +2 or greater in
staining intensity.
8. The method of claim 1, further comprising identifying a
mutation, polymorphism, deletion, or insertion in at least one of
said two or more markers.
9. The method of claim 8, wherein said identifying is by IHC
analysis, microarray analysis, ISH, FISH, PCR, real-time PCR,
sequencing, or a combination thereof.
10. The method of claim 1, wherein said determining comprises at
least three markers from said group.
11. The method of claim 1, wherein said determining comprises at
least five markers from said group.
12. The method of claim 1, wherein said two or more markers
comprise two or more of HSP90, Survivin, RRM1, SSTR3, DNMT3B,
VEGFA, SSTR4, RRM2, SRC, RRM2B, HSP90AA1, SSTR2, FLT1, SSTR5, YES1,
BRCA1, RRM1, DHFR, KDR, EPHA2, RXRG, and LCK.
13. The method of claim 1, wherein said two or more markers
comprise two or more of BRCA1, RRM1, SRC, DHFR, and KDR.
14. The method of claim 1, wherein said two or more markers
comprise BRCA1, RRM1, SRC, DHFR, and KDR.
15. The method of claim 1, wherein said two or more markers
comprise SPARC, TOP2A and PTEN.
16. The method of claim 15, wherein said SPARC, TOP2A and PTEN are
determined by IHC.
17. The method of claim 1, wherein said two or more markers
comprise CD52.
18. The method of claim 17, wherein said level of CD52 is an mRNA
expression level.
19. The method of claim 1, wherein the cancer comprises metastatic
cancer.
20. The method of claim 1, wherein the cancer comprises a cancer of
one or more of adipose tissue, adrenal cortex, adrenal gland,
adrenal gland-medulla, appendix, bladder, blood vessel, bone, bone
cartilage, brain, breast, cartilage, cervix, colon, colon sigmoid,
dendritic cells, skeletal muscle, enodmetrium, esophagus, fallopian
tube, fibroblast, gallbladder, kidney, larynx, liver, lung, lymph
node, melanocytes, mesothelial lining, myoepithelial cells,
osteoblasts, ovary, pancreas, parotid, prostate, salivary gland,
sinus tissue, skeletal muscle, skin, small intestine, smooth
muscle, stomach, synovium, joint lining tissue, tendon, testis,
thymus, thyroid, uterus, and uterus corpus.
21. The method of claim 1, wherein the cancer comprises a cancer of
one or more of the accessory, sinuses, middle ear, inner ear,
adrenal glands, appendix, hematopoietic system, bones and joints,
spinal cord, breast, cerebellum, cervix uteri, connective and soft
tissue, corpus uteri, esophagus, eye, nose, eyeball, fallopian
tube, extrahepatic bile ducts, other mouth, intrahepatic bile
ducts, kidney, appendix-colon, larynx, lip, liver, lung and
bronchus, lymph nodes, cerebral, spinal, nasal cartilage excl.
retina, oropharynx, endocrine glands, female genital, ovary,
pancreas, penis, scrotum, pituitary gland, pleura, prostate gland,
rectum, renal, pelvis, ureter, peritoneum, salivary gland, skin,
small intestine, stomach, testis, thymus, thyroid gland, tongue,
urinary bladder, uterus, vagina, labia, and vulva.
22. The method of claim 1, wherein said predetermined reference
level is a normal reference level.
23. The method of claim 22, wherein said identifying comprises
identifying markers with differential expression levels based on
said comparison.
Description
RELATED APPLICATIONS
[0001] This application is a continuation of U.S. Utility
application Ser. No. 12/579,241, filed on Oct. 14, 2009, which
claims the benefit of U.S. Provisional Application Nos. 61/105,335,
filed Oct. 14, 2008, and 61/106,921, filed Oct. 20, 2008, each of
which are incorporated herein in its entirety. This application is
also a continuation-in-part of U.S. Utility application Ser. No.
11/750,721, filed on May 18, 2007, which claims the benefit of U.S.
Provisional Application No. 60/747,645, filed May 18, 2006, each of
which are incorporated herein in its entirety.
FIELD OF INVENTION
[0002] The present invention generally relates to the application
of molecular profiling to identify biomarker patterns or biomarker
signature sets for specific tumor types or cancers. The present
invention also provides a system and method for determining medical
intervention for a particular tumor type, cancer, or disease state
based on the biomarker patterns or biomarker signature sets. The
identification of biomarker patterns or biomarker signature sets
can be conducted at any stage of the disease. In particular, the
present invention relates to the identification of biomarker
patterns and biomarker signature sets for advanced stage cancers or
diseases by tumor type or tissue type. The present invention also
relates to the identification of biomarkers to be used for
detecting particular cancers or disease states and efficient
detection methods for detecting particular cancers or disease
states.
BACKGROUND
[0003] Disease states in patients are typically treated with
treatment regimens or therapies that are selected based on clinical
based criteria; that is, a treatment therapy or regimen is selected
for a patient based on the determination that the patient has been
diagnosed with a particular disease (which diagnosis has been made
from classical diagnostic assays). Although the molecular
mechanisms behind various disease states have been the subject of
studies for years, the specific application of a diseased
individual's molecular profile in determining treatment regimens
and therapies for that individual has been disease specific and not
widely pursued.
[0004] Some treatment regimens have been determined using molecular
profiling in combination with clinical characterization of a
patient such as observations made by a physician (such as a code
from the International Classification of Diseases, for example, and
the dates such codes were determined), laboratory test results,
x-rays, biopsy results, statements made by the patient, and any
other medical information typically relied upon by a physician to
make a diagnosis in a specific disease. However, using a
combination of selection material based on molecular profiling and
clinical characterizations (such as the diagnosis of a particular
type of cancer) to determine a treatment regimen or therapy
presents a risk that an effective treatment regimen may be
overlooked for a particular individual since some treatment
regimens may work well for different disease states even though
they are associated with treating a particular type of disease
state. Patients with metastatic cancer are of particular concern
for treating physicians.
[0005] The majority of patients with metastatic cancer eventually
run out of treatment options for their tumors. These patients have
very limited options after their tumor has progressed on standard
front line and second line (and sometimes third line and beyond)
therapies. Although these patients may participate in Phase I and
Phase II clinical trials for new anticancer agents, they must
usually meet very strict eligibility criteria to do so. Studies
have shown that when patients participate in these types of trials,
the new anticancer agent may give response rates of anywhere from
5% to 10% on average in Phase I settings to 12% in Phase II
settings. These patients also have the option of electing to
receive the best supportive care to treat their symptoms.
[0006] There has recently been an explosion of interest in
developing new anticancer agents that are more targeted against a
cell surface receptor or an up regulated or amplified gene product.
This approach has met with some success (e.g. Herceptin against
HER2/neu in breast cancer cells, rituximab against CD20 in lymphoma
cells, bevacizamab against VEGF, Cetuximab against EGFR, etc.).
However, patients' tumors still eventually progress on these
therapies. If a larger number of targets or molecular findings such
as molecular mechanisms, genes, gene expressed proteins, and/or
combinations of such were measured in a patient's tumor, one may
find additional targets or molecular findings that can be exploited
by using specific therapeutic agents. Identifying multiple agents
that can treat multiple targets or underlying mechanisms would
provide a metastatic cancer patient with a viable therapeutic
alternative to those treatment regimens which currently exist.
[0007] Accordingly, there is a need for the identification of
biomarker patterns or biomarker signature sets for specific tumor
types or cancers and there is a particular need for drug resistant
expression profiles for specific tumor types or cancers. There is
also a need for a system and method for determining medical
intervention for a particular tumor type, cancer, or disease state
based on the biomarker patterns or biomarker signature sets.
SUMMARY
[0008] One aspect of the present invention involves a system and
method for determining individualized medical intervention for a
particular disease state. One exemplary method for determining
medical intervention for a disease state includes the steps of
performing a test for a gene and/or a test for a gene expressed
protein from a biological sample of a diseased individual,
determining which genes and/or gene expressed proteins exhibited
change in expression compared to a reference, and identifying a
drug therapy used to interact with the gene and/or gene expressed
proteins that exhibited a change of expression that is not single
disease restricted. In one aspect of this exemplary embodiment of
the invention, the step of identifying a drug therapy used to
interact with a gene and/or gene expressed protein that exhibited a
change in expression may include the step of identifying a drug
therapy from an automated review of an extensive literature
database and/or data generated from clinical trials.
[0009] The present invention is also directed to identifying
biomarker patterns or biomarker signature sets for specific tumor
types, cancers, or disease states by performing a test for at least
one gene and/or a test for at least one gene expressed protein and
determining which genes and/or gene expressed proteins exhibited a
change in expression for a particular tumor type or tissue type
compared to a normal reference for that particular tissue type. The
step of performing a test for at least one gene and/or a test for
at least one gene expressed protein may include the step of
performing an immunohistochemical (IHC) analysis and/or a micro
array analysis.
[0010] Further, the step of performing a micro array analysis may
include the step of performing an analysis using an expression
micro array, a comparative genomic hybridization (CGH) micro array,
a single nucleotide polymorphism (SNP) micro array, a fluorescent
in-situ hybridization (ISH), an in-situ hybridization (ISH), and a
proteomic array. In addition, the step of performing an IHC
analysis may include the step of performing an IHC analysis for a
gene expressed protein which includes at least one of Her2/Neu, ER,
PR, c-kit, EGFR, MLH1, MSH2, CD20, p53, Cyclin D1, bcl2, COX-2,
Androgen receptor, CD52, PDGFR, AR, CD25, VEGF, HSP90, PTEN, RRM1,
SPARC, Survivin, TOP2A, and Topoisomerase II alpha.
[0011] In another aspect of the invention, the step of performing a
micro array analysis in the above-described exemplary method for
determining medical intervention for a disease state may include
the step of performing a micro array analysis for a gene which
includes at least one of BCL2, HIF1A, AR, ESR1, PDGFRA, KIT,
PDGFRB, CDW52, ZAP70, PGR, SPARC, GART, GSTP1, NFKBIA, MSH2,
TXNRD1, HDAC1, PDGFC, PTEN, CD33, TYMS, RXRB, ADA, TNF, ERCC3,
RAF1, VEGF, TOP1, TOP2A, BRCA2, TK1, FOLR2, TOP2B, MLH1, IL2RA,
DNMT1, HSPCA, ERBR2, ERBB2, SSTR1, VHL, VDR, PTGS2, POLA, CES2,
EGFR, OGFR, ASNS, NFKB2, RARA, MS4A1, DCK, DNMT3A, EREG,
Epiregulin, FOLR1, GNRH1, GNRHR1, FSHB, FSHR, FSHPRH1, folate
receptor, HGF, HIG1, IL13RA1, LTB, ODC1, PPARG, PPARGC1,
Lymphotoxin Beta Receptor, Myc, Topoisomerase II, TOPO2B, TXN,
VEGFC, ACE2, ADH1C, ADH4, AGT, AREG, CA2, CDK2, caveolin, NFKB1,
ASNS, BDCA1, CD52, DHFR, DNMT3B, EPHA2, FLT1, HSP90AA1, KDR, LCK,
MGMT, RRM1, RRM2, RRM2B, RXRG, SRC, SSTR2, SSTR3, SSTR4, SSTR5,
VEGFA, and YES1.
[0012] In yet another aspect of the above-described exemplary
method of the present invention, the step of performing a test for
at least one gene and/or a test for at least one gene expressed
protein from a biological sample of a diseased individual may
include the step of performing an immunohistochemical analysis on a
tumor and the step of determining which genes and/or gene expressed
proteins exhibit a change in expression compared to a reference may
include the step of determining whether 30% or more of the tumor
cells were +2 or greater staining for a particular gene expressed
protein. In still another aspect of the above-described exemplary
method of the present invention, the step of performing a test for
at least one gene and/or a test for at least one gene expressed
protein from a biological sample of a diseased individual may
include the step of performing a micro array analysis on a tumor
and the step of determining which genes and/or gene expressed
proteins exhibit a change in expression compared to a reference may
include the step of identifying which genes are up-regulated or
down-regulated by determining whether the full change of expression
for a particular gene relative to a normal tissue of origin
reference is significant at p<0.001.
[0013] The method of the present invention for determining
individualized medical intervention for a disease state referred to
above may also include the step of providing a patient profile
report which identifies the change in expression for the genes
and/or gene expressed proteins along with a possible drug therapy
for interaction with each of the genes and/or gene expressed
proteins that exhibit a change in expression.
[0014] Another exemplary embodiment of the present invention is
directed to a method for identifying a drug therapy or protocol
capable of interacting with one or more molecular targets which
make up a biomarker pattern or biomarker signature set which
includes the steps of identifying one or more molecular targets
that exhibit a change in expression when compared to a normal
reference which make up a biomarker pattern or biomarker signature
set in a plurality of individuals having the same tumor type,
cancer, or disease state, administrating a drug therapy or protocol
to the diseased individuals that exhibit the biomarker pattern or
biomarker signature set, and determining any changes in the
biomarker pattern or biomarker signature set of the diseased
individuals after the drug therapy. Further, in one aspect of this
exemplary embodiment of a method for identifying a drug therapy or
protocol capable of interacting with one or more molecular targets,
the step of identifying one or more molecular targets that exhibit
a change in expression when compared to a normal reference which
make up a biomarker pattern or biomarker signature set in a
plurality of individuals having the same tumor type, cancer, or
disease state includes the step of performing a test for at least
one gene and/or a test for at least one gene expressed protein from
a biological sample of the diseased individuals where the test
comprises an immunohistochemical (IHC) analysis and/or a micro
array analysis.
[0015] In yet another exemplary embodiment of the present
invention, a system is provided for determining individualized
medical intervention for a disease state where the system includes
a host server, a user interface for accessing the host server to
access and input data, a processor for processing the inputted
data, a memory coupled to the processor for storing the processed
data and instructions for: a) accessing a molecular profile taken
from a biological specimen of a patient b) determining whether at
least one of a gene, a gene expressed protein, a molecular
mechanism, and other molecular findings resulting from the
molecular profile exhibit change in expression compared to a normal
reference, and c) accessing a drug therapy database to identify one
or more drug therapies that interact with a gene, a gene expressed
protein, a molecular mechanism, and/or other molecular findings
that exhibited a change in expression, and a display means for
displaying a gene, a gene expressed protein, a molecular mechanism,
and other molecular findings exhibiting a change in expression and
the drug therapies that interact with them. With respect to the
exemplary embodiment of the present invention directed to the
system for determining individualized medical intervention for a
disease state, the molecular profile taken from the biological
specimen may include the same immunohistochemical (IHC) analysis
and micro array analysis described above with reference to other
exemplary embodiments of the present invention. In addition, the
different types of these analyses along with the genes analyzed
using these analyses may be the same as those described above with
reference to other exemplary embodiments of the present
invention.
[0016] Still another exemplary embodiment of the present invention
is directed to a method for determining medical intervention for a
disease state which includes the steps of performing at least one
molecular test for at least one target from a biological sample of
a diseased individual, determining whether the target exhibits a
change in expression compared to a reference, and identifying at
least one non-disease specific agent that interacts with the target
that exhibits a change in expression. The step of identifying at
least one non-diseased specific agent that interacts with the
target may include the step of identifying a drug therapy from an
automated review of an extensive literature base and/or an
automated review of data generated from clinical trials. In
addition, the exemplary embodiment of the present invention
directed to a method for determining medical intervention for a
disease state may also include the step of providing a patient
profile report which includes the patient's test results for
various targets and any proposed therapies based on those
results.
[0017] The step of performing at least one molecular test for at
least one target from a biological sample of a diseased individual
in the exemplary embodiment of the present invention directed to a
method for determining medical intervention for a disease state may
include all of the above-described analyses relating to
immunohistochemical (IHC) analysis and micro array analysis and the
genes analyzed using those analyses.
BRIEF DESCRIPTION OF THE DRAWINGS
[0018] FIG. 1 illustrates a block diagram of an exemplary
embodiment of a system for determining individualized medical
intervention for a particular disease state that utilizes molecular
profiling of a patient's biological specimen that is non disease
specific.
[0019] FIG. 2 is a flowchart of an exemplary embodiment of a method
for determining individualized medical intervention for a
particular disease state that utilizes molecular profiling of a
patient's biological specimen that is non disease specific.
[0020] FIGS. 3A through 3D illustrate an exemplary patient profile
report in accordance with step 80 of FIG. 2.
[0021] FIG. 4 is a flowchart of an exemplary embodiment of a method
for identifying a drug therapy/agent capable of interacting with a
target.
[0022] FIGS. 5-14 are flowcharts and diagrams illustrating various
parts of an information-based personalized medicine drug discovery
system and method in accordance with the present invention.
[0023] FIGS. 15-25 are computer screen print outs associated with
various parts of the information-based personalized medicine drug
discovery system and method shown in FIGS. 5-14.
[0024] FIGS. 26A through 26H represent a table that shows the
frequency of a significant change in expression of gene expressed
proteins by tumor type.
[0025] FIGS. 27A through 27H represent a table that shows the
frequency of a significant change in expression of certain genes by
tumor type.
[0026] FIGS. 28A through 28O represent a table that shows the
frequency of a significant change in expression for certain gene
expressed proteins by tumor type.
[0027] FIG. 29 is a table which shows biomarkers (gene expressed
proteins) tagged as targets in order of frequency based on FIG.
28.
[0028] FIGS. 30A through 30O represent a table that shows the
frequency of a significant change in expression for certain genes
by tumor type.
[0029] FIG. 31 is a table which shows genes tagged as targets in
order of frequency based on FIG. 30.
DETAILED DESCRIPTION
[0030] The detailed description of exemplary embodiments herein
makes reference to the accompanying drawings and pictures, which
show the exemplary embodiment by way of illustration and its best
mode. While these exemplary embodiments are described in sufficient
detail to enable those skilled in the art to practice the
invention, it should be understood that other embodiments may be
realized and that logical and mechanical changes may be made
without departing from the spirit and scope of the invention. Thus,
the detailed description herein is presented for purposes of
illustration only and not of limitation. For example, the steps
recited in any of the method or process descriptions may be
executed in any order and are not limited to the order presented.
Moreover, any of the functions or steps may be outsourced to or
performed by one or more third parties. Furthermore, any reference
to singular includes plural embodiments, and any reference to more
than one component may include a singular embodiment.
[0031] For the sake of brevity, conventional data networking,
application development and other functional aspects of the systems
(and components of the individual operating components of the
systems) may not be described in detail herein. Furthermore, the
connecting lines shown in the various figures contained herein are
intended to represent exemplary functional relationships and/or
physical couplings between the various elements. It should be noted
that many alternative or additional functional relationships or
physical connections may be present in a practical system.
[0032] The various system components discussed herein may include
one or more of the following: a host server or other computing
systems including a processor for processing digital data; a memory
coupled to the processor for storing digital data; an input
digitizer coupled to the processor for inputting digital data; an
application program stored in the memory and accessible by the
processor for directing processing of digital data by the
processor; a display device coupled to the processor and memory for
displaying information derived from digital data processed by the
processor; and a plurality of databases. Various databases used
herein may include: patient data such as family history, demography
and environmental data, biological sample data, prior treatment and
protocol data, patient clinical data, molecular profiling data of
biological samples, data on therapeutic drug agents and/or
investigative drugs, a gene library, a disease library, a drug
library, patient tracking data, file management data, financial
management data, billing data and/or like data useful in the
operation of the system. As those skilled in the art will
appreciate, user computer may include an operating system (e.g.,
Windows NT, 95/98/2000, OS2, UNIX, Linux, Solaris, MacOS, etc.) as
well as various conventional support software and drivers typically
associated with computers. The computer may include any suitable
personal computer, network computer, workstation, minicomputer,
mainframe or the like. User computer can be in a home or
medical/business environment with access to a network. In an
exemplary embodiment, access is through a network or the Internet
through a commercially-available web-browser software package.
[0033] As used herein, the term "network" shall include any
electronic communications means which incorporates both hardware
and software components of such. Communication among the parties
may be accomplished through any suitable communication channels,
such as, for example, a telephone network, an extranet, an
intranet, Internet, point of interaction device, personal digital
assistant (e.g., Palm Pilot.RTM., Blackberry.RTM.), cellular phone,
kiosk, etc.), online communications, satellite communications,
off-line communications, wireless communications, transponder
communications, local area network (LAN), wide area network (WAN),
networked or linked devices, keyboard, mouse and/or any suitable
communication or data input modality. Moreover, although the system
is frequently described herein as being implemented with TCP/IP
communications protocols, the system may also be implemented using
IPX, Appletalk, IP-6, NetBIOS, OSI or any number of existing or
future protocols. If the network is in the nature of a public
network, such as the Internet, it may be advantageous to presume
the network to be insecure and open to eavesdroppers. Specific
information related to the protocols, standards, and application
software utilized in connection with the Internet is generally
known to those skilled in the art and, as such, need not be
detailed herein. See, for example, DILIP NAIK, INTERNET STANDARDS
AND PROTOCOLS (1998); JAVA 2 COMPLETE, various authors, (Sybex
1999); DEBORAH RAY AND ERIC RAY, MASTERING HTML 4.0 (1997); and
LOSHIN, TCP/IP CLEARLY EXPLAINED (1997) and DAVID GOURLEY AND BRIAN
TOTTY, HTTP, THE DEFINITIVE GUIDE (2002), the contents of which are
hereby incorporated by reference.
[0034] The various system components may be independently,
separately or collectively suitably coupled to the network via data
links which includes, for example, a connection to an Internet
Service Provider (ISP) over the local loop as is typically used in
connection with standard modem communication, cable modem, Dish
networks, ISDN, Digital Subscriber Line (DSL), or various wireless
communication methods, see, e.g., GILBERT HELD, UNDERSTANDING DATA
COMMUNICATIONS (1996), which is hereby incorporated by reference.
It is noted that the network may be implemented as other types of
networks, such as an interactive television (ITV) network.
Moreover, the system contemplates the use, sale or distribution of
any goods, services or information over any network having similar
functionality described herein.
[0035] As used herein, "transmit" may include sending electronic
data from one system component to another over a network
connection. Additionally, as used herein, "data" may include
encompassing information such as commands, queries, files, data for
storage, and the like in digital or any other form.
[0036] The system contemplates uses in association with web
services, utility computing, pervasive and individualized
computing, security and identity solutions, autonomic computing,
commodity computing, mobility and wireless solutions, open source,
biometrics, grid computing and/or mesh computing.
[0037] Any databases discussed herein may include relational,
hierarchical, graphical, or object-oriented structure and/or any
other database configurations. Common database products that may be
used to implement the databases include DB2 by IBM (White Plains,
N.Y.), various database products available from Oracle Corporation
(Redwood Shores, Calif.), Microsoft Access or Microsoft SQL Server
by Microsoft Corporation (Redmond, Wash.), or any other suitable
database product. Moreover, the databases may be organized in any
suitable manner, for example, as data tables or lookup tables. Each
record may be a single file, a series of files, a linked series of
data fields or any other data structure. Association of certain
data may be accomplished through any desired data association
technique such as those known or practiced in the art. For example,
the association may be accomplished either manually or
automatically. Automatic association techniques may include, for
example, a database search, a database merge, GREP, AGREP, SQL,
using a key field in the tables to speed searches, sequential
searches through all the tables and files, sorting records in the
file according to a known order to simplify lookup, and/or the
like. The association step may be accomplished by a database merge
function, for example, using a "key field" in pre-selected
databases or data sectors.
[0038] More particularly, a "key field" partitions the database
according to the high-level class of objects defined by the key
field. For example, certain types of data may be designated as a
key field in a plurality of related data tables and the data tables
may then be linked on the basis of the type of data in the key
field. The data corresponding to the key field in each of the
linked data tables is preferably the same or of the same type.
However, data tables having similar, though not identical, data in
the key fields may also be linked by using AGREP, for example. In
accordance with one embodiment, any suitable data storage technique
may be utilized to store data without a standard format. Data sets
may be stored using any suitable technique, including, for example,
storing individual files using an ISO/IEC 7816-4 file structure;
implementing a domain whereby a dedicated file is selected that
exposes one or more elementary files containing one or more data
sets; using data sets stored in individual files using a
hierarchical filing system; data sets stored as records in a single
file (including compression, SQL accessible, hashed via one or more
keys, numeric, alphabetical by first tuple, etc.); Binary Large
Object (BLOB); stored as ungrouped data elements encoded using
ISO/IEC 7816-6 data elements; stored as ungrouped data elements
encoded using ISO/IEC Abstract Syntax Notation (ASN.1) as in
ISO/IEC 8824 and 8825; and/or other proprietary techniques that may
include fractal compression methods, image compression methods,
etc.
[0039] In one exemplary embodiment, the ability to store a wide
variety of information in different formats is facilitated by
storing the information as a BLOB. Thus, any binary information can
be stored in a storage space associated with a data set. The BLOB
method may store data sets as ungrouped data elements formatted as
a block of binary via a fixed memory offset using either fixed
storage allocation, circular queue techniques, or best practices
with respect to memory management (e.g., paged memory, least
recently used, etc.). By using BLOB methods, the ability to store
various data sets that have different formats facilitates the
storage of data by multiple and unrelated owners of the data sets.
For example, a first data set which may be stored may be provided
by a first party, a second data set which may be stored may be
provided by an unrelated second party, and yet a third data set
which may be stored, may be provided by a third party unrelated to
the first and second party. Each of these three exemplary data sets
may contain different information that is stored using different
data storage formats and/or techniques. Further, each data set may
contain subsets of data that also may be distinct from other
subsets.
[0040] As stated above, in various embodiments, the data can be
stored without regard to a common format. However, in one exemplary
embodiment, the data set (e.g., BLOB) may be annotated in a
standard manner when provided for manipulating the data. The
annotation may comprise a short header, trailer, or other
appropriate indicator related to each data set that is configured
to convey information useful in managing the various data sets. For
example, the annotation may be called a "condition header",
"header", "trailer", or "status", herein, and may comprise an
indication of the status of the data set or may include an
identifier correlated to a specific issuer or owner of the data.
Subsequent bytes of data may be used to indicate for example, the
identity of the issuer or owner of the data, user,
transaction/membership account identifier or the like. Each of
these condition annotations are further discussed herein.
[0041] The data set annotation may also be used for other types of
status information as well as various other purposes. For example,
the data set annotation may include security information
establishing access levels. The access levels may, for example, be
configured to permit only certain individuals, levels of employees,
companies, or other entities to access data sets, or to permit
access to specific data sets based on the transaction, issuer or
owner of data, user or the like. Furthermore, the security
information may restrict/permit only certain actions such as
accessing, modifying, and/or deleting data sets. In one example,
the data set annotation indicates that only the data set owner or
the user are permitted to delete a data set, various identified
users may be permitted to access the data set for reading, and
others are altogether excluded from accessing the data set.
However, other access restriction parameters may also be used
allowing various entities to access a data set with various
permission levels as appropriate. The data, including the header or
trailer may be received by a stand alone interaction device
configured to add, delete, modify, or augment the data in
accordance with the header or trailer.
[0042] One skilled in the art will also appreciate that, for
security reasons, any databases, systems, devices, servers or other
components of the system may consist of any combination thereof at
a single location or at multiple locations, wherein each database
or system includes any of various suitable security features, such
as firewalls, access codes, encryption, decryption, compression,
decompression, and/or the like.
[0043] The computing unit of the web client may be further equipped
with an Internet browser connected to the Internet or an intranet
using standard dial-up, cable, DSL or any other Internet protocol
known in the art. Transactions originating at a web client may pass
through a firewall in order to prevent unauthorized access from
users of other networks. Further, additional firewalls may be
deployed between the varying components of CMS to further enhance
security.
[0044] Firewall may include any hardware and/or software suitably
configured to protect CMS components and/or enterprise computing
resources from users of other networks. Further, a firewall may be
configured to limit or restrict access to various systems and
components behind the firewall for web clients connecting through a
web server. Firewall may reside in varying configurations including
Stateful Inspection, Proxy based and Packet Filtering among others.
Firewall may be integrated within an web server or any other CMS
components or may further reside as a separate entity.
[0045] The computers discussed herein may provide a suitable
website or other Internet-based graphical user interface which is
accessible by users. In one embodiment, the Microsoft Internet
Information Server (IIS), Microsoft Transaction Server (MTS), and
Microsoft SQL Server, are used in conjunction with the Microsoft
operating system, Microsoft NT web server software, a Microsoft SQL
Server database system, and a Microsoft Commerce Server.
Additionally, components such as Access or Microsoft SQL Server,
Oracle, Sybase, Informix MySQL, Interbase, etc., may be used to
provide an Active Data Object (ADO) compliant database management
system.
[0046] Any of the communications, inputs, storage, databases or
displays discussed herein may be facilitated through a website
having web pages. The term "web page" as it is used herein is not
meant to limit the type of documents and applications that might be
used to interact with the user. For example, a typical website
might include, in addition to standard HTML documents, various
forms, Java applets, JavaScript, active server pages (ASP), common
gateway interface scripts (CGI), extensible markup language (XML),
dynamic HTML, cascading style sheets (CSS), helper applications,
plug-ins, and the like. A server may include a web service that
receives a request from a web server, the request including a URL
(http://yahoo.com/stockquotes/ge) and an IP address
(123.56.789.234). The web server retrieves the appropriate web
pages and sends the data or applications for the web pages to the
IP address. Web services are applications that are capable of
interacting with other applications over a communications means,
such as the internet. Web services are typically based on standards
or protocols such as XML, XSLT, SOAP, WSDL and UDDI. Web services
methods are well known in the art, and are covered in many standard
texts. See, e.g., ALEX NGHIEM, IT WEB SERVICES: A ROADMAP FOR THE
ENTERPRISE (2003), hereby incorporated by reference.
[0047] The web-based clinical database for the system and method of
the present invention preferably has the ability to upload and
store clinical data files in native formats and is searchable on
any clinical parameter. The database is also scalable and may
utilize an EAV data model (metadata) to enter clinical annotations
from any study for easy integration with other studies. In
addition, the web-based clinical database is flexible and may be
XML and XSLT enabled to be able to add user customized questions
dynamically. Further, the database includes exportability to CDISC
ODM.
[0048] Practitioners will also appreciate that there are a number
of methods for displaying data within a browser-based document.
Data may be represented as standard text or within a fixed list,
scrollable list, drop-down list, editable text field, fixed text
field, pop-up window, and the like. Likewise, there are a number of
methods available for modifying data in a web page such as, for
example, free text entry using a keyboard, selection of menu items,
check boxes, option boxes, and the like.
[0049] The system and method may be described herein in terms of
functional block components, screen shots, optional selections and
various processing steps. It should be appreciated that such
functional blocks may be realized by any number of hardware and/or
software components configured to perform the specified functions.
For example, the system may employ various integrated circuit
components, e.g., memory elements, processing elements, logic
elements, look-up tables, and the like, which may carry out a
variety of functions under the control of one or more
microprocessors or other control devices. Similarly, the software
elements of the system may be implemented with any programming or
scripting language such as C, C++, Macromedia Cold Fusion,
Microsoft Active Server Pages, Java, COBOL, assembler, PERL, Visual
Basic, SQL Stored Procedures, extensible markup language (XML),
with the various algorithms being implemented with any combination
of data structures, objects, processes, routines or other
programming elements. Further, it should be noted that the system
may employ any number of conventional techniques for data
transmission, signaling, data processing, network control, and the
like. Still further, the system could be used to detect or prevent
security issues with a client-side scripting language, such as
JavaScript, VBScript or the like. For a basic introduction of
cryptography and network security, see any of the following
references: (1) "Applied Cryptography: Protocols, Algorithms, And
Source Code In C," by Bruce Schneier, published by John Wiley &
Sons (second edition, 1995); (2) "Java Cryptography" by Jonathan
Knudson, published by O'Reilly & Associates (1998); (3)
"Cryptography & Network Security: Principles & Practice" by
William Stallings, published by Prentice Hall; all of which are
hereby incorporated by reference.
[0050] As used herein, the term "end user", "consumer", "customer",
"client", "treating physician", "hospital", or "business" may be
used interchangeably with each other, and each shall mean any
person, entity, machine, hardware, software or business. Each
participant is equipped with a computing device in order to
interact with the system and facilitate online data access and data
input. The customer has a computing unit in the form of a personal
computer, although other types of computing units may be used
including laptops, notebooks, hand held computers, set-top boxes,
cellular telephones, touch-tone telephones and the like. The
owner/operator of the system and method of the present invention
has a computing unit implemented in the form of a computer-server,
although other implementations are contemplated by the system
including a computing center shown as a main frame computer, a
mini-computer, a PC server, a network of computers located in the
same of different geographic locations, or the like. Moreover, the
system contemplates the use, sale or distribution of any goods,
services or information over any network having similar
functionality described herein.
[0051] In one exemplary embodiment, each client customer may be
issued an "account" or "account number". As used herein, the
account or account number may include any device, code, number,
letter, symbol, digital certificate, smart chip, digital signal,
analog signal, biometric or other identifier/indicia suitably
configured to allow the consumer to access, interact with or
communicate with the system (e.g., one or more of an
authorization/access code, personal identification number (PIN),
Internet code, other identification code, and/or the like). The
account number may optionally be located on or associated with a
charge card, credit card, debit card, prepaid card, embossed card,
smart card, magnetic stripe card, bar code card, transponder, radio
frequency card or an associated account. The system may include or
interface with any of the foregoing cards or devices, or a fob
having a transponder and RFID reader in RF communication with the
fob. Although the system may include a fob embodiment, the
invention is not to be so limited. Indeed, system may include any
device having a transponder which is configured to communicate with
RFID reader via RF communication. Typical devices may include, for
example, a key ring, tag, card, cell phone, wristwatch or any such
form capable of being presented for interrogation. Moreover, the
system, computing unit or device discussed herein may include a
"pervasive computing device," which may include a traditionally
non-computerized device that is embedded with a computing unit. The
account number may be distributed and stored in any form of
plastic, electronic, magnetic, radio frequency, wireless, audio
and/or optical device capable of transmitting or downloading data
from itself to a second device.
[0052] As will be appreciated by one of ordinary skill in the art,
the system may be embodied as a customization of an existing
system, an add-on product, upgraded software, a stand alone system,
a distributed system, a method, a data processing system, a device
for data processing, and/or a computer program product.
Accordingly, the system may take the form of an entirely software
embodiment, an entirely hardware embodiment, or an embodiment
combining aspects of both software and hardware. Furthermore, the
system may take the form of a computer program product on a
computer-readable storage medium having computer-readable program
code means embodied in the storage medium. Any suitable
computer-readable storage medium may be utilized, including hard
disks, CD-ROM, optical storage devices, magnetic storage devices,
and/or the like.
[0053] The system and method is described herein with reference to
screen shots, block diagrams and flowchart illustrations of
methods, apparatus (e.g., systems), and computer program products
according to various embodiments. It will be understood that each
functional block of the block diagrams and the flowchart
illustrations, and combinations of functional blocks in the block
diagrams and flowchart illustrations, respectively, can be
implemented by computer program instructions.
[0054] Referring now to FIGS. 2-25 the process flows and
screenshots depicted are merely embodiments and are not intended to
limit the scope of the invention as described herein. For example,
the steps recited in any of the method or process descriptions may
be executed in any order and are not limited to the order
presented. It will be appreciated that the following description
makes appropriate references not only to the steps and user
interface elements depicted in FIGS. 2-25, but also to the various
system components as described above with reference to FIG. 1.
[0055] These computer program instructions may be loaded onto a
general purpose computer, special purpose computer, or other
programmable data processing apparatus to produce a machine, such
that the instructions that execute on the computer or other
programmable data processing apparatus create means for
implementing the functions specified in the flowchart block or
blocks. These computer program instructions may also be stored in a
computer-readable memory that can direct a computer or other
programmable data processing apparatus to function in a particular
manner, such that the instructions stored in the computer-readable
memory produce an article of manufacture including instruction
means which implement the function specified in the flowchart block
or blocks. The computer program instructions may also be loaded
onto a computer or other programmable data processing apparatus to
cause a series of operational steps to be performed on the computer
or other programmable apparatus to produce a computer-implemented
process such that the instructions which execute on the computer or
other programmable apparatus provide steps for implementing the
functions specified in the flowchart block or blocks.
[0056] Accordingly, functional blocks of the block diagrams and
flowchart illustrations support combinations of means for
performing the specified functions, combinations of steps for
performing the specified functions, and program instruction means
for performing the specified functions. It will also be understood
that each functional block of the block diagrams and flowchart
illustrations, and combinations of functional blocks in the block
diagrams and flowchart illustrations, can be implemented by either
special purpose hardware-based computer systems which perform the
specified functions or steps, or suitable combinations of special
purpose hardware and computer instructions. Further, illustrations
of the process flows and the descriptions thereof may make
reference to user windows, webpages, websites, web forms, prompts,
etc. Practitioners will appreciate that the illustrated steps
described herein may comprise in any number of configurations
including the use of windows, webpages, web forms, popup windows,
prompts and the like. It should be further appreciated that the
multiple steps as illustrated and described may be combined into
single webpages and/or windows but have been expanded for the sake
of simplicity. In other cases, steps illustrated and described as
single process steps may be separated into multiple webpages and/or
windows but have been combined for simplicity.
[0057] Benefits, other advantages, and solutions to problems have
been described herein with regard to specific embodiments. However,
the benefits, advantages, solutions to problems, and any element(s)
that may cause any benefit, advantage, or solution to occur or
become more pronounced are not to be construed as critical,
required, or essential features or elements of any or all the
claims or the invention. The scope of the invention is accordingly
to be limited by nothing other than the appended claims, in which
reference to an element in the singular is not intended to mean
"one and only one" unless explicitly so stated, but rather "one or
more." All structural, chemical, and functional equivalents to the
elements of the above-described exemplary embodiments that are
known to those of ordinary skill in the art are expressly
incorporated herein by reference and are intended to be encompassed
by the present claims. Moreover, it is not necessary for a device
or method to address each and every problem sought to be solved by
the present invention, for it to be encompassed by the present
claims. Furthermore, no element, component, or method step in the
present disclosure is intended to be dedicated to the public
regardless of whether the element, component, or method step is
explicitly recited in the claims. No claim element herein is to be
construed under the provisions of 35 U.S.C. 112, sixth paragraph,
unless the element is expressly recited using the phrase "means
for." As used herein, the terms "comprises", "comprising", or any
other variation thereof, are intended to cover a non-exclusive
inclusion, such that a process, method, article, or apparatus that
comprises a list of elements does not include only those elements
but may include other elements not expressly listed or inherent to
such process, method, article, or apparatus. Further, no element
described herein is required for the practice of the invention
unless expressly described as "essential" or "critical".
[0058] FIG. 1 is a block diagram of an exemplary embodiment of a
system 10 for determining individualized medical intervention for a
particular disease state that utilizes molecular profiling of a
patient's biological specimen. System 10 includes a user interface
12, a host server 14 including a processor 16 for processing data,
a memory 18 coupled to the processor, an application program 20
stored in the memory 18 and accessible by the processor 16 for
directing processing of the data by the processor 16, a plurality
of internal databases 22 and external databases 24, and an
interface with a wired or wireless communications network 26 (such
as the Internet, for example). System 10 may also include an input
digitizer 28 coupled to the processor 16 for inputting digital data
from data that is received from user interface 12.
[0059] User interface 12 includes an input device 30 and a display
32 for inputting data into system 10 and for displaying information
derived from the data processed by processor 16. User interface 12
may also include a printer 34 for printing the information derived
from the data processed by the processor 16 such as patient reports
that may include test results for targets and proposed drug
therapies based on the test results.
[0060] Internal databases 22 may include, but are not limited to,
patient biological sample/specimen information and tracking,
clinical data, patient data, patient tracking, file management,
study protocols, patient test results from molecular profiling, and
billing information and tracking. External databases 24 nay
include, but are not limited to, drug libraries, gene libraries,
disease libraries, and public and private databases such as
UniGene, OMIM, GO, TIGR, GenBank, KEGG and Biocarta.
[0061] Various methods may be used in accordance with system 10.
FIG. 2 shows a flowchart of an exemplary embodiment of a method 50
for determining individualized medical intervention for a
particular disease state that utilizes molecular profiling of a
patient's biological specimen that is non disease specific. In
order to determine a medical intervention for a particular disease
state using molecular profiling that is independent of disease
lineage diagnosis (i.e. not single disease restricted), at least
one test is performed for at least one target from a biological
sample of a diseased patient in step 52. A target is defined as any
molecular finding that may be obtained from molecular testing. For
example, a target may include one or more genes, one or more gene
expressed proteins, one or more molecular mechanisms, and/or
combinations of such. For example, the expression level of a target
can be determined by the analysis of mRNA levels or the target or
gene, or protein levels of the gene. Tests for finding such targets
may include, but are not limited, fluorescent in-situ hybridization
(FISH), an in-situ hybridization (ISH), and other molecular tests
known to those skilled in the art. PCR-based methods, such as
real-time PCR or quantitative PCR can be used. Furthermore,
microarray analysis, such as a comparative genomic hybridization
(CGH) micro array, a single nucleotide polymorphism (SNP)
microarray, a proteomic array, or antibody array analysis can also
be used in the methods disclosed herein. In some embodiments,
microarray analysis comprises identifying whether a gene is
up-regulated or down-regulated relative to a reference with a
significance of p<0.001. Tests or analyses of targets can also
comprise immunohistochemical (IHC) analysis. In some embodiments,
IHC analysis comprises determining whether 30% or more of a sample
is stained, if the staining intensity is +2 or greater, or
both.
[0062] Furthermore, the methods disclosed herein also including
profiling more than one target. For example, the expression of a
plurality of genes can be identified. Furthermore, identification
of a plurality of targets in a sample can be by one method or by
various means. For example, the expression of a first gene can be
determined by one method and the expression level of a second gene
determined by a different method. Alternatively, the same method
can be used to detect the expression level of the first and second
gene. For example, the first method can be IHC and the second by
microarray analysis, such as detecting the gene expression of a
gene.
[0063] In some embodiments, molecular profiling can also including
identifying a genetic variant, such as a mutation, polymorphism
(such as a SNP), deletion, or insertion of a target. For example,
identifying a SNP in a gene can be determined by microarray
analysis, real-time PCR, or sequencing. Other methods disclosed
herein can also be used to identify variants of one or more
targets.
[0064] Accordingly, one or more of the following may be performed:
an IHC analysis in step 54, a microanalysis in step 56, and other
molecular tests know to those skilled in the art in step 58.
[0065] Biological samples are obtained from diseased patients by
taking a biopsy of a tumor, conducting minimally invasive surgery
if no recent tumor is available, obtaining a sample of the
patient's blood, or a sample of any other biological fluid
including, but not limited to, cell extracts, nuclear extracts,
cell lysates or biological products or substances of biological
origin such as excretions, blood, sera, plasma, urine, sputum,
tears, feces, saliva, membrane extracts, and the like.
[0066] In step 60, a determination is made as to whether one or
more of the targets that were tested for in step 52 exhibit a
change in expression compared to a normal reference for that
particular target. In one exemplary method of the invention, an IHC
analysis may be performed in step 54 and a determination as to
whether any targets from the IHC analysis exhibit a change in
expression is made in step 64 by determining whether 30% or more of
the biological sample cells were +2 or greater staining for the
particular target. It will be understood by those skilled in the
art that there will be instances where +1 or greater staining will
indicate a change in expression in that staining results may vary
depending on the technician performing the test and type of target
being tested. In another exemplary embodiment of the invention, a
micro array analysis may be performed in step 56 and a
determination as to whether any targets from the micro array
analysis exhibit a change in expression is made in step 66 by
identifying which targets are up-regulated or down-regulated by
determining whether the fold change in expression for a particular
target relative to a normal tissue of origin reference is
significant at p<0.001. A change in expression may also be
evidenced by an absence of one or more genes, gene expressed
proteins, molecular mechanisms, or other molecular findings.
[0067] After determining which targets exhibit a change in
expression in step 60, at least one non-disease specific agent is
identified that interacts with each target having a changed
expression in step 70. An agent may be any drug or compound having
a therapeutic effect. A non-disease specific agent is a therapeutic
drug or compound not previously associated with treating the
patient's diagnosed disease that is capable of interacting with the
target from the patient's biological sample that has exhibited a
change in expression. Some of the non-disease specific agents that
have been found to interact with specific targets found in
different cancer patients are shown in Table 1 below.
TABLE-US-00001 TABLE 1 Patients Target(s) Found Treatment(s)
Advanced Pancreatic HER 2/neu (IHC/Array) Herceptin .TM. Cancer
Advanced Pancreatic EGFR (IHC), HIF 1.alpha. Erbitux .TM., Cancer
Rapamycin .TM. Advanced Ovarian ERCC3 (Array) Irofulvene Cancer
Advanced Adenoid Vitamin D receptors, Calcitriol .TM., Cystic
Carcinoma Androgen receptors Flutamide .TM.
[0068] Finally, in step 80, a patient profile report may be
provided which includes the patient's test results for various
targets and any proposed therapies based on those results. An
exemplary patient profile report 100 is shown in FIGS. 3A-3D.
Patient profile report 100 shown in FIG. 3A identifies the targets
tested 102, those targets tested that exhibited significant changes
in expression 104, and proposed non-disease specific agents for
interacting with the targets 106. Patient profile report 100 shown
in FIG. 3B identifies the results 108 of immunohistochemical
analysis for certain gene expressed proteins 110 and whether a gene
expressed protein is a molecular target 112 by determining whether
30% or more of the tumor cells were +2 or greater staining. Report
100 also identifies immunohistochemical tests that were not
performed 114. Patient profile report 100 shown in FIG. 3C
identifies the genes analyzed 116 with a micro array analysis and
whether the genes were under expressed or over expressed 118
compared to a reference. Finally, patient profile report 100 shown
in FIG. 3D identifies the clinical history 120 of the patient and
the specimens that were submitted 122 from the patient.
[0069] FIG. 4 shows a flowchart of an exemplary embodiment of a
method 200 for identifying a drug therapy/agent capable of
interacting with a target. In step 202, a molecular target is
identified which exhibits a change in expression in a number of
diseased individuals. Next, in step 204, a drug therapy/agent is
administered to the diseased individuals. After drug therapy/agent
administration, any changes in the molecular target identified in
step 202 are identified in step 206 in order to determine if the
drug therapy/agent administered in step 204 interacts with the
molecular targets identified in step 202. If it is determined that
the drug therapy/agent administered in step 204 interacts with a
molecular target identified in step 202, the drug therapy/agent may
be approved for treating patients exhibiting a change in expression
of the identified molecular target instead of approving the drug
therapy/agent for a particular disease.
[0070] FIGS. 5-14 are flowcharts and diagrams illustrating various
parts of an information-based personalized medicine drug discovery
system and method in accordance with the present invention. FIG. 5
is a diagram showing an exemplary clinical decision support system
of the information-based personalized medicine drug discovery
system and method of the present invention. Data obtained through
clinical research and clinical care such as clinical trial data,
biomedical/molecular imaging data, genomics/proteomics/chemical
library/literature/expert curation, biospecimen tracking/LIMS,
family history/environmental records, and clinical data are
collected and stored as databases and datamarts within a data
warehouse. FIG. 6 is a diagram showing the flow of information
through the clinical decision support system of the
information-based personalized medicine drug discovery system and
method of the present invention using web services. A user
interacts with the system by entering data into the system via
form-based entry/upload of data sets, formulating queries and
executing data analysis jobs, and acquiring and evaluating
representations of output data. The data warehouse in the web based
system is where data is extracted, transformed, and loaded from
various database systems. The data warehouse is also where common
formats, mapping and transformation occurs. The web based system
also includes datamarts which are created based on data views of
interest.
[0071] A flow chart of an exemplary clinical decision support
system of the information-based personalized medicine drug
discovery system and method of the present invention is shown in
FIG. 7. The clinical information management system includes the
laboratory information management system and the medical
information contained in the data warehouses and databases includes
medical information libraries, such as drug libraries, gene
libraries, and disease libraries, in addition to literature text
mining Both the information management systems relating to
particular patients and the medical information databases and data
warehouses come together at a data junction center where diagnostic
information and therapeutic options can be obtained. A financial
management system may also be incorporated in the clinical decision
support system of the information-based personalized medicine drug
discovery system and method of the present invention.
[0072] FIG. 8 is a diagram showing an exemplary biospecimen
tracking and management system which may be utilized as part of the
information-based personalized medicine drug discovery system and
method of the present invention. FIG. 8 shows two host medical
centers which forward specimens to a tissue/blood bank. The
specimens may go through laboratory analysis prior to shipment.
Research may also be conducted on the samples via micro array,
genotyping, and proteomic analysis. This information can be
redistributed to the tissue/blood bank. FIG. 9 depicts a flow chart
of an exemplary biospecimen tracking and management system which
may be utilized with the information-based personalized medicine
drug discovery system and method of the present invention. The host
medical center obtains samples from patients and then ships the
patient samples to a molecular profiling laboratory which may also
perform RNA and DNA isolation and analysis.
[0073] A diagram showing a method for maintaining a clinical
standardized vocabulary for use with the information-based
personalized medicine drug discovery system and method of the
present invention is shown in FIG. 10. FIG. 10 illustrates how
physician observations and patient information associated with one
physician's patient may be made accessible to another physician to
enable the other physician to utilize the data in making diagnostic
and therapeutic decisions for their patients.
[0074] FIG. 11 shows a schematic of an exemplary micro array gene
expression database which may be used as part of the
information-based personalized medicine drug discovery system and
method of the present invention. The micro array gene expression
database includes both external databases and internal databases
which can be accessed via the web based system. External databases
may include, but are not limited to, UniGene, GO, TIGR, GenBank,
KEGG. The internal databases may include, but are not limited to,
tissue tracking, LIMS, clinical data, and patient tracking FIG. 12
shows a diagram of an exemplary micro array gene expression
database data warehouse which may be used as part of the
information-based personalized medicine drug discovery system and
method of the present invention. Laboratory data, clinical data,
and patient data may all be housed in the micro array gene
expression database data warehouse and the data may in turn be
accessed by public/private release and utilized by data analysis
tools.
[0075] Another schematic showing the flow of information through an
information-based personalized medicine drug discovery system and
method of the present invention is shown in FIG. 13. Like FIG. 7,
the schematic includes clinical information management, medical and
literature information management, and financial management of the
information-based personalized medicine drug discovery system and
method of the present invention. FIG. 14 is a schematic showing an
exemplary network of the information-based personalized medicine
drug discovery system and method of the present invention.
Patients, medical practitioners, host medical centers, and labs all
share and exchange a variety of information in order to provide a
patient with a proposed therapy or agent based on various
identified targets.
[0076] FIGS. 15-25 are computer screen print outs associated with
various parts of the information-based personalized medicine drug
discovery system and method shown in FIGS. 5-14. FIGS. 15 and 16
show computer screens where physician information and insurance
company information is entered on behalf of a client. FIGS. 17-19
show computer screens in which information can be entered for
ordering analysis and tests on patient samples.
[0077] FIG. 20 is a computer screen showing micro array analysis
results of specific genes tested with patient samples. This
information and computer screen is similar to the information
detailed in the patient profile report shown in FIG. 3C. FIG. 22 is
a computer screen that shows immunohistochemistry test results for
a particular patient for various genes. This information is similar
to the information contained in the patient profile report shown in
FIG. 3B.
[0078] FIG. 21 is a computer screen showing selection options for
finding particular patients, ordering tests and/or results, issuing
patient reports, and tracking current cases/patients.
[0079] FIG. 23 is a computer screen which outlines some of the
steps for creating a patient profile report as shown in FIGS. 3A
through 3D. FIG. 24 shows a computer screen for ordering an
immunohistochemistry test on a patient sample and FIG. 25 shows a
computer screen for entering information regarding a primary tumor
site for micro array analysis. It will be understood by those
skilled in the art that any number and variety of computer screens
may be utilized to enter the information necessary for utilizing
the information-based personalized medicine drug discovery system
and method of the present invention and to obtain information
resulting from utilizing the information-based personalized
medicine drug discovery system and method of the present
invention.
[0080] FIGS. 26-31 represent tables that show the frequency of a
significant change in expression of certain genes and/or gene
expressed proteins by tumor type, i.e. the number of times that a
gene and/or gene expressed protein was flagged as a target by tumor
type as being significantly overexpressed or underexpressed (see
also Examples 1-3). The tables show the total number of times a
gene and/or gene expressed protein was overexpressed or
underexpressed in a particular tumor type and whether the change in
expression was determined by immunohistochemistry analysis (FIG.
26, FIG. 28) or microarray analysis (FIG. 27, 30). The tables also
identify the total number of times an overexpression of any gene
expressed protein occurred in a particular tumor type using
immunohistochemistry and the total number of times an
overexpression or underexpression of any gene occurred in a
particular tumor type using gene microarray analysis.
[0081] Thus the present invention provides methods and systems for
analyzing diseased tissue using IHC testing and gene microarray
testing in accordance with IHC and microarray testing as previously
described above. The patients can be in an advanced stage of
disease. The biomarker patterns or biomarker signature sets in a
number of tumor types, diseased tissue types, or diseased cells
including adipose, adrenal cortex, adrenal gland, adrenal
gland-medulla, appendix, bladder, blood vessel, bone, bone
cartilage, brain, breast, cartilage, cervix, colon, colon sigmoid,
dendritic cells, skeletal muscle, enodmetrium, esophagus, fallopian
tube, fibroblast, gallbladder, kidney, larynx, liver, lung, lymph
node, melanocytes, mesothelial lining, myoepithelial cells,
osteoblasts, ovary, pancreas, parotid, prostate, salivary gland,
sinus tissue, skeletal muscle, skin, small intestine, smooth
muscle, stomach, synovium, joint lining tissue, tendon, testis,
thymus, thyroid, uterus, and uterus corpus can be determined.
[0082] The biomarker patterns or biomarker signature sets in a
number of tumor types, diseased tissue types, or diseased cells
including accessory, sinuses, middle and inner ear, adrenal glands,
appendix, hematopoietic system, bones and joints, spinal cord,
breast, cerebellum, cervix uteri, connective and soft tissue,
corpus uteri, esophagus, eye, nose, eyeball, fallopian tube,
extrahepatic bile ducts, other mouth, intrahepatic bile ducts,
kidney, appendix-colon, larynx, lip, liver, lung and bronchus,
lymph nodes, cerebral, spinal, nasal cartilage, excl. retina, eye,
nos, oropharynx, other endocrine glands, other female genital,
ovary, pancreas, penis and scrotum, pituitary gland, pleura,
prostate gland, rectum renal pelvis, ureter, peritonem, salivary
gland, skin, small intestine, stomach, testis, thymus, thyroid
gland, tongue, unknown, urinary bladder, uterus, nos, vagina &
labia, and vulva, nos can also be determined.
[0083] Thus the biomarker patterns or biomarker signature sets can
be used to determine a therapeutic agent or therapeutic protocol
that is capable of interacting with the biomarker pattern or
signature set. For example, with advanced breast cancer,
immunohistochemistry analysis can be used to determine one or more
gene expressed proteins that are overexpressed. Accordingly, a
biomarker pattern or biomarker signature set can be identified for
advanced stage breast cancer and a therapeutic agent or therapeutic
protocol can be identified which is capable of interacting with the
biomarker pattern or signature set.
[0084] These examples of biomarker patterns or biomarker signature
sets for advanced stage breast cancer are just one example of the
extensive number of biomarker patterns or biomarker signature sets
for a number of advanced stage diseases or cancers that can be
identified from the tables depicted in FIGS. 26-31. In addition, a
number of non disease specific therapies or therapeutic protocols
may be identified for treating patients with these biomarker
patterns or biomarker signature sets by utilizing method steps of
the present invention described above such as depicted in FIGS. 1-2
and FIGS. 5-14.
[0085] The biomarker patterns and/or biomarker signature sets
disclosed in the table depicted in FIGS. 26 and 28, and the tables
depicted in FIGS. 27 and 30 may be used for a number of purposes
including, but not limited to, specific cancer/disease detection,
specific cancer/disease treatment, and identification of new drug
therapies or protocols for specific cancers/diseases. The biomarker
patterns and/or biomarker signature sets disclosed in the table
depicted in FIGS. 26 and 28, and the tables depicted in FIGS. 27
and 30 can also represent drug resistant expression profiles for
the specific tumor type or cancer type. The biomarker patterns
and/or biomarker signature sets disclosed in the table depicted in
FIGS. 26 and 28, and the tables depicted in FIGS. 27 and 30
represent advanced stage drug resistant profiles.
[0086] The biomarker patterns and/or biomarker signature sets can
comprise at least one biomarker. In yet other embodiments, the
biomarker patterns or signature sets can comprise at least 2, 3, 4,
5, 6, 7, 8, 9, or 10 biomarkers. In some embodiments, the biomarker
signature sets or biomarker patterns can comprise at least 15, 20,
30, 40, 50, or 60 biomarkers. Analysis of the one or more
biomarkers can be by one or more methods. For example, analysis of
2 biomarkers can be performed using microarrays. Alternatively, one
biomarker may be analyzed by IHC and another by microarray. Various
combinations of methods and biomarkers are contemplated herein.
[0087] The one or more biomarkers can be selected from the group
consisting of, but not limited to: Her2/Neu, ER, PR, c-kit, EGFR,
MLH1, MSH2, CD20, p53, Cyclin D1, bcl2, COX-2, Androgen receptor,
CD52, PDGFR, AR, CD25, VEGF, HSP90, PTEN, RRM1, SPARC, Survivin,
TOP2A, BCL2, HIF1A, AR, ESR1, PDGFRA, KIT, PDGFRB, CDW52, ZAP70,
PGR, SPARC, GART, GSTP1, NFKBIA, MSH2, TXNRD1, HDAC1, PDGFC, PTEN,
CD33, TYMS, RXRB, ADA, TNF, ERCC3, RAF1, VEGF, TOP1, TOP2A, BRCA2,
TK1, FOLR2, TOP2B, MLH1, IL2RA, DNMT1, HSPCA, ERBR2, ERBB2, SSTR1,
VHL, VDR, PTGS2, POLA, CES2, EGFR, OGFR, ASNS, NFKB2, RARA, MS4A1,
DCK, DNMT3A, EREG, Epiregulin, FOLR1, GNRH1, GNRHR1, FSHB, FSHR,
FSHPRH1, folate receptor, HGF, HIG1, IL13RA1, LTB, ODC1, PPARG,
PPARGC1, Lymphotoxin Beta Receptor, Myc, Topoisomerase II, TOPO2B,
TXN, VEGFC, ACE2, ADH1C, ADH4, AGT, AREG, CA2, CDK2, caveolin,
NFKB1, ASNS, BDCA1, CD52, DHFR, DNMT3B, EPHA2, FLT1, HSP90AA1, KDR,
LCK, MGMT, RRM1, RRM2, RRM2B, RXRG, SRC, SSTR2, SSTR3, SSTR4,
SSTR5, VEGFA, or YES1.
[0088] For example, a biological sample from an individual can be
analyzed to determine a biomarker pattern or biomarker signature
set that comprises a biomarker such as HSP90, Survivin, RRM1,
SSTRS3, DNMT3B, VEGFA, SSTR4, RRM2, SRC, RRM2B, HSP90AA1, STR2,
FLT1, SSTR5, YES1, BRCA1, RRM1, DHFR, KDR, EPHA2, RXRG, or LCK. In
other embodiments, the biomarker SPARC, HSP90, TOP2A, PTEN,
Survivin, or RRM1 forms part of the biomarker pattern or biomarker
signature set. In yet other embodiments, the biomarker MGMT,
SSTRS3, DNMT3B, VEGFA, SSTR4, RRM2, SRC, RRM2B, HSP90AA1, STR2,
FLT1, SSTR5, YES1, BRCA1, RRM1, DHFR, KDR, EPHA2, RXRG, CD52, or
LCK is included in a biomarker pattern or biomarker signature
set.
[0089] The expression level of HSP90, Survivin, RRM1, SSTRS3,
DNMT3B, VEGFA, SSTR4, RRM2, SRC, RRM2B, HSP90AA1, STR2, FLT1,
SSTR5, YES1, BRCA1, RRM1, DHFR, KDR, EPHA2, RXRG, or LCK can be
determined and used to identify a therapeutic for an individual.
The expression level of the biomarker can be used to form a
biomarker pattern or biomarker signature set. Determining the
expression level can be by analyzing the levels of mRNA or protein,
such as by microarray analysis or IHC. In some embodiments, the
expression level of a biomarker is performed by IHC, such as for
SPARC, TOP2A, or PTEN, and used to identify a therapeutic for an
individual. The results of the IHC can be used to form a biomarker
pattern or biomarker signature set. In yet other embodiments, a
biological sample from an individual or subject is analyzed for the
expression level of CD52, such as by determining the mRNA
expression level by methods including, but not limited to,
microarray analysis. The expression level of CD52 can be used to
identify a therapeutic for the individual. The expression level of
CD52 can be used to form a biomarker pattern or biomarker signature
set.
[0090] As described herein, the molecular profiling of one or more
targets can be used to determine or identify a therapeutic for an
individual. For example, the expression level of one or more
biomarkers can be used to determine or identify a therapeutic for
an individual. The one or more biomarkers, such as those disclosed
herein, can be used to form a biomarker pattern or biomarker
signature set, which is used to identify a therapeutic for an
individual. In some embodiments, the therapeutic identified is one
that the individual has not previously been treated with.
[0091] For example, a reference biomarker pattern has been
established for a particular therapeutic, such that individuals
with the reference biomarker pattern will be responsive to that
therapeutic. An individual with a biomarker pattern that differs
from the reference, for example the expression of a gene in the
biomarker pattern is changed or different from that of the
reference, would not be administered that therapeutic. In another
example, an individual exhibiting a biomarker pattern that is the
same or substantially the same as the reference is advised to be
treated with that therapeutic. In some embodiments, the individual
has not previously been treated with that therapeutic and thus a
new therapeutic has been identified for the individual.
[0092] It will be understood that the foregoing description is of
preferred exemplary embodiments of the invention and that the
invention is not limited to the specific forms shown or described
herein. Various modifications may be made in the design,
arrangement, and type of elements disclosed herein, as well as the
steps of utilizing the invention.
EXAMPLES
Example 1
IHC and Microarray Testing of Over 500 Patients
[0093] The data reflected in the table depicted in FIGS. 26A-H and
FIGS. 27A-27H relates to 544 patients whose diseased tissue
underwent IHC testing (FIG. 26) and 540 patients whose diseased
tissue underwent gene microarray testing (FIG. 27) in accordance
with IHC and microarray testing as previously described above. The
patients were all in advanced stages of disease.
[0094] The data show biomarker patterns or biomarker signature sets
in a number of tumor types, diseased tissue types, or diseased
cells including adipose, adrenal cortex, adrenal gland, adrenal
gland-medulla, appendix, bladder, blood vessel, bone, bone
cartilage, brain, breast, cartilage, cervix, colon, colon sigmoid,
dendritic cells, skeletal muscle, enodmetrium, esophagus, fallopian
tube, fibroblast, gallbladder, kidney, larynx, liver, lung, lymph
node, melanocytes, mesothelial lining, myoepithelial cells,
osteoblasts, ovary, pancreas, parotid, prostate, salivary gland,
sinus tissue, skeletal muscle, skin, small intestine, smooth
muscle, stomach, synovium, joint lining tissue, tendon, testis,
thymus, thyroid, uterus, and uterus corpus.
[0095] In 99 individuals with advanced breast cancer,
immunohistochemistry analysis of 20 gene expressed proteins (FIG.
26B) showed that the gene expressed proteins analyzed were
overexpressed a total of 367 times and that 16.35% of that total
overexpression was attributable to HSP90 overexpression followed by
12.53% of the overexpression being attributable to TOP2A
overexpression and 11.17% of the overexpression being attributable
to SPARC. In addition, 9.81% of the overexpression was attributable
to androgen receptor overexpression, 9.54% of the overexpression
was attributable to PDGFR overexpression, and 9.26% of the
overexpression was attributable to c-kit overexpression.
[0096] Accordingly, a biomarker pattern or biomarker signature set
can be identified for advanced stage breast cancer and a
therapeutic agent or therapeutic protocol can be identified which
is capable of interacting with the biomarker pattern or signature
set.
[0097] Another biomarker pattern or biomarker signature set for
advanced stage breast cancer is shown from the microarray data in
the table represented by FIGS. 27A-H. For example, in 100
individuals with advanced breast cancer (FIG. 27B), gene microarray
analysis of 64 genes showed that the genes analyzed exhibited a
change in expression a total of 1,158 times and that 6.39% of that
total change in expression was attributable to SSTR3 change in
expression followed by 5.79% of the change in expression being
attributable to VDR change in expression and 5.35% of the change in
expression being attributable to BRCA2 change in expression.
Accordingly, another biomarker pattern or biomarker signature set
can be identified for advanced stage breast cancer and another
therapeutic agent or therapeutic protocol can be identified which
is capable of interacting with this biomarker pattern or signature
set.
Example 2
IHC Testing of Over 1300 Patients
[0098] FIGS. 28A through 28O represent a table that shows the
frequency of a significant change in expression of certain gene
expressed proteins by tumor type, i.e. the number of times that a
gene expressed protein was flagged as a target by tumor type as
being significantly overexpressed by immunohistochemistry analysis.
The table also identifies the total number of times an
overexpression of any gene expressed protein occurred in a
particular tumor type using immunohistochemistry.
[0099] The data reflected in the table depicted in FIGS. 28A
through 28O relates to 1392 patients whose diseased tissue
underwent IHC testing in accordance with IHC testing as previously
described above. The patients were all in advanced stages of
disease.
[0100] The data show biomarker patterns or biomarker signature sets
in a number of tumor types, diseased tissue types, or diseased
cells including accessory, sinuses, middle and inner ear, adrenal
glands, appendix, hematopoietic system, bones and joints, spinal
cord, breast, cerebellum, cervix uteri, connective and soft tissue,
corpus uteri, esophagus, eye, nose, eyeball, fallopian tube,
extrahepatic bile ducts, other mouth, intrahepatic bile ducts,
kidney, appendix-colon, larynx, lip, liver, lung and bronchus,
lymph nodes, cerebral, spinal, nasal cartilage, excl. retina, eye,
nos, oropharynx, other endocrine glands, other female genital,
ovary, pancreas, penis and scrotum, pituitary gland, pleura,
prostate gland, rectum renal pelvis, ureter, peritonem, salivary
gland, skin, small intestine, stomach, testis, thymus, thyroid
gland, tongue, unknown, urinary bladder, uterus, nos, vagina &
labia, and vulva, nos.
[0101] In 254 individuals with advanced breast cancer,
immunohistochemistry analysis of 19 gene expressed proteins (FIG.
28C) showed that the gene expressed proteins analyzed were
overexpressed a total of 767 times and that 13.43% of that total
overexpression was attributable to SPARC overexpression followed by
12.26% of the overexpression being attributable to c-kit
overexpression and 11.47% of the overexpression being attributable
to EGFR. In addition, 11.34% of the overexpression was attributable
to androgen receptor overexpression, 11.08% of the overexpression
was attributable to HSP90 overexpression, and 10.43% of the
overexpression was attributable to PDGFR overexpression.
Accordingly, a biomarker pattern or biomarker signature set can be
identified for advanced stage breast cancer and a therapeutic agent
or therapeutic protocol can be identified which is capable of
interacting with the biomarker pattern or signature set.
[0102] FIG. 29 depicts a table showing biomarkers (gene expressed
proteins) tagged as targets in order of frequency in all tissues
that were IHC tested. Immunohistochemistry of the 19 gene expressed
proteins showed that the 19 gene expressed proteins were tagged
3878 times as targets in the various tissues tested and that EGFR
was the gene expressed protein that was overexpressed the most
frequently followed by SPARC.
Example 3
Microarray Testing of Over 300 Patients
[0103] FIGS. 30A through 30O represent a table that shows the
frequency of a significant change in expression of certain genes by
tumor type, i.e. the number of times that a gene was flagged as a
target by tumor type as being significantly overexpressed or
underexpressed by microarray analysis. The table also identifies
the total number of times an overexpression or underexpression of
any gene occurred in a particular tumor type using gene microarray
analysis.
[0104] The data reflected in the table depicted in FIGS. 30A
through 30O relates to 379 patients whose diseased tissue underwent
gene microarray testing in accordance microarray testing as
previously described above. The patients were all in advanced
stages of disease. The data show biomarker patterns or biomarker
signature sets in a number of tumor types, diseased tissue types,
or diseased cells including accessory, sinuses, middle and inner
ear, adrenal glands, anal canal and anus, appendix, blood, bone
marrow & hematopoietic sys, bones and joints, brain &
cranial nerves and spinal cord (excl. ventricle & cerebellum),
breast, cerebellum, cervix uteri, connective & soft tissue,
corpus uteri, esophagus, eye, nos, eyeball, fallopian tube,
gallbladder 7 extrahepatic bile ducts, gum, floor of mouth &
other mouth, intrahepatic bile ducts, kidney, large intestine
(excl. appendix-colon), larynx, lip, liver, lung & bronchus,
lymph nodes, meninges (cerebral, spinal), nasal cavity (including
nasal cartilage), orbit & lacrimal gland (excl. retina, eye,
nos), oropharynx, other endocrine glands, other fenale genital,
ovary, pancreas, penis & scrotum, pituitary gland, pleura,
prostate gland, rectum, renal pelvis & ureter, retroperitoneum
& peritoneum, salivary gland, skin, small intestine, stomach,
testis, thymus, thyroid gland, tongue, unknown, unspecified
digestive organs, urinary bladder, uterus, nos, vagina & labia,
and vulva, nos.
[0105] For example, in 168 individuals with advanced breast cancer
(FIG. 30C), microarray analysis of 63 genes showed that the genes
analyzed were either overexpressed or underexpressed a total of
1863 times and that 5.05% of that total change in expression was
attributable to SSTR3 change in expression followed by 4.83% of the
change in expression being attributable to NKFBIA change in
expression and 4.62% of the change in expression being attributable
to VDR. In addition, 4.35% of the change in expression was
attributable to MGMT change in expression, 4.19% of the change in
expression was attributable to ADA change in expression, and 3.97%
of the change in expression was attributable to CES2 change in
expression.
[0106] FIG. 31 depicts a table showing biomarkers as targets in
order of frequency in all tissues that were tested.
* * * * *
References