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WO2016127999A1 - Neuropeptide y as a prognostic marker of prostate cancer - Google Patents

Neuropeptide y as a prognostic marker of prostate cancer Download PDF

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Publication number
WO2016127999A1
WO2016127999A1 PCT/DK2016/050035 DK2016050035W WO2016127999A1 WO 2016127999 A1 WO2016127999 A1 WO 2016127999A1 DK 2016050035 W DK2016050035 W DK 2016050035W WO 2016127999 A1 WO2016127999 A1 WO 2016127999A1
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WIPO (PCT)
Prior art keywords
npy
score
erg
plasma
individual
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PCT/DK2016/050035
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French (fr)
Inventor
Pernilla WIKSTRÖM
Amilcar FLORES-MORALES
Diego IGLESIAS GATO
Anders Bergh
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University Of Copenhagen
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Publication of WO2016127999A1 publication Critical patent/WO2016127999A1/en

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    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
    • C12Q1/00—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions
    • C12Q1/68—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions involving nucleic acids
    • C12Q1/6876—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes
    • C12Q1/6883—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes for diseases caused by alterations of genetic material
    • C12Q1/6886—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes for diseases caused by alterations of genetic material for cancer
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
    • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
    • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
    • G01N33/53—Immunoassay; Biospecific binding assay; Materials therefor
    • G01N33/574—Immunoassay; Biospecific binding assay; Materials therefor for cancer
    • G01N33/57407—Specifically defined cancers
    • G01N33/57434—Specifically defined cancers of prostate
    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
    • C12Q2600/00—Oligonucleotides characterized by their use
    • C12Q2600/118—Prognosis of disease development
    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
    • C12Q2600/00—Oligonucleotides characterized by their use
    • C12Q2600/158—Expression markers
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N2800/00—Detection or diagnosis of diseases
    • G01N2800/52—Predicting or monitoring the response to treatment, e.g. for selection of therapy based on assay results in personalised medicine; Prognosis

Definitions

  • Neuropeptide Y as a prognostic marker of prostate cancer Field of invention
  • the present invention relates to the finding that Neuropeptide Y (NPY) can be used as a marker for establishing a prognosis for prostate cancer.
  • NPY Neuropeptide Y
  • Disclosed herein is a method for establishing a prognosis by determining the levels of NPY and optionally of ERG in a sample isolated from an individual suffering from or suspected of suffering from prostate cancer.
  • the present methods provide a reliable prognosis independently of the Gleason score (GS), but are even more reliable when performed on individuals with a GS of 7 or less.
  • GS Gleason score
  • Prostate cancer is the most diagnosed cancer among men in Western societies and a leading cause of death.
  • PSA Prostate Specific Antigen
  • the wide implementation of Prostate Specific Antigen (PSA) testing has dramatically increased the number and lowered the age of patients diagnosed with prostate cancer.
  • Most of PSA screened patients in fact harbour non- aggressive tumours that will not threaten the patient's life or cause significant morbidity if left untreated.
  • the existence of potentially curative interventions for localized prostate cancer in the form of radical prostatectomy and radiation therapy, combined with diagnostic inability to precisely identify patients that harbour the aggressive manifestation of the disease has led to a situation of considerable overtreatment.
  • NPY is a 36 amino acid-long polypeptide (SEQ ID NO: 3) widely distributed in the central and peripheral nervous system of mammals. NPY is the most abundant neuropeptide in the brain and is known to induce vasoconstriction, to inhibit noradrenaline release at a pre-synaptic level, and to regulate diverse functions including blood pressure, stress, pain, hormone secretion, reproduction, circadian rhythm and food intake. NPY has been implicated in feeding disorders, epilepsy, hypertension, pain disorders, depression and anxiety.
  • NPY is the result of cleavage of pro-neuropeptide Y (pro-NPY), a 97-amino acid long peptide (SEQ ID NO: 1) which is cleaved into NPY (alternative name: neuropeptide tyrosine), and C-flanking peptide of NPY (CPON).
  • the present invention is based on the finding that NPY alone or in combination with ERG can be used as a prognostic marker in prostate cancer patients.
  • the inventors have surprisingly found that high levels of NPY reflect a bad prognosis, in particular in patients with low Gleason scores.
  • high expression of both NPY and ERG can also be used as a prognostic marker and reflect a bad prognosis, in particular in patients with low Gleason scores.
  • a bad prognosis is an increased risk of dying of prostate cancer within 20 years, while a good prognosis means that the patient is substantially not at risk of dying of prostate cancer within 20 years.
  • determining the levels of NPY in a sample isolated from an individual suffering from or suspected of suffering from prostate cancer can be used in a method for establishing a prognosis for prostate cancer.
  • the present methods provide a reliable prognosis independently of the GS, but are even more reliable when performed on individuals with a GS of 7 or less.
  • the prognostic can also be established by determining not only the level of NPY but also the level of ERG, as detailed above.
  • the present methods are thus advantageous to prevent overmedication and surgical procedures on individuals who are likely not to benefit from them. It follows that the present invention also is capable of identifying individuals who will benefit from immediate treatment.
  • the invention relates to a method for establishing a prognosis in an individual suffering from or at risk of suffering from prostate cancer, said method comprising the steps of determining the level of NPY in a sample isolated from said individual and assigning an NPY score to said level of NPY and establishing the prognosis based on said NPY score.
  • the invention relates to NPY for use in the prognosis of prostate- cancer specific mortality.
  • the invention relates to a kit for performing the method of the invention, comprising an anti-NPY antibody recognising at least the C-terminal part of NPY, an anti-ERG antibody recognising ERG and instructions for use.
  • FIG. 1 Pro-NPY expression is elevated in prostate tumours.
  • A Scatter plot of the different relative expression of proteins quantified in "low risk” prostate tumours defined as tumours with predominant Gleason Grade 3 (GG3) versus "high risk” tumours, predominant GG4, distributed according to the probability of being true expressed as -log of Student's t-test p value.
  • X-axis high risk vs low risk log2 (difference of mean ratios); Y-axis: -log(t-test p value).
  • B MS/MS spectrum of the most commonly identified NPY peptide across all samples. Peptide matches to the c- terminal domain of NPY (pro-NPY). Y-axis: relative abundance.
  • C pro-NPY immunoreactivity in prostate tumours and benign neighbouring tissue (left) and in GS ⁇ 6 and GS>6 (right) was measured on prostate tissue samples from a "watchful waiting" cohort. Chi square p value is shown.
  • X- axis (from left to right): breast, colon, liver, lung, oral, ovary, pancreas, prostate, stomach, uterus; Y-axis: number of cases
  • X-axis carcinoid, cervical, endometrial, glioma, head and neck, lymphoma, melanoma, prostate, renal, skin, testis, thyroid, urothelial.
  • Y axis number of cases.
  • FIG. 1 Kaplan-Meier analysis of the tumours Gleason score (GS) relative to prostate cancer-free survival in the TURP cohort (Y-axis). X-axis: time in years. (B)
  • FIG. 6 Kaplan-Meier analysis of the tumours Gleason scores (GS) relative to biochemical recurrence (BCR)-free survival (Y-axis) in the prostatectomy cohort. X- axis: time in months.
  • B Kaplan-Meier analysis of pro-NPY (NPY), ERG or the combined expression relative to BCR-free survival (BCR) (Y-axis) in the prostatectomy cohort. First row: pro-NPY; second row: ERG; third tow: combined pro-NPY and ERG. In the left panels, expression across all GS is analysed; in the middle panels expression is analysed for GS>6; in the right panels, expression is analysed for GS ⁇ 6.
  • NPY+ NPY score is positive; NPY-: NPY score is negative.
  • X-axis time in months.
  • FIG. 7 High Pro-NPY and ERG expression levels correlate to poor prognosis in patients with GS ⁇ 7.
  • A Kaplan-Meier analysis of pro-NPY expression in patients with 4 ⁇ GS ⁇ 7.
  • X-axis time in years; Y-axis: percent survival.
  • B Kaplan-Meier analysis of pro-NPY and ERG expression in patients with 4 ⁇ GS ⁇ 7.
  • X-axis time in years; Y-axis: percent survival.
  • FIG. 8 Plasma NPY levels predict prostate cancer specific mortality. NPY plasma levels were divided in quartiles and their relation to prostate cancer specific mortality was analysed using the Kaplan-Meier method. X-axis: time in months; Y-axis: PCa specific survival.
  • Figure 9 Detection of pro-NPY and CPON by capillary electrophoresis (Peggy Sue system, Proteinsimple).
  • Gleason grading The Gleason grading system is used to evaluate the prognosis of men with prostate cancer. A Gleason score is given based on the microscopic appearance of prostate cancer tissues. Five histologic patterns can be observed and are assessed microscopically by a pathologist upon examination of the tissues.
  • Pattern 1 The cancerous prostate closely resembles normal prostate tissue. The glands are small, well-formed, and closely packed. This corresponds to a well differentiated carcinoma.
  • Pattern 2 The tissue still has well-formed glands, but they are larger and have more tissue between them, implying that the stroma has increased. This also corresponds to a moderately differentiated carcinoma.
  • Pattern 3 The tissue still has recognizable glands, but the cells are darker. At high magnification, some of these cells have left the glands and are beginning to invade the surrounding tissue or having an infiltrative pattern. This corresponds to a moderately differentiated carcinoma.
  • Pattern 4 The tissue has few recognizable glands. Many cells are invading the surrounding tissue in neoplastic clumps. This corresponds to a poorly differentiated carcinoma.
  • Pattern 5 The tissue does not have any or only a few recognizable glands. There are often just sheets of cells throughout the surrounding tissue. This corresponds to an anaplastic carcinoma.
  • Gleason pattern 3 is by far the most common.
  • the pathologist assigns a grade to the tumour specimen depending on the observed patterns.
  • a primary grade is assigned to the dominant pattern of the tumour (greater than 50% of the total pattern seen).
  • a secondary grade is assigned to the next-most frequent pattern (less than 50%, but at least 5%, of the pattern of the total cancer observed).
  • a tertiary grade is assigned where there is a small component of a third (generally more aggressive) pattern.
  • the Gleason score is calculated by summing up the Gleason Grades (GG) of:
  • the GS is the sum of the GG of the primary pattern and of the secondary pattern
  • the GS is the sum of the GG of the primary pattern and the GG for the pattern having the highest GG.
  • Gleason scores range from 2 to 10, with 2 representing the best-differentiated tumours and 10 the least-differentiated tumours. Gleason scores have often been categorized into groups that show similar biologic behaviour: low-grade (well-differentiated), intermediate-grade, moderate to poorly-differentiated or high-grade. The Gleason scores are typically used to define prognostic grade groups as: Gleason score ⁇ 6
  • Prostate cancers with a Gleason score ⁇ 6 are commonly considered to have rather good prognoses.
  • Immunohistochemistry refers to the process of detecting antigens (e.g., proteins) in cells of a tissue section by exploiting the principle of antibodies binding specifically to antigens in biological tissues. Immunohistochemical staining is widely used in the diagnosis of abnormal cells such as those found in cancerous tumours. Visualising an antibody-antigen interaction can be accomplished in a number of ways. In the most common instance, an antibody is conjugated to an enzyme, such as peroxidase, that can catalyse a colour-producing reaction.
  • an enzyme such as peroxidase
  • the antibody can also be tagged by a fluorophore, such as fluorescein or rhodamine.
  • IR Immunoreactivity or immune reactivity
  • the invention in a first aspect, relates to a method for establishing a prognosis in an individual suffering from or at risk of suffering from prostate cancer, said method comprising the steps of determining the level of NPY in a sample isolated from said individual and assigning an NPY score to said level of NPY and establishing the prognosis based on said NPY score.
  • the present method is useful for establishing a prognosis in an individual suffering from prostate cancer, suspected of suffering from prostate cancer or at risk of suffering from prostate cancer.
  • the individual may have been diagnosed with prostate cancer with diagnostic methods known in the art.
  • Individuals suffering from urinary or sexual problems and seeking medical advice typically undergo a digital rectal examination which can be followed by other tests if prostate cancer is suspected to be present. These other tests can also be performed as part of a screening program to detect prostate cancer early in men with no or few symptoms.
  • Such tests may include a PSA (prostate-specific antigen) blood test.
  • PSA prostate-specific antigen
  • Healthy men have PSA levels under 4 ng/mL of blood.
  • the chance of having prostate cancer goes up as the PSA level goes up.
  • the PSA level usually goes above 4 ng/mL of blood.
  • a PSA level between 4 and 10 ng/mL of blood corresponds to a 1 in 4 chance of having prostate cancer. If the PSA is more than 10, the chance of having prostate cancer is over 50%.
  • PSA levels are only indicative of a risk of having prostate cancer.
  • the presence of prostate cancer needs to be confirmed or infirmed by biopsy.
  • the PSA level can be used to determine whether or not a biopsy is needed.
  • the PSA test can also be useful if prostate cancer has already been diagnosed. In men diagnosed with prostate cancer, the PSA test can be used together with physical exam results and tumour grade determined from a biopsy to help decide if other tests (such as CT scans or bone scans) are needed.
  • the PSA test is often used to predict whether the cancer has spread: very high PSA levels can indicate that the cancer has spread beyond the prostate. This may affect treatment options, since some forms of therapy (such as surgery and radiation) are not likely to be helpful if the cancer has spread to the lymph nodes, bones, or other organs.
  • the PSA test is often also used for monitoring the evolution of the prostate cancer during and after treatment.
  • TRUS transrectal ultrasound
  • DRE digital rectal examination
  • TRUS can be used to get an image of the prostate when high PSA levels or abnormal digital rectal examination (DRE) results have been observed. It can be used to measure the size of the prostate gland, which can help determine the PSA density and may also affect the options of treatment.
  • TRUS is also used as a guide during some forms of treatment such as brachytherapy or cryosurgery.
  • Definitive diagnosis of prostate cancer usually requires a biopsy. Investigation of the biopsy under the microscope is usually performed by pathologists, which grade the cancer. In some cases several biopsies are needed in order to confirm the presence of prostate cancer.
  • a common grading system is based on Gleason grading (GG).
  • GG Gleason grading
  • a pathologist assigns a grade to the tumour specimen depending on the histological patterns observed in the biopsy sample.
  • a primary grade is assigned to the dominant pattern of the tumour
  • a secondary grade is assigned to the next- most frequent pattern (less than 50%, but at least 5%, of the pattern of the total cancer observed).
  • a tertiary grade is assigned where there is a small component of a third (generally more aggressive) pattern.
  • a Gleason score is then calculated by summing up the Gleason Grades (GG) of: If only two patterns are seen, the GS is the sum of the GG of the primary pattern and of the secondary pattern;
  • the GS is the sum of the GG of the primary pattern and the GG for the pattern having the highest GG.
  • Prostate cancers with a Gleason score ⁇ 6 are commonly considered to have rather good prognoses, i.e. no increased risk of dying of prostate cancer within 20 years following diagnosis.
  • Other grading or classification systems exist, examples of which include the D'Amico classification, where patients are stratified by low, intermediate, or high risk based on stage, grade, and PSA levels; the Partin tables, which predict pathologic outcomes (margin status, extraprostatic extension, and seminal vesicle invasion) based on stage, grade, and PSA levels; the Kattan nomograms, which predict recurrence after surgery and/or radiation therapy, based on data available either at time of diagnosis or after surgery; and the UCSF Cancer of the Prostate Risk Assessment (CAPRA) score, which predicts both pathologic status and recurrence after surgery.
  • CAPRA Prostate Risk Assessment
  • an individual suffering from prostate cancer is an individual diagnosed with prostate cancer, for example by one of the methods described above.
  • the GS of the cancer in said individual can be 2, 3, 4, 5, 6, 7, 8, 9 or 10.
  • An individual at risk of suffering from prostate cancer, or an individual suspected of suffering from prostate cancer is an individual which has not been diagnosed with prostate cancer, for example individuals presenting several symptoms usually associated with prostate cancer (urinary or sexual problems, high PSA levels, abnormal DRE results) but where a biopsy has not yet been performed or the biopsy results are negative. Other individuals may be considered at risk of developing prostate cancer based e.g. on their medical history or their family history.
  • Treatments typically used for individuals suffering from prostate cancer include active monitoring (or active surveillance), watchful waiting or active therapy.
  • Active surveillance of an individual is usually carried out by a practitioner, wherein the cancer is monitored and active therapy is used if the cancer starts to grow in order to cure the individual. Active surveillance is carried out by monitoring the appearance of new symptoms or the aggravation of existing symptoms, measuring PSA levels, performing DRE and/or biopsy at fixed points in time.
  • Watchful waiting means that treatment is postponed, e.g. because there are no symptoms, because treatment might never be needed or because cure is not possible for various reasons.
  • Watchful waiting is typically used for individuals having localised prostate cancer with no symptoms but having a medical history or a medical background preventing radical treatment, or individuals having locally advanced or metastatic prostate cancer with no symptoms. Blood tests and other tests such as DRE and/or biopsy are used in watchful waiting.
  • Active therapy includes methods such as, but not limited to, the administration of a medicament, external beam radiation therapy, brachytherapy, radical prostatectomy, hormone therapy, cryotherapy and high frequency ultra sound therapy, and
  • the present method for establishing a prognosis in an individual suffering from or at risk of suffering from prostate cancer comprises a step of determining the NPY level in a sample isolated from said individual and assigning a positive or negative NPY score to said NPY level.
  • the sample may be a prostate tissue sample, such as a biopsy sample, a blood sample, a urine sample, or any sample wherein the NPY level can be measured.
  • the NPY level is determined by measuring the level of a fragment of NPY. In other embodiments, the NPY level is determined by measuring the level of pro-NPY.
  • NPY levels can be determined by various methods known in the art. Such methods include analytic biochemistry assays such as ELISA (enzyme-linked immunosorbent assay) or measuring the immunoreactivity of NPY by assays such as
  • immunohistochemical assays any method allowing determination of NPY level in the individual can be used in the present method, including physical methods such as liquid chromatography, mass spectrometry, capillary electrophoresis, nuclear magnetic resonance, and any other quantitative method. Several methods may be combined, for example capillary electrophoresis may be combined with detection using an antibody.
  • NPY and/or levels of CPON can be detected and measured by any of the methods listed herein. If the method involves antibodies, the skilled person will know how to determine whether the antibody is suitable for determining NPY and/or CPON levels. For instance, some antibodies against mature NPY may enable detection of pro- NPY. Some antibodies against pro-NPY may enable detection of CPON. Some antibodies against pro-NPY may enable detection of mature NPY.
  • the NPY level in a blood sample isolated from said individual is determined by measuring the plasma level of mature NPY with an analytic biochemistry assay such as ELISA.
  • Suitable antibodies for performing ELISA include antibodies capable of recognising and specifically binding to NPY.
  • the antibody recognises at least the C-terminal part of NPY.
  • the antibody specifically binds to at least the C-terminal part of NPY.
  • the antibody recognises and specifically binds to pro-NPY.
  • the level of NPY is determined by measuring the
  • the immunoreactivity can be determined by immunohistochemistry by methods known in the art.
  • the prostate tissue sample is stained with an antibody capable of recognising and specifically binding to at least a part of NPY, such as at least the C-terminal part of NPY.
  • the staining may be direct (with only one antibody) or indirect, using an unlabelled, primary antibody and a labelled, secondary antibody which recognises the primary antibody.
  • the staining can optionally be further amplified by using a biotin-conjugated secondary antibody.
  • the stained sample is counterstained, for example with a compound specifically staining a given class of molecules or with a compound staining the whole cell. The stained sample is then examined and the extent of staining is determined.
  • an NPY score is assigned.
  • the NPY score is positive if the NPY level is above a threshold value and negative if the NPY level is below said threshold value.
  • the NPY level is determined in a blood sample isolated from said individual and a plasma NPY level of 160 pg/mL plasma or more, such as 170 pg/mL plasma or more, such as 180 pg/mL plasma or more, such as 190 pg/mL plasma or more, such as 200 pg/mL plasma or more, such as 210 pg/mL plasma or more, such as 220 pg/mL plasma or more, such as 230 pg/mL plasma or more, such as 240 pg/mL plasma or more, such as 250 pg/mL plasma or more, such as 260 pg/mL plasma or more, such as 270 pg/mL plasma or more, such as 280 pg/mL plasma or more, such as 290 pg/mL plasma or more, such as 300 pg/mL plasma or more, such as 310 pg/mL plasma or more, such as 320 pg/
  • a plasma NPY level less than 160 pg/mL plasma such as less than 150 pg/mL pg/mL plasma, such as less than 140 pg/mL plasma, such as less than 130 pg/mL plasma, such as less than 120 pg/mL plasma, such as less than 110 pg/mL plasma, such as less than 100 pg/mL plasma, corresponds to a negative NPY score.
  • the plasma NPY level is less than a cut-off value, the NPY score is negative. If the plasma NPY level is equal to or more than said cut-off value, the NPY score is positive.
  • the cut-off value is 160 pg NPY/mL plasma.
  • the NPY level is determined by measuring immunoreactivity of NPY in a prostate tissue sample isolated from said individual and the NPY score is positive if NPY is detected in a proportion of the sample which is above a threshold value.
  • the NPY score is positive if NPY is detected in 25% of the sample or more, such as in 30% of the sample or more, such as in 35% of the sample or more, such as in 35% of the sample or more, such as in 40% of the sample or more, such as in 50% of the sample or more, such as in 60% of the sample or more, such as in 70% of the sample or more, such as in 80% of the sample or more, such as in 90% of the sample or more, such as in 100% of the sample.
  • the NPY score is negative if NPY is detected in a proportion of the sample which is below a threshold value. In some embodiments, the NPY score is negative if NPY is detected in less than 25% of the sample, such as in less than 20% of the sample, such as in less than 15% of the sample, such as in less than 10% of the sample, such as in less than 5% of the sample, or if NPY is not detected in any part of the sample.
  • a positive NPY score as defined above is assigned after measuring the NPY levels in a sample isolated from an individual suffering from prostate cancer.
  • the GS of the prostate cancer is 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2.
  • the GS of the prostate cancer is 8 or more, such as 9 or more, such as 10.
  • the prostate cancer is low-grade (or well-differentiated) or intermediate-grade (or moderately-differentiated). In other embodiments, the prostate cancer is poorly-differentiated (or high-grade).
  • the GS of the prostate cancer is 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2.
  • the GS of the prostate cancer is 7 or more, such as 8 or more, such as 9 or more, such as 10.
  • the GS of the prostate cancer is 10 or less, such as 9 or less, such as 8 or less, such as 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. It will be understood that although particularly useful for establishing a prognosis in an individual with a low GS, the methods disclosed herein can be used to establish a prognosis in an individual with any GS value.
  • the hazard ratio, sensitivity and/or specificity of the method may vary depending on the GS. In some embodiments, the lower the GS, the higher the hazard ratio for an individual having a positive NPY score. In some embodiments, the lower the GS, the higher the specificity and/or sensitivity of the method.
  • the method of the invention allows establishing a prognosis in an individual suffering from or at risk of suffering from prostate cancer.
  • a positive NPY score corresponds to a bad prognosis, while a negative NPY score corresponds to a good prognosis.
  • a bad prognosis reflects that there is a risk for the individual of dying of prostate cancer within 20 years.
  • a good prognosis reflects that there is substantially no risk for the individual of dying of prostate cancer within 20 years.
  • the present method allows classification of the severity of the prostate cancer.
  • a positive NPY score is as defined above and indicates that the individual is at increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score.
  • the hazard ratio with a 95% confidence interval for individuals with a low GS is between 1.08 and 5.81.
  • Such individuals have an increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score, wherein said risk is increased by a factor of 1.08 or more, such as 1.5 or more, such as 2.0 or more, such as 2.50 or more, such as 2.51 or more, such as 3.0 or more, such as 3.5 or more, such as 4.0 or more, such as 4.5 or more, such as 5.0 or more, such as 5.5 or more, such as 5.81 or more, where a low GS is 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2.
  • the hazard ratio with a 95% confidence interval for individuals with a low GS or less is between 1.6 and 16.84
  • individuals have an increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score, wherein said risk is increased by a factor of 1.6 or more, such as 1.7 or more, such as 2.0 or more, such as 3.0 or more, such as 4.0 or more, such as 5.0 or more, such as 5.2 or more, such as 6.0 or more, such as 7.0 or more, such as 8.0 or more, such as 9.0 or more, such as 10.0 or more, such as 12.0 or more , such as 14.0 or more , such as 16.8 or more, such as 16.84, where a low GS is 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2.
  • the hazard ratio with a 95% confidence interval for individuals independent of the value of the GS is 1.21 or more, such as 1.30 or more, such as 1.40 or more, such as 1.50 or more, such as 1.60 or more, such as 1.70 or more, such as 1.80 or more, such as 1.90 or more, such as 2.00 or more, such as 2.10 or more, such as 2.13 or more, such as 2.20 or more, such as 2.30 or more, such as 2.40 or more, such as 2.50 or more, such as 2.60 or more, such as 2.70 or more, such as 2.80 or more, such as 2.90 or more, such as 3.00 or more, such as 3.10 or more, such as 3.20 or more, such as 3.30 or more, such as 3.40 or more, such as 3.50 or more, such as 3.60 or more, such as 3.70 or more, such as 3.73.
  • the hazard ratio with a 95% confidence interval for individuals independent of the value of the GS is between 1.21 and 3.73.
  • individuals have an increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score, wherein said risk is increased by a factor of 1.21 or more, such as 1.30 or more, such as 1.40 or more, such as 1.50 or more, such as 1.60 or more, such as 1.70 or more, such as 1.80 or more, such as 1.90 or more, such as 2.00 or more, such as 2.10 or more, such as 2.13 or more, such as 2.20 or more, such as 2.30 or more, such as 2.40 or more, such as 2.50 or more, such as 2.60 or more, such as 2.70 or more, such as 2.80 or more, such as 2.90 or more, such as 3.00 or more, such as 3.10 or more, such as 3.20 or more, such as 3.30 or more, such as 3.40 or more, such as 3.50 or
  • a positive NPY score indicates that the prostate cancer is aggressive and progressing rapidly, and a negative NPY score indicates that the prostate cancer is progressing slowly.
  • the degree of aggressiveness of the cancer is expected to correlate to the prognosis.
  • a positive NPY score indicates that the individual is in need of active therapy, while a negative NPY score indicates that the individual is not in need of active therapy.
  • Active therapy includes methods such as, but not limited to, the administration of a medicament, surgical castration, external beam radiation therapy, brachytherapy, radical prostatectomy, hormone therapy, cryotherapy and/or high frequency ultra sound therapy.
  • active therapy comprises the administration of a medicament, where the medicament is selected from the group consisting of a GnRH-agonist, a GnRH-antagonist, an estrogen, an LHRH agonist, an LHRH antagonist, an androgen synthesis inhibitor and an androgen receptor antagonist.
  • the present method may further comprise a step of treating the individual.
  • the method comprises a step of treating the individual if the NPY score is positive.
  • the method comprises a step of treating the individual if the NPY score is negative.
  • the method does not comprise a step of treating the individual if the NPY score is negative.
  • the prognosis as defined above i.e. risk of prostate cancer- specific death, aggressiveness of the cancer, hazard ratios or need for active therapy, might vary over time.
  • the present method is performed repeatedly and the levels of NPY are monitored over time, such as once a year, such as every second year, such as every third year, such as every fifth year.
  • ERG levels i.e. risk of prostate cancer- specific death, aggressiveness of the cancer, hazard ratios or need for active therapy.
  • ERG ETS-related gene
  • ERG is encoded by a proto-oncogene.
  • ERG is a member of the ETS (erythroblast transformation-specific) family of transcription factors and functions as a transcriptional regulator.
  • ERG can fuse with TMPRSS2 protein to form an oncogenic fusion gene that is commonly found in human prostate cancer. This fusion gene is critical to the progression of cancer because it disrupts the ability of the cells to differentiate into proper prostate epithelial cells creating unregulated and unorganized tissue. 90% of prostate cancers overexpressing ERG also possess a fusion TMPRSS2- ERG gene.
  • the inventors have surprisingly found that the ERG protein can, together with NPY, be used as a biomarker of prostate cancer progression.
  • the present method further comprises the steps of determining the level of ERG in said sample and assigning to said level of ERG an ERG score, where the ERG score is positive if ERG is expressed and negative if ERG is not expressed.
  • the level of ERG can be determined by methods known in the art, in particular by analytic biochemistry assays such as ELISA (enzyme-linked immunosorbent assay) or by measuring the immunoreactivity of ERG by assays such as immunohistochemical assays. It is to be understood that any method allowing determination of ERG level in the individual can be used in the present method.
  • the level of ERG is determined by measuring the
  • IR immunoreactivity
  • the prostate tissue sample is stained with an antibody capable of recognising and specifically binding to at least a part of ERG.
  • the staining may be direct (with only one antibody) or indirect, using an unlabelled, primary antibody and a labelled, secondary antibody which recognises the primary antibody.
  • the staining can optionally be further amplified by using a biotin-conjugated secondary antibody.
  • the stained sample is counterstained, for example with a compound specifically staining a given class of molecules or with a compound staining the whole cell.
  • the stained sample is then examined and the extent of staining is determined.
  • an ERG score is assigned.
  • the ERG score is positive if the ERG level is above a threshold value and negative if the ERG level is below said threshold value.
  • the ERG score is positive if it is detected in the prostate tissue sample, and negative if it is not detected in the prostate tissue sample.
  • the ERG level is determined by measuring immunoreactivity of ERG in a prostate tissue sample isolated from said individual.
  • the ERG score is positive if ERG is detected in a proportion of the sample which is above a threshold value and negative if it is detected in a proportion of the sample which is below a threshold value.
  • the threshold value is 10%. In other embodiments, the threshold value is 5%. In other embodiments, the threshold value is 1 %.
  • the ERG score is positive if ERG is detected in 10% of the sample or more, such as in 15% of the sample or more, such as 20% of the sample or more, such as in 25% of the sampler or more, such as in 30% of the sample or more, such as in 35% of the sample or more, such as in 35% of the sample or more, such as in 40% of the sample or more, such as in 50% of the sample or more, such as in 60% of the sample or more, such as in 70% of the sample or more, such as in 80% of the sample or more, such as in 90% of the sample or more, such as in 100% of the sample.
  • the NPY level is determined by measuring immunoreactivity of NPY in a prostate tissue sample isolated from said individual and the NPY score is positive if NPY is detected in a proportion of the sample which is above a threshold value.
  • the NPY score is positive if NPY is detected in 25% of the sample or more, such as in 30% of the sample or more, such as in 35% of the sample or more, such as in 35% of the sample or more, such as in 40% of the sample or more, such as in 50% of the sample or more, such as in 60% of the sample or more, such as in 70% of the sample or more, such as in 80% of the sample or more, such as in 90% of the sample or more, such as in 100% of the sample.
  • the NPY score is negative if NPY is detected in a proportion of the sample which is below a threshold value. In some embodiments, the NPY score is negative if NPY is detected in less than 25% of the sample, such as in less than 20% of the sample, such as in less than 15% of the sample, such as in less than 10% of the sample, such as in less than 5% of the sample, or if NPY is not detected in any part of the sample. In some embodiments, a positive ERG score as defined above is assigned after measuring the ERG levels in a sample isolated from an individual suffering from prostate cancer. In some embodiments, the GS of the prostate cancer is 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2.
  • the GS of the prostate cancer is 8 or more, such as 9 or more, such as 10.
  • the prostate cancer is low-grade (or well-differentiated) or intermediate-grade (or moderately-differentiated).
  • the prostate cancer is poorly-differentiated (or high-grade).
  • the method of the invention allows establishing a prognosis in an individual suffering from or at risk of suffering from prostate cancer.
  • a positive NPY score together with a positive ERG score corresponds to a bad prognosis, while at least one of the NPY score and ERG score being negative corresponds to a good prognosis.
  • the prognosis is good if:
  • the NPY score is positive and the ERG score is negative
  • a bad prognosis reflects that there is a risk for the individual of dying of prostate cancer within 20 years.
  • a good prognosis reflects that there is substantially no risk for the individual of dying of prostate cancer within 20 years.
  • a positive NPY score and a positive ERG score are as defined above and together indicate that the individual is at increased risk of prostate cancer- specific mortality compared to an individual with at least one of the NPY score and ERG score being negative.
  • the hazard ratio with a 95% confidence interval for individuals with a low GS is 3.0 or more, such as 5.55 or more, such as 6.0 or more, such as 10.0 or more, such as 15.0 or more, such as 17.31 or more, such as 20.0 or more, such as 25.0 or more, such as 30.0 or more, such as 35.0 or more, such as 40.0 or more, such as 45.0 or more, such as 50.0 or more, such as 54.02 or more, such as 55.0 or more; where a low GS is 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2.
  • the hazard ratio with a 95% confidence interval for individuals with a low GS or less is between 5.55 and 54.02.
  • individuals have an increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score, wherein said risk is increased by a factor of 3.0 or more, such as 5.55 or more, such as 6.0 or more, such as 10.0 or more, such as 15.0 or more, such as 17.31 or more, such as 20.0 or more, such as 25.0 or more, such as 30.0 or more, such as 35.0 or more, such as 40.0 or more, such as 45.0 or more, such as 50.0 or more, such as 54.02 or more, such as 55.0 or more.
  • a positive NPY score and a positive ERG score are as defined above and together indicate that the individual is at increased risk of prostate cancer- specific mortality compared to an individual with at least one of the NPY score and ERG score being negative.
  • the hazard ratio with a 95% confidence interval for individuals with a low GS is between 20 and 750, such as between 23.98 and 724.1 1.
  • the hazard ratio with a 95% confidence interval is 20 or more, such as 30.0 or more, such as 40.0 or more, such as 50.0 or more, such as 75.0 or more, such as 100.0 or more, such as 150.0 or more, such as 200.0 or more, such as 300.0 or more, such as 400.0 or more, such as 500.0 or more, such as 600.0 or more, such as 700.0 or more, such as 724.0 or more, where a low GS is 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2.
  • Such individuals have an increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score, wherein said risk is increased by a factor of 20 or more, such as 30.0 or more, such as 40.0 or more, such as 50.0 or more, such as 75.0 or more, such as 100.0 or more, such as 150.0 or more, such as 200.0 or more, such as 300.0 or more, such as 400.0 or more, such as 500.0 or more, such as 600.0 or more, such as 700.0 or more, such as 724.0 or more.
  • a factor of 20 or more such as 30.0 or more, such as 40.0 or more, such as 50.0 or more, such as 75.0 or more, such as 100.0 or more, such as 150.0 or more, such as 200.0 or more, such as 300.0 or more, such as 400.0 or more, such as 500.0 or more, such as 600.0 or more, such as 700.0 or more, such as 724.0 or more.
  • the hazard ratio with a 95% confidence interval for individuals independent of the value of the GS is 2.0 or more, such as 2.64 or more, such as 3.0 or more, such as 3.5 or more, such as 4.0 or more, such as 4.5 or more, such as 5.0 or more, such as 6.0 or more, such as 7.0 or more, such as 7.5 or more, such as 8.0 or more, such as 8.5 or more, such as 9.0 or more, such as 9.5 or more, such as 9.65 or more.
  • the hazard ratio with a 95% confidence interval for individuals independent of the value of the GS is between 2.64 and 9.65.
  • Such individuals have an increased risk of prostate cancer-specific mortality compared to an individual with at least one of the NPY score and ERG score being negative, wherein said risk is increased by a factor of 2.0 or more, such as 2.64 or more, such as 3.0 or more, such as 3.5 or more, such as 4.0 or more, such as 4.5 or more, such as 5.0 or more, such as 6.0 or more, such as 7.0 or more, such as 7.5 or more, such as 8.0 or more, such as 8.5 or more, such as 9.0 or more, such as 9.5 or more, such as 9.65 or more.
  • a factor of 2.0 or more such as 2.64 or more, such as 3.0 or more, such as 3.5 or more, such as 4.0 or more, such as 4.5 or more, such as 5.0 or more, such as 6.0 or more, such as 7.0 or more, such as 7.5 or more, such as 8.0 or more, such as 8.5 or more, such as 9.0 or more, such as 9.5 or more, such as 9.65 or more.
  • a positive NPY score and a positive ERG score together indicate that the prostate cancer is aggressive and progressing rapidly, while at least one of the NPY score and ERG score being negative indicates that the prostate cancer is progressing slowly. Without being bound by theory, the degree of aggressiveness of the cancer is expected to correlate to the prognosis.
  • a positive NPY score and/or a positive ERG score as defined above are assigned after measuring the NPY and ERG levels in a sample isolated from an individual suffering from prostate cancer.
  • the GS of the prostate cancer is 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2.
  • the GS of the prostate cancer is 8 or more, such as 9 or more, such as 10.
  • the prostate cancer is low-grade (or well-differentiated) or intermediate-grade (or moderately-differentiated).
  • the prostate cancer is poorly-differentiated (or high-grade).
  • the GS of the prostate cancer is 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2.
  • the GS of the prostate cancer is 7 or more, such as 8 or more, such as 9 or more, such as 10.
  • the GS of the prostate cancer is 10 or less, such as 9 or less, such as 8 or less, such as 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. It will be understood that although particularly useful for establishing a prognosis in an individual with a low GS, the methods disclosed herein can be used to establish a prognosis in an individual with any GS value.
  • the hazard ratio, sensitivity and/or specificity of the method may vary depending on the GS. In some embodiments, the lower the GS, the higher the hazard ratio for an individual having a positive NPY score and a positive ERG score. In some embodiments, the lower the GS, the higher the specificity and/or sensitivity of the method.
  • the present method may further comprise a step of treating the individual.
  • the method comprises a step of treating the individual if the NPY score and the ERG score are positive.
  • the method comprises a step of treating the individual if at least one of the NPY score and ERG score is negative.
  • the method does not comprise a step of treating the individual if at least one of the NPY score and ERG score is negative.
  • the method does not comprise a step of treating the individual if both the NPY score and the ERG score are negative.
  • a positive NPY score and a positive ERG score together indicate that the individual is in need of active therapy, while at least one of the NPY score and ERG score being negative indicates that the individual is not in need of active therapy.
  • Active therapy includes methods such as, but not limited to, the administration of a medicament, surgical castration, external beam radiation therapy, brachytherapy, radical prostatectomy, hormone therapy, cryotherapy and/or high frequency ultra sound therapy.
  • active therapy comprises the administration of a medicament, where the medicament is selected from the group consisting of a GnRH-agonist, a GnRH-antagonist, an estrogen, an LHRH agonist, an LHRH antagonist, an androgen synthesis inhibitor and an androgen receptor antagonist.
  • the prognosis as defined above i.e. risk of prostate cancer- specific death, aggressiveness of the cancer, hazard ratios or need for active therapy, might vary overtime.
  • the present method is performed repeatedly and the levels of NPY and ERG are monitored over time, such as once a year, such as every second year, such as every third year, such as every fifth year.
  • the invention thus relates to NPY for use in the prognosis of prostate cancer-specific mortality.
  • determining the levels of NPY in a sample isolated from an individual suffering from or suspected of suffering from prostate cancer can be used in a method for establishing a prognosis for prostate cancer as disclosed herein.
  • the present methods provide a reliable prognosis independently of the GS, but appear even more reliable when performed on individuals with a GS of 7 or less, or with a GS of 6 or less.
  • the prognostic can also be established by determining not only the level of NPY but also the level of ERG, as detailed above.
  • the invention relates to a kit for performing the method of the invention, comprising an anti-NPY antibody recognising at least the C-terminal part of NPY, an anti-ERG antibody recognising ERG and instructions for use.
  • the kit disclosed herein may comprise other reagents and/or materials necessary for performing the method of the invention.
  • the kit may also comprise synthetic or recombinant variants of NPY and/or ERG, istopically labelled variants of NPY and/or ERG, chemically modified variants of NPY and/or ERG, fluorescently labelled variants of NPY and/or ERG.
  • variants may be used as standard composition in order to allow precise quantification of NPY and/or ERG, respectively, in a sample isolated from an individual.
  • Radical prostatectomy specimens collected at the Umea University Hospital were frozen or formalin fixed and preserved in paraffin.
  • Paraffin sections were macro-dissected to isolate control tissue (defined as non-malignant tissue without high grade of inflammation, atrophy, or PIN) and prostate cancer of different Gleason scores for mass spectrometry analysis.
  • Epithelial-rich areas >50 % epithelial cells were selected, mainly from the peripheral prostate zone. Frozen prostate sections were used for histochemistry.
  • Tissue microarrays from a historical cohort of men with prostate cancer (detected after transurethral resection of the prostate due to voiding symptoms) and followed by watchful waiting were used to evaluate NPY prognostic predictive value.
  • a cohort of 122 patients (Ahlqvist et al., 2013) treated with radical prostatectomy at the Skane University Hospital, Malmo, Sweden was used to study ERG and NPY expression in relation with disease relapse after prostatectomy also known as biochemical recurrence (BCR). The studies were approved by the Ethics Committee, Lund University, Sweden, and the Helsinki Declaration of Human Rights was strictly observed.
  • Cell lines and culture conditions were used to evaluate NPY prognostic predictive value.
  • LNCaP, PC-3, 22Rv1 and WPMY-1 were purchased from LGC standards (Sweden). Cells were maintained in RPMI medium supplemented with 10% FBS.
  • SI LAC proteome isotopic labelling
  • cells were cultured for at least 10 generations in arginine and lysine depleted RPMI medium (Biowest) supplemented with 28 and 48 mg/L Arg10 ( 13 C 6 ; 15 N 4 ) and Lys8 ( 13 C 6 ; 15 N 2 ) respectively (Cambridge isotope laboratories, Inc) and 10% dialyzed FBS (SIGMA).
  • Protein extracts of SI LAC labelled LNCaP, PC-3, 22Rv1 and WPMY-1 were mixed in a 27:27:27: 19 ratio and used as spike-in standard in all subsequent mass spectrometry analyses.
  • Whole protein extracts were purified from FFPE specimens (10-20 sections of about 100 mm 2 tissue) essentially as described (Ostasiewicz et al., 2010) mixed in equimolar amounts with the isotopically labeled protein standard obtained from the cell lines and trypsin digested following the Filter-Aid Sample Preparation (FASP) methodology.
  • FASP Filter-Aid Sample Preparation
  • the resulting tryptic peptides were further fractionated by Strong Anion Exchange chromatography (SAX) into six fractions to reduce sample complexity and maximize depth of proteome coverage.
  • SAX Strong Anion Exchange chromatography
  • Tissue microarray Tissue microarray (TMA) and whole paired tissue sections were deparaffinized in xylene and rehydrated through graded ethanol. Immunohistochemistry was performed in one batch for each protein and cohort by using the ultraView Universal DAB Detection kit with the CC1 antigen retrieval technique in the automatic VENTANA Benchmark Ultra system, according to manufacturer ' s description (Roche Diagnostics, Mannheim, Germany). For immunohistochemistry of NPY alone, the primary antibody was anti-NPY (diluted 1 :500, HPA044572, Atlas Antibodies). Immunoreactivity (IR) was scored as 0 ( ⁇ 25 % positive cells) or 1 (>25 % intensely stained cells).
  • Example 2 Identification of a novel biomarker of disease progression.
  • GG histological Gleason grade
  • pro-NPY peptide identified by mass spectrometry corresponded to a portion of the protein C-terminal end (amino acid residues 68 to 97 of SEQ ID NO: 1), which is normally proteolytically processed to generate mature NPY (amino acid residues 1 to 67 of SEQ ID NO: 1) (Fig. 1 B).
  • the most abundant peptide corresponds to residues 68 to 80 of NPY (SEQ ID NO: 1). Therefore, an antibody generated against the C-terminal domain of pro-NPY was used to assess its expression levels by IHC analysis in a cohort of 289 prostate cancer specimens treated with watchful waiting, of which 197 had associated benign prostate tissue.
  • the samples were obtained from transurethral prostate resection (TURP) procedures from a population that has not been screened for PSA and has been followed up for median of 22 years.
  • Pro-NPY immunoreactivity (IR) was stratified as negative (Fig. 4A, upper panels) or positive (Fig. 4B, lower panels).
  • the overall inspection of IHC data revealed that 40% of the tumours exhibit moderate (>25% stained cells) or strong staining (>75% stained cells) for pro- NPY (corresponding to a positive NPY score NPY+) and significant differences in expression levels of pro-NPY between normal and tumour tissues were observed (Fig. 1 C).
  • Tumours with GS > 6 showed significantly increased expression of pro-NPY than tumours with GS ⁇ 6, confirming the findings obtained by mass spectrometry analysis (Fig. 1 C).
  • pro- NPY levels were no longer predictive of death for patients with high Gleason score tumours (GS > 6) but an increased mortality was observed for patients carrying low Gleason tumours (GS ⁇ 6) exhibiting high levels of pro-NPY [HR: 5.2 (1.6-16.84)], indicating that pro-NPY levels could be particularly useful for the identification of aggressive tumours at an early stage (Fig. 2B).
  • GS > 6 When tumours with Gleason tumours GS ⁇ 7 were evaluated, we found that those with high levels of pro-NPY exhibit increased risk of prostate cancer specific mortality HR: 2.51 (1.08-5.81).
  • ERG expression has been previously analyzed in this cohort and demonstrated to be related to increased risk of disease related mortality as well as to other factors of prognostic significance, such as cell proliferation and angiogenesis (Hagglof et al., 2014).
  • NPY and ERG can be used in combination as prognostic markers for evaluating the aggressiveness of prostate tumours, in particular in tumours with low Gleason scores.
  • prognostic biomarkers that can identify aggressive tumours among those normally deemed to exhibit low to intermediate risk based on Gleason grading can provide physicians with better tools to select patients that will benefit from active therapy more accurately.
  • pro-NPY levels in prostate tissue samples are predictive of prostate cancer-specific mortality in a watchful waiting cohort, and show that this is especially true for patients with low-grade tumours.
  • Patients bearing Gleason 6 tumours and high levels of NPY have 5-fold increased risk of dying from prostate cancer.
  • Example 5 Measuring NPY and CPON secreted from prostate cancer cells.
  • C-flanking peptide of NPY (CPON) and pro-NPY secreted by VCaP prostate cancer cells were analysed by capillary electrophoresis (Fig. 9).
  • the CPON was detected by an anti-proNPY antibody.
  • results using the anti-proNPY antibody from Atlas antibodies (HPA044572) are shown.
  • Recombinant pro-NPY fragment can be detected by antibodies against mature NPY.
  • results using the Millipore AB1583 against NPY are shown.

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Abstract

The present invention relates to the finding that Neuropeptide Y (NPY) can be used as a marker for establishing a prognosis for prostate cancer. Disclosed herein is a method for establishing a prognosis by determining the levels of NPY and optionally of ERG in a sample isolated from an individual suffering from or suspected of suffering from prostate cancer. NPY may be determined by ELISA employing an antibody which binds to the C-terminal portion of pro-NPY. The present methods provide a reliable prognosis independently of the Gleason score (GS), but are even more reliable when performed on individuals with a GS of 7 or less.

Description

Neuropeptide Y as a prognostic marker of prostate cancer Field of invention The present invention relates to the finding that Neuropeptide Y (NPY) can be used as a marker for establishing a prognosis for prostate cancer. Disclosed herein is a method for establishing a prognosis by determining the levels of NPY and optionally of ERG in a sample isolated from an individual suffering from or suspected of suffering from prostate cancer. The present methods provide a reliable prognosis independently of the Gleason score (GS), but are even more reliable when performed on individuals with a GS of 7 or less.
Background of invention
Prostate cancer (PCa) is the most diagnosed cancer among men in Western societies and a leading cause of death. The wide implementation of Prostate Specific Antigen (PSA) testing has dramatically increased the number and lowered the age of patients diagnosed with prostate cancer. Most of PSA screened patients in fact harbour non- aggressive tumours that will not threaten the patient's life or cause significant morbidity if left untreated. The existence of potentially curative interventions for localized prostate cancer in the form of radical prostatectomy and radiation therapy, combined with diagnostic inability to precisely identify patients that harbour the aggressive manifestation of the disease has led to a situation of considerable overtreatment. In fact, it has been estimated that in order to prevent one prostate-cancer death, 1410 men (or 1068 men who actually underwent screening) would have to be PSA screened, and an additional 48 men would have to be treated (Schroder et al., 2009). Screening and treatment are heavy on society, be it from a financial point of view or a human point of view. Side-effects are often associated with treatment, which results in reduced quality of life. However, prostate cancer is often slowly progressing. Thus, in individuals where the cancer is not very aggressive and is progressing slowly, treatment sometimes has more negative effects than beneficial effects. It has been reported that neuropeptide Y (NPY) is highly expressed in some prostate tumour tissues (Uhlen et al., 2010). NPY is a 36 amino acid-long polypeptide (SEQ ID NO: 3) widely distributed in the central and peripheral nervous system of mammals. NPY is the most abundant neuropeptide in the brain and is known to induce vasoconstriction, to inhibit noradrenaline release at a pre-synaptic level, and to regulate diverse functions including blood pressure, stress, pain, hormone secretion, reproduction, circadian rhythm and food intake. NPY has been implicated in feeding disorders, epilepsy, hypertension, pain disorders, depression and anxiety. NPY is the result of cleavage of pro-neuropeptide Y (pro-NPY), a 97-amino acid long peptide (SEQ ID NO: 1) which is cleaved into NPY (alternative name: neuropeptide tyrosine), and C-flanking peptide of NPY (CPON).
High NPY expression was recently demonstrated preferentially in prostate tumours harbouring the TRMPSS2-ERG fusion gene (Massoner et al, 2014). However, the use of NPY alone or together with ERG (SEQ ID NO: 2) as markers for predicting the aggressiveness of prostate tumours and cancer-free survival has, to the best of our knowledge, never been reported.
Therefore, better prognostics tools for predicting the aggressiveness of prostate localized tumours are needed.
Summary of invention The present invention is based on the finding that NPY alone or in combination with ERG can be used as a prognostic marker in prostate cancer patients. The inventors have surprisingly found that high levels of NPY reflect a bad prognosis, in particular in patients with low Gleason scores. Moreover, the inventors have found that high expression of both NPY and ERG can also be used as a prognostic marker and reflect a bad prognosis, in particular in patients with low Gleason scores. A bad prognosis is an increased risk of dying of prostate cancer within 20 years, while a good prognosis means that the patient is substantially not at risk of dying of prostate cancer within 20 years. As disclosed herein, determining the levels of NPY in a sample isolated from an individual suffering from or suspected of suffering from prostate cancer can be used in a method for establishing a prognosis for prostate cancer. The present methods provide a reliable prognosis independently of the GS, but are even more reliable when performed on individuals with a GS of 7 or less. The prognostic can also be established by determining not only the level of NPY but also the level of ERG, as detailed above.
The present methods are thus advantageous to prevent overmedication and surgical procedures on individuals who are likely not to benefit from them. It follows that the present invention also is capable of identifying individuals who will benefit from immediate treatment.
In one aspect, the invention relates to a method for establishing a prognosis in an individual suffering from or at risk of suffering from prostate cancer, said method comprising the steps of determining the level of NPY in a sample isolated from said individual and assigning an NPY score to said level of NPY and establishing the prognosis based on said NPY score.
In another aspect, the invention relates to NPY for use in the prognosis of prostate- cancer specific mortality.
In yet another aspect, the invention relates to a kit for performing the method of the invention, comprising an anti-NPY antibody recognising at least the C-terminal part of NPY, an anti-ERG antibody recognising ERG and instructions for use.
Description of Drawings
Figure 1. Pro-NPY expression is elevated in prostate tumours. (A) Scatter plot of the different relative expression of proteins quantified in "low risk" prostate tumours defined as tumours with predominant Gleason Grade 3 (GG3) versus "high risk" tumours, predominant GG4, distributed according to the probability of being true expressed as -log of Student's t-test p value. X-axis: high risk vs low risk log2 (difference of mean ratios); Y-axis: -log(t-test p value). (B) MS/MS spectrum of the most commonly identified NPY peptide across all samples. Peptide matches to the c- terminal domain of NPY (pro-NPY). Y-axis: relative abundance. (C) pro-NPY immunoreactivity in prostate tumours and benign neighbouring tissue (left) and in GS≤6 and GS>6 (right) was measured on prostate tissue samples from a "watchful waiting" cohort. Chi square p value is shown.
Figure 2. High Pro-NPY expression levels correlates to poor prognosis. Kaplan- Meier analysis of pro-NPY expression relative to prostate cancer-free survival. X-axis: time in years. Y-axis: PCa specific survival in percentage. (A): Left panel: Tumours of all GS. Specificity: 64.6% (56.3 to 72.3); sensitivity: 60% (45.18 to 73.6). Right panel: GS≤6 (right). Specificity: 68.56% (58.8 to 77.3); sensitivity: 75% (42.8 to 94.5). Hazard ratios (HR) with 95% interval coefficient are shown. Log-rank p value and number of patients per group are shown. NPY-: negative for NPY; NPY+: positive for NPY. (B) Left panel: pro-NPY IR measured in prostate tumours. Right panel: pro-NPY IR measured in various tumours. X- axis (from left to right): breast, colon, liver, lung, oral, ovary, pancreas, prostate, stomach, uterus; Y-axis: number of cases
Figure 3. High Pro-NPY and high ERG expression levels correlate to poor prognosis. Kaplan-Meier analysis of combined pro-NPY and/or ERG expression relative to prostate cancer-free survival. X-axis: time in years. Y-axis: PCa specific survival in percentage. (A) Tumours of all GS. Specificity: 85.81 % (79.13 to 91); sensitivity: 54% (39.32 to 68.19). (B) GS>6 (left) or GS≤6 (right). Specificity: 94% (87.4 to 97.77); sensitivity: 72.7% (39 to 94). Hazard ratio (HR) with 95% interval coefficient is shown as well as specificity and sensitivity of NPY to predict PCa survival. Log-rank p value and number of patients per group are shown. In order to calculate HR and marker specificity and sensitivity, patients positive for both pro-NPY and ERG were compared with patients being negative for at least one of the markers. NPY-: negative for NPY; NPY+: positive for NPY. Figure 4. Pro-NPY in prostate cancer. (A) Representative pictures of pro-NPY expression evaluated by IHC. Pro-NPY immunoreactivity (IR) was scored as negative (NPY-) or positive (NPY+). (B) Quantification of pro-NPY expression was retrieved from the Human Protein Atlas project database for additional cancer types (tumour number is indicated, n). From left to right, on X-axis: carcinoid, cervical, endometrial, glioma, head and neck, lymphoma, melanoma, prostate, renal, skin, testis, thyroid, urothelial. Y axis: number of cases.
Figure 5. (A) Kaplan-Meier analysis of the tumours Gleason score (GS) relative to prostate cancer-free survival in the TURP cohort (Y-axis). X-axis: time in years. (B)
Kaplan-Meier analysis of ERG expression relative to prostate cancer-free survival in all tumours (left) or restricted to tumours with GS≤ 6 (right).
Figure 6. (A) Kaplan-Meier analysis of the tumours Gleason scores (GS) relative to biochemical recurrence (BCR)-free survival (Y-axis) in the prostatectomy cohort. X- axis: time in months. (B) Kaplan-Meier analysis of pro-NPY (NPY), ERG or the combined expression relative to BCR-free survival (BCR) (Y-axis) in the prostatectomy cohort. First row: pro-NPY; second row: ERG; third tow: combined pro-NPY and ERG. In the left panels, expression across all GS is analysed; in the middle panels expression is analysed for GS>6; in the right panels, expression is analysed for GS≤ 6. When the combination of pro-NPY/ERG is analysed, patients positive for both ERG and pro-NPY were compared with patients being negative for at least one of the markers. NPY+: NPY score is positive; NPY-: NPY score is negative. X-axis: time in months.
Figure 7. High Pro-NPY and ERG expression levels correlate to poor prognosis in patients with GS <7. (A) Kaplan-Meier analysis of pro-NPY expression in patients with 4≤GS≤7. X-axis: time in years; Y-axis: percent survival. (B) Kaplan-Meier analysis of pro-NPY and ERG expression in patients with 4≤GS≤7. X-axis: time in years; Y-axis: percent survival.
Figure 8. Plasma NPY levels predict prostate cancer specific mortality. NPY plasma levels were divided in quartiles and their relation to prostate cancer specific mortality was analysed using the Kaplan-Meier method. X-axis: time in months; Y-axis: PCa specific survival.
Figure 9. Detection of pro-NPY and CPON by capillary electrophoresis (Peggy Sue system, Proteinsimple). Samples used: (A) standard, recombinant CPON; (B, E) standard, recombinant pro-NPY; (C) DMEM/F12 medium supplemented with 10% FBS; (D) DMEM/F12 medium supplemented with 10% FBS after culturing VCaP prostate cancer; (F) recombinant NPY.
Definitions
Gleason grading: The Gleason grading system is used to evaluate the prognosis of men with prostate cancer. A Gleason score is given based on the microscopic appearance of prostate cancer tissues. Five histologic patterns can be observed and are assessed microscopically by a pathologist upon examination of the tissues.
Pattern 1 : The cancerous prostate closely resembles normal prostate tissue. The glands are small, well-formed, and closely packed. This corresponds to a well differentiated carcinoma.
Pattern 2: The tissue still has well-formed glands, but they are larger and have more tissue between them, implying that the stroma has increased. This also corresponds to a moderately differentiated carcinoma.
Pattern 3: The tissue still has recognizable glands, but the cells are darker. At high magnification, some of these cells have left the glands and are beginning to invade the surrounding tissue or having an infiltrative pattern. This corresponds to a moderately differentiated carcinoma.
Pattern 4: The tissue has few recognizable glands. Many cells are invading the surrounding tissue in neoplastic clumps. This corresponds to a poorly differentiated carcinoma.
Pattern 5: The tissue does not have any or only a few recognizable glands. There are often just sheets of cells throughout the surrounding tissue. This corresponds to an anaplastic carcinoma.
Prostate cancer of Gleason patterns 1 and 2 are rarely seen. Gleason pattern 3 is by far the most common.
The pathologist assigns a grade to the tumour specimen depending on the observed patterns. A primary grade is assigned to the dominant pattern of the tumour (greater than 50% of the total pattern seen). A secondary grade is assigned to the next-most frequent pattern (less than 50%, but at least 5%, of the pattern of the total cancer observed). A tertiary grade is assigned where there is a small component of a third (generally more aggressive) pattern.
The Gleason score (GS) is calculated by summing up the Gleason Grades (GG) of:
If only two patterns are seen, the GS is the sum of the GG of the primary pattern and of the secondary pattern;
If three patterns are seen, the GS is the sum of the GG of the primary pattern and the GG for the pattern having the highest GG.
Gleason scores range from 2 to 10, with 2 representing the best-differentiated tumours and 10 the least-differentiated tumours. Gleason scores have often been categorized into groups that show similar biologic behaviour: low-grade (well-differentiated), intermediate-grade, moderate to poorly-differentiated or high-grade. The Gleason scores are typically used to define prognostic grade groups as: Gleason score≤ 6
(prognostic grade group I); Gleason score 3+4=7 (prognostic grade group II); Gleason score 4+3=7 (prognostic grade group III); Gleason score 4+4=8 (prognostic grade group IV); Gleason scores 9-10 (prognostic grade group V). Prostate cancers with a Gleason score≤ 6 are commonly considered to have rather good prognoses.
Immunohistochemistry: Immunohistochemistry or IHC refers to the process of detecting antigens (e.g., proteins) in cells of a tissue section by exploiting the principle of antibodies binding specifically to antigens in biological tissues. Immunohistochemical staining is widely used in the diagnosis of abnormal cells such as those found in cancerous tumours. Visualising an antibody-antigen interaction can be accomplished in a number of ways. In the most common instance, an antibody is conjugated to an enzyme, such as peroxidase, that can catalyse a colour-producing reaction.
Alternatively, the antibody can also be tagged by a fluorophore, such as fluorescein or rhodamine.
Immunoreactivity or immune reactivity (IR): IR refers herein to the extent with which an antibody used in immunohistochemistry reacts with an antigen present in the examined tissue. Detailed description of the invention
The invention is as defined in the claims.
Method for prognosis of prostate cancer
In a first aspect, the invention relates to a method for establishing a prognosis in an individual suffering from or at risk of suffering from prostate cancer, said method comprising the steps of determining the level of NPY in a sample isolated from said individual and assigning an NPY score to said level of NPY and establishing the prognosis based on said NPY score.
Prostate cancer
The present method is useful for establishing a prognosis in an individual suffering from prostate cancer, suspected of suffering from prostate cancer or at risk of suffering from prostate cancer. The individual may have been diagnosed with prostate cancer with diagnostic methods known in the art. Individuals suffering from urinary or sexual problems and seeking medical advice typically undergo a digital rectal examination which can be followed by other tests if prostate cancer is suspected to be present. These other tests can also be performed as part of a screening program to detect prostate cancer early in men with no or few symptoms.
Such tests may include a PSA (prostate-specific antigen) blood test. Healthy men have PSA levels under 4 ng/mL of blood. The chance of having prostate cancer goes up as the PSA level goes up. When prostate cancer develops, the PSA level usually goes above 4 ng/mL of blood. However, about 15% of men with a PSA below 4 ng/mL of blood will have prostate cancer on a biopsy. A PSA level between 4 and 10 ng/mL of blood corresponds to a 1 in 4 chance of having prostate cancer. If the PSA is more than 10, the chance of having prostate cancer is over 50%. Thus PSA levels are only indicative of a risk of having prostate cancer. The presence of prostate cancer needs to be confirmed or infirmed by biopsy. The PSA level can be used to determine whether or not a biopsy is needed. Different approaches exist with different PSA level cutoff values: some practitioners recommend a biopsy if the PSA is 4 ng/mL of blood or more, while others use lower values such as 2.5 ng/mL of blood. Other factors such as age, race, medical history, family history, may also influence the choice of cutoff value.
The PSA test can also be useful if prostate cancer has already been diagnosed. In men diagnosed with prostate cancer, the PSA test can be used together with physical exam results and tumour grade determined from a biopsy to help decide if other tests (such as CT scans or bone scans) are needed. The PSA test is often used to predict whether the cancer has spread: very high PSA levels can indicate that the cancer has spread beyond the prostate. This may affect treatment options, since some forms of therapy (such as surgery and radiation) are not likely to be helpful if the cancer has spread to the lymph nodes, bones, or other organs.
Finally, the PSA test is often also used for monitoring the evolution of the prostate cancer during and after treatment.
Other tests include imaging of the prostate, e.g. by transrectal ultrasound (TRUS). TRUS can be used to get an image of the prostate when high PSA levels or abnormal digital rectal examination (DRE) results have been observed. It can be used to measure the size of the prostate gland, which can help determine the PSA density and may also affect the options of treatment. TRUS is also used as a guide during some forms of treatment such as brachytherapy or cryosurgery.
Definitive diagnosis of prostate cancer usually requires a biopsy. Investigation of the biopsy under the microscope is usually performed by pathologists, which grade the cancer. In some cases several biopsies are needed in order to confirm the presence of prostate cancer.
A common grading system is based on Gleason grading (GG). A pathologist assigns a grade to the tumour specimen depending on the histological patterns observed in the biopsy sample. A primary grade is assigned to the dominant pattern of the tumour
(greater than 50% of the total pattern seen). A secondary grade is assigned to the next- most frequent pattern (less than 50%, but at least 5%, of the pattern of the total cancer observed). A tertiary grade is assigned where there is a small component of a third (generally more aggressive) pattern. A Gleason score (GS) is then calculated by summing up the Gleason Grades (GG) of: If only two patterns are seen, the GS is the sum of the GG of the primary pattern and of the secondary pattern;
- If three patterns are seen, the GS is the sum of the GG of the primary pattern and the GG for the pattern having the highest GG.
Gleason scores range from 2 to 10, with 2 representing the best-differentiated tumours and 10 the least-differentiated tumours. Gleason scores have often been categorized into groups that show similar biologic behaviour: low-grade or well-differentiated (GS≤ 6), intermediate-grade or moderately-differentiated (GS = 7), and poorly-differentiated or high-grade (8≤ GS≤ 10). The Gleason scores are typically used to define prognostic grade groups as: Gleason score≤ 6 (prognostic grade group I); Gleason score 3+4=7 (prognostic grade group II); Gleason score 4+3=7 (prognostic grade group III); Gleason score 4+4=8 (prognostic grade group IV); Gleason scores 9-10
(prognostic grade group V). Prostate cancers with a Gleason score≤ 6 are commonly considered to have rather good prognoses, i.e. no increased risk of dying of prostate cancer within 20 years following diagnosis. Other grading or classification systems exist, examples of which include the D'Amico classification, where patients are stratified by low, intermediate, or high risk based on stage, grade, and PSA levels; the Partin tables, which predict pathologic outcomes (margin status, extraprostatic extension, and seminal vesicle invasion) based on stage, grade, and PSA levels; the Kattan nomograms, which predict recurrence after surgery and/or radiation therapy, based on data available either at time of diagnosis or after surgery; and the UCSF Cancer of the Prostate Risk Assessment (CAPRA) score, which predicts both pathologic status and recurrence after surgery.
In the present context, an individual suffering from prostate cancer is an individual diagnosed with prostate cancer, for example by one of the methods described above. The GS of the cancer in said individual can be 2, 3, 4, 5, 6, 7, 8, 9 or 10.
An individual at risk of suffering from prostate cancer, or an individual suspected of suffering from prostate cancer, is an individual which has not been diagnosed with prostate cancer, for example individuals presenting several symptoms usually associated with prostate cancer (urinary or sexual problems, high PSA levels, abnormal DRE results) but where a biopsy has not yet been performed or the biopsy results are negative. Other individuals may be considered at risk of developing prostate cancer based e.g. on their medical history or their family history.
Treatments typically used for individuals suffering from prostate cancer include active monitoring (or active surveillance), watchful waiting or active therapy. Active surveillance of an individual is usually carried out by a practitioner, wherein the cancer is monitored and active therapy is used if the cancer starts to grow in order to cure the individual. Active surveillance is carried out by monitoring the appearance of new symptoms or the aggravation of existing symptoms, measuring PSA levels, performing DRE and/or biopsy at fixed points in time. Watchful waiting means that treatment is postponed, e.g. because there are no symptoms, because treatment might never be needed or because cure is not possible for various reasons. Watchful waiting is typically used for individuals having localised prostate cancer with no symptoms but having a medical history or a medical background preventing radical treatment, or individuals having locally advanced or metastatic prostate cancer with no symptoms. Blood tests and other tests such as DRE and/or biopsy are used in watchful waiting.
Active therapy includes methods such as, but not limited to, the administration of a medicament, external beam radiation therapy, brachytherapy, radical prostatectomy, hormone therapy, cryotherapy and high frequency ultra sound therapy, and
combinations thereof.
NPY levels
The present method for establishing a prognosis in an individual suffering from or at risk of suffering from prostate cancer comprises a step of determining the NPY level in a sample isolated from said individual and assigning a positive or negative NPY score to said NPY level. The sample may be a prostate tissue sample, such as a biopsy sample, a blood sample, a urine sample, or any sample wherein the NPY level can be measured. In some embodiments, the NPY level is determined by measuring the level of a fragment of NPY. In other embodiments, the NPY level is determined by measuring the level of pro-NPY.
NPY levels can be determined by various methods known in the art. Such methods include analytic biochemistry assays such as ELISA (enzyme-linked immunosorbent assay) or measuring the immunoreactivity of NPY by assays such as
immunohistochemical assays. It is to be understood that any method allowing determination of NPY level in the individual can be used in the present method, including physical methods such as liquid chromatography, mass spectrometry, capillary electrophoresis, nuclear magnetic resonance, and any other quantitative method. Several methods may be combined, for example capillary electrophoresis may be combined with detection using an antibody.
Levels of NPY and/or levels of CPON can be detected and measured by any of the methods listed herein. If the method involves antibodies, the skilled person will know how to determine whether the antibody is suitable for determining NPY and/or CPON levels. For instance, some antibodies against mature NPY may enable detection of pro- NPY. Some antibodies against pro-NPY may enable detection of CPON. Some antibodies against pro-NPY may enable detection of mature NPY.
In some embodiments, the NPY level in a blood sample isolated from said individual is determined by measuring the plasma level of mature NPY with an analytic biochemistry assay such as ELISA. Suitable antibodies for performing ELISA include antibodies capable of recognising and specifically binding to NPY. In some embodiments, the antibody recognises at least the C-terminal part of NPY. In some embodiments, the antibody specifically binds to at least the C-terminal part of NPY. In some
embodiments, the antibody recognises and specifically binds to pro-NPY.
In other embodiments, the level of NPY is determined by measuring the
immunoreactivity (IR) of NPY in a prostate tissue sample isolated from said individual. The immunoreactivity can be determined by immunohistochemistry by methods known in the art. In some embodiments, the prostate tissue sample is stained with an antibody capable of recognising and specifically binding to at least a part of NPY, such as at least the C-terminal part of NPY. The staining may be direct (with only one antibody) or indirect, using an unlabelled, primary antibody and a labelled, secondary antibody which recognises the primary antibody. In embodiments where a primary and a secondary antibody are used, the staining can optionally be further amplified by using a biotin-conjugated secondary antibody. Optionally, the stained sample is counterstained, for example with a compound specifically staining a given class of molecules or with a compound staining the whole cell. The stained sample is then examined and the extent of staining is determined.
NPY score
After determining the NPY level, an NPY score is assigned. The NPY score is positive if the NPY level is above a threshold value and negative if the NPY level is below said threshold value.
In some embodiments, the NPY level is determined in a blood sample isolated from said individual and a plasma NPY level of 160 pg/mL plasma or more, such as 170 pg/mL plasma or more, such as 180 pg/mL plasma or more, such as 190 pg/mL plasma or more, such as 200 pg/mL plasma or more, such as 210 pg/mL plasma or more, such as 220 pg/mL plasma or more, such as 230 pg/mL plasma or more, such as 240 pg/mL plasma or more, such as 250 pg/mL plasma or more, such as 260 pg/mL plasma or more, such as 270 pg/mL plasma or more, such as 280 pg/mL plasma or more, such as 290 pg/mL plasma or more, such as 300 pg/mL plasma or more, such as 310 pg/mL plasma or more, such as 320 pg/mL plasma or more, such as 330 pg/mL plasma or more, such as 340 pg/mL plasma or more, corresponds to a positive NPY score.
A plasma NPY level less than 160 pg/mL plasma, such as less than 150 pg/mL pg/mL plasma, such as less than 140 pg/mL plasma, such as less than 130 pg/mL plasma, such as less than 120 pg/mL plasma, such as less than 110 pg/mL plasma, such as less than 100 pg/mL plasma, corresponds to a negative NPY score. Thus in some embodiments, if the plasma NPY level is less than a cut-off value, the NPY score is negative. If the plasma NPY level is equal to or more than said cut-off value, the NPY score is positive. In one embodiment, the cut-off value is 160 pg NPY/mL plasma.
In other embodiments, the NPY level is determined by measuring immunoreactivity of NPY in a prostate tissue sample isolated from said individual and the NPY score is positive if NPY is detected in a proportion of the sample which is above a threshold value. In some embodiments, the NPY score is positive if NPY is detected in 25% of the sample or more, such as in 30% of the sample or more, such as in 35% of the sample or more, such as in 35% of the sample or more, such as in 40% of the sample or more, such as in 50% of the sample or more, such as in 60% of the sample or more, such as in 70% of the sample or more, such as in 80% of the sample or more, such as in 90% of the sample or more, such as in 100% of the sample. The NPY score is negative if NPY is detected in a proportion of the sample which is below a threshold value. In some embodiments, the NPY score is negative if NPY is detected in less than 25% of the sample, such as in less than 20% of the sample, such as in less than 15% of the sample, such as in less than 10% of the sample, such as in less than 5% of the sample, or if NPY is not detected in any part of the sample.
In some embodiments, a positive NPY score as defined above is assigned after measuring the NPY levels in a sample isolated from an individual suffering from prostate cancer. In some embodiments, the GS of the prostate cancer is 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. In other embodiments, the GS of the prostate cancer is 8 or more, such as 9 or more, such as 10. In some embodiments, the prostate cancer is low-grade (or well-differentiated) or intermediate-grade (or moderately-differentiated). In other embodiments, the prostate cancer is poorly-differentiated (or high-grade). Thus in some embodiments the GS of the prostate cancer is 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. In other embodiments, the GS of the prostate cancer is 7 or more, such as 8 or more, such as 9 or more, such as 10. In other embodiments, the GS of the prostate cancer is 10 or less, such as 9 or less, such as 8 or less, such as 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. It will be understood that although particularly useful for establishing a prognosis in an individual with a low GS, the methods disclosed herein can be used to establish a prognosis in an individual with any GS value. The hazard ratio, sensitivity and/or specificity of the method may vary depending on the GS. In some embodiments, the lower the GS, the higher the hazard ratio for an individual having a positive NPY score. In some embodiments, the lower the GS, the higher the specificity and/or sensitivity of the method.
Prognosis
The method of the invention allows establishing a prognosis in an individual suffering from or at risk of suffering from prostate cancer. A positive NPY score corresponds to a bad prognosis, while a negative NPY score corresponds to a good prognosis. A bad prognosis reflects that there is a risk for the individual of dying of prostate cancer within 20 years. A good prognosis reflects that there is substantially no risk for the individual of dying of prostate cancer within 20 years. Thus in some embodiments the present method allows classification of the severity of the prostate cancer.
In some embodiments, a positive NPY score is as defined above and indicates that the individual is at increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score. The hazard ratio with a 95% confidence interval for individuals with a low GS is between 1.08 and 5.81. Thus such individuals have an increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score, wherein said risk is increased by a factor of 1.08 or more, such as 1.5 or more, such as 2.0 or more, such as 2.50 or more, such as 2.51 or more, such as 3.0 or more, such as 3.5 or more, such as 4.0 or more, such as 4.5 or more, such as 5.0 or more, such as 5.5 or more, such as 5.81 or more, where a low GS is 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2.
In some embodiments the hazard ratio with a 95% confidence interval for individuals with a low GS or less is between 1.6 and 16.84 Thus such individuals have an increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score, wherein said risk is increased by a factor of 1.6 or more, such as 1.7 or more, such as 2.0 or more, such as 3.0 or more, such as 4.0 or more, such as 5.0 or more, such as 5.2 or more, such as 6.0 or more, such as 7.0 or more, such as 8.0 or more, such as 9.0 or more, such as 10.0 or more, such as 12.0 or more , such as 14.0 or more , such as 16.8 or more, such as 16.84, where a low GS is 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. The hazard ratio with a 95% confidence interval for individuals independent of the value of the GS (i.e. 2≤ GS≤ 10) is 1.21 or more, such as 1.30 or more, such as 1.40 or more, such as 1.50 or more, such as 1.60 or more, such as 1.70 or more, such as 1.80 or more, such as 1.90 or more, such as 2.00 or more, such as 2.10 or more, such as 2.13 or more, such as 2.20 or more, such as 2.30 or more, such as 2.40 or more, such as 2.50 or more, such as 2.60 or more, such as 2.70 or more, such as 2.80 or more, such as 2.90 or more, such as 3.00 or more, such as 3.10 or more, such as 3.20 or more, such as 3.30 or more, such as 3.40 or more, such as 3.50 or more, such as 3.60 or more, such as 3.70 or more, such as 3.73. In some embodiments the hazard ratio with a 95% confidence interval for individuals independent of the value of the GS (i.e. 2≤ GS≤ 10) is between 1.21 and 3.73. Thus such individuals have an increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score, wherein said risk is increased by a factor of 1.21 or more, such as 1.30 or more, such as 1.40 or more, such as 1.50 or more, such as 1.60 or more, such as 1.70 or more, such as 1.80 or more, such as 1.90 or more, such as 2.00 or more, such as 2.10 or more, such as 2.13 or more, such as 2.20 or more, such as 2.30 or more, such as 2.40 or more, such as 2.50 or more, such as 2.60 or more, such as 2.70 or more, such as 2.80 or more, such as 2.90 or more, such as 3.00 or more, such as 3.10 or more, such as 3.20 or more, such as 3.30 or more, such as 3.40 or more, such as 3.50 or more, such as 3.60 or more, such as 3.70 or more, such as 3.73.
In some embodiments, a positive NPY score indicates that the prostate cancer is aggressive and progressing rapidly, and a negative NPY score indicates that the prostate cancer is progressing slowly. Without being bound by theory, the degree of aggressiveness of the cancer is expected to correlate to the prognosis.
In some embodiments, a positive NPY score indicates that the individual is in need of active therapy, while a negative NPY score indicates that the individual is not in need of active therapy. Active therapy includes methods such as, but not limited to, the administration of a medicament, surgical castration, external beam radiation therapy, brachytherapy, radical prostatectomy, hormone therapy, cryotherapy and/or high frequency ultra sound therapy. In some embodiments, active therapy comprises the administration of a medicament, where the medicament is selected from the group consisting of a GnRH-agonist, a GnRH-antagonist, an estrogen, an LHRH agonist, an LHRH antagonist, an androgen synthesis inhibitor and an androgen receptor antagonist.
The present method may further comprise a step of treating the individual. In some embodiments, the method comprises a step of treating the individual if the NPY score is positive. In other embodiments, the method comprises a step of treating the individual if the NPY score is negative. In other embodiments, the method does not comprise a step of treating the individual if the NPY score is negative.
It will be understood that the prognosis as defined above, i.e. risk of prostate cancer- specific death, aggressiveness of the cancer, hazard ratios or need for active therapy, might vary over time. Thus in some embodiments the present method is performed repeatedly and the levels of NPY are monitored over time, such as once a year, such as every second year, such as every third year, such as every fifth year. ERG levels
ERG (ETS-related gene) is encoded by a proto-oncogene. ERG is a member of the ETS (erythroblast transformation-specific) family of transcription factors and functions as a transcriptional regulator. ERG can fuse with TMPRSS2 protein to form an oncogenic fusion gene that is commonly found in human prostate cancer. This fusion gene is critical to the progression of cancer because it disrupts the ability of the cells to differentiate into proper prostate epithelial cells creating unregulated and unorganized tissue. 90% of prostate cancers overexpressing ERG also possess a fusion TMPRSS2- ERG gene. The inventors have surprisingly found that the ERG protein can, together with NPY, be used as a biomarker of prostate cancer progression.
In some embodiments, the present method further comprises the steps of determining the level of ERG in said sample and assigning to said level of ERG an ERG score, where the ERG score is positive if ERG is expressed and negative if ERG is not expressed. The level of ERG can be determined by methods known in the art, in particular by analytic biochemistry assays such as ELISA (enzyme-linked immunosorbent assay) or by measuring the immunoreactivity of ERG by assays such as immunohistochemical assays. It is to be understood that any method allowing determination of ERG level in the individual can be used in the present method.
In some embodiments, the level of ERG is determined by measuring the
immunoreactivity (IR) of ERG in a prostate tissue sample isolated from said individual. The immunoreactivity can be determined by immunohistochemistry by methods known in the art. In some embodiments, the prostate tissue sample is stained with an antibody capable of recognising and specifically binding to at least a part of ERG. The staining may be direct (with only one antibody) or indirect, using an unlabelled, primary antibody and a labelled, secondary antibody which recognises the primary antibody. In embodiments where a primary and a secondary antibody are used, the staining can optionally be further amplified by using a biotin-conjugated secondary antibody.
Optionally, the stained sample is counterstained, for example with a compound specifically staining a given class of molecules or with a compound staining the whole cell. The stained sample is then examined and the extent of staining is determined.
ERG score
After determining the ERG level, an ERG score is assigned. The ERG score is positive if the ERG level is above a threshold value and negative if the ERG level is below said threshold value.
In some embodiments, the ERG score is positive if it is detected in the prostate tissue sample, and negative if it is not detected in the prostate tissue sample.
In other embodiments, the ERG level is determined by measuring immunoreactivity of ERG in a prostate tissue sample isolated from said individual. In some embodiments, the ERG score is positive if ERG is detected in a proportion of the sample which is above a threshold value and negative if it is detected in a proportion of the sample which is below a threshold value. In some embodiments, the threshold value is 10%. In other embodiments, the threshold value is 5%. In other embodiments, the threshold value is 1 %. In some embodiments, the ERG score is positive if ERG is detected in 10% of the sample or more, such as in 15% of the sample or more, such as 20% of the sample or more, such as in 25% of the sampler or more, such as in 30% of the sample or more, such as in 35% of the sample or more, such as in 35% of the sample or more, such as in 40% of the sample or more, such as in 50% of the sample or more, such as in 60% of the sample or more, such as in 70% of the sample or more, such as in 80% of the sample or more, such as in 90% of the sample or more, such as in 100% of the sample. In other embodiments, the NPY level is determined by measuring immunoreactivity of NPY in a prostate tissue sample isolated from said individual and the NPY score is positive if NPY is detected in a proportion of the sample which is above a threshold value. In some embodiments, the NPY score is positive if NPY is detected in 25% of the sample or more, such as in 30% of the sample or more, such as in 35% of the sample or more, such as in 35% of the sample or more, such as in 40% of the sample or more, such as in 50% of the sample or more, such as in 60% of the sample or more, such as in 70% of the sample or more, such as in 80% of the sample or more, such as in 90% of the sample or more, such as in 100% of the sample. The NPY score is negative if NPY is detected in a proportion of the sample which is below a threshold value. In some embodiments, the NPY score is negative if NPY is detected in less than 25% of the sample, such as in less than 20% of the sample, such as in less than 15% of the sample, such as in less than 10% of the sample, such as in less than 5% of the sample, or if NPY is not detected in any part of the sample. In some embodiments, a positive ERG score as defined above is assigned after measuring the ERG levels in a sample isolated from an individual suffering from prostate cancer. In some embodiments, the GS of the prostate cancer is 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. In other embodiments, the GS of the prostate cancer is 8 or more, such as 9 or more, such as 10. In some embodiments, the prostate cancer is low-grade (or well-differentiated) or intermediate-grade (or moderately-differentiated). In other embodiments, the prostate cancer is poorly-differentiated (or high-grade). Herein is thus also disclosed a method wherein a positive NPY score and a positive ERG score together are predictive of increased risk of prostate-cancer specific mortality of an individual compared to the risk in an individual with at least one of the NPY score and ERG score being negative.
The method of the invention allows establishing a prognosis in an individual suffering from or at risk of suffering from prostate cancer. A positive NPY score together with a positive ERG score corresponds to a bad prognosis, while at least one of the NPY score and ERG score being negative corresponds to a good prognosis. In other words, the prognosis is good if:
the NPY score and the ERG score are negative
the NPY score is positive and the ERG score is negative
the NPY score is negative and the ERG score is positive. A bad prognosis reflects that there is a risk for the individual of dying of prostate cancer within 20 years. A good prognosis reflects that there is substantially no risk for the individual of dying of prostate cancer within 20 years.
In some embodiments, a positive NPY score and a positive ERG score are as defined above and together indicate that the individual is at increased risk of prostate cancer- specific mortality compared to an individual with at least one of the NPY score and ERG score being negative. The hazard ratio with a 95% confidence interval for individuals with a low GS is 3.0 or more, such as 5.55 or more, such as 6.0 or more, such as 10.0 or more, such as 15.0 or more, such as 17.31 or more, such as 20.0 or more, such as 25.0 or more, such as 30.0 or more, such as 35.0 or more, such as 40.0 or more, such as 45.0 or more, such as 50.0 or more, such as 54.02 or more, such as 55.0 or more; where a low GS is 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. In some embodiments the hazard ratio with a 95% confidence interval for individuals with a low GS or less is between 5.55 and 54.02. Thus such individuals have an increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score, wherein said risk is increased by a factor of 3.0 or more, such as 5.55 or more, such as 6.0 or more, such as 10.0 or more, such as 15.0 or more, such as 17.31 or more, such as 20.0 or more, such as 25.0 or more, such as 30.0 or more, such as 35.0 or more, such as 40.0 or more, such as 45.0 or more, such as 50.0 or more, such as 54.02 or more, such as 55.0 or more.
In some embodiments, a positive NPY score and a positive ERG score are as defined above and together indicate that the individual is at increased risk of prostate cancer- specific mortality compared to an individual with at least one of the NPY score and ERG score being negative. The hazard ratio with a 95% confidence interval for individuals with a low GS is between 20 and 750, such as between 23.98 and 724.1 1. In some embodiments, the hazard ratio with a 95% confidence interval is 20 or more, such as 30.0 or more, such as 40.0 or more, such as 50.0 or more, such as 75.0 or more, such as 100.0 or more, such as 150.0 or more, such as 200.0 or more, such as 300.0 or more, such as 400.0 or more, such as 500.0 or more, such as 600.0 or more, such as 700.0 or more, such as 724.0 or more, where a low GS is 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. Thus such individuals have an increased risk of prostate cancer-specific mortality compared to an individual with a negative NPY score, wherein said risk is increased by a factor of 20 or more, such as 30.0 or more, such as 40.0 or more, such as 50.0 or more, such as 75.0 or more, such as 100.0 or more, such as 150.0 or more, such as 200.0 or more, such as 300.0 or more, such as 400.0 or more, such as 500.0 or more, such as 600.0 or more, such as 700.0 or more, such as 724.0 or more.
The hazard ratio with a 95% confidence interval for individuals independent of the value of the GS (i.e. 2≤ GS≤ 10) is 2.0 or more, such as 2.64 or more, such as 3.0 or more, such as 3.5 or more, such as 4.0 or more, such as 4.5 or more, such as 5.0 or more, such as 6.0 or more, such as 7.0 or more, such as 7.5 or more, such as 8.0 or more, such as 8.5 or more, such as 9.0 or more, such as 9.5 or more, such as 9.65 or more. In some embodiments the hazard ratio with a 95% confidence interval for individuals independent of the value of the GS (i.e. 2≤ GS≤ 10) is between 2.64 and 9.65. Thus such individuals have an increased risk of prostate cancer-specific mortality compared to an individual with at least one of the NPY score and ERG score being negative, wherein said risk is increased by a factor of 2.0 or more, such as 2.64 or more, such as 3.0 or more, such as 3.5 or more, such as 4.0 or more, such as 4.5 or more, such as 5.0 or more, such as 6.0 or more, such as 7.0 or more, such as 7.5 or more, such as 8.0 or more, such as 8.5 or more, such as 9.0 or more, such as 9.5 or more, such as 9.65 or more.
In some embodiments, a positive NPY score and a positive ERG score together indicate that the prostate cancer is aggressive and progressing rapidly, while at least one of the NPY score and ERG score being negative indicates that the prostate cancer is progressing slowly. Without being bound by theory, the degree of aggressiveness of the cancer is expected to correlate to the prognosis. In some embodiments, a positive NPY score and/or a positive ERG score as defined above are assigned after measuring the NPY and ERG levels in a sample isolated from an individual suffering from prostate cancer. In some embodiments, the GS of the prostate cancer is 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. In other embodiments, the GS of the prostate cancer is 8 or more, such as 9 or more, such as 10. In some embodiments, the prostate cancer is low-grade (or well-differentiated) or intermediate-grade (or moderately-differentiated). In other embodiments, the prostate cancer is poorly-differentiated (or high-grade). Thus in some embodiments the GS of the prostate cancer is 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. In other embodiments, the GS of the prostate cancer is 7 or more, such as 8 or more, such as 9 or more, such as 10. In other embodiments, the GS of the prostate cancer is 10 or less, such as 9 or less, such as 8 or less, such as 7 or less, such as 6 or less, such as 5 or less, such as 4 or less, such as 3 or less, such as 2. It will be understood that although particularly useful for establishing a prognosis in an individual with a low GS, the methods disclosed herein can be used to establish a prognosis in an individual with any GS value. The hazard ratio, sensitivity and/or specificity of the method may vary depending on the GS. In some embodiments, the lower the GS, the higher the hazard ratio for an individual having a positive NPY score and a positive ERG score. In some embodiments, the lower the GS, the higher the specificity and/or sensitivity of the method.
The present method may further comprise a step of treating the individual. In some embodiments, the method comprises a step of treating the individual if the NPY score and the ERG score are positive. In other embodiments, the method comprises a step of treating the individual if at least one of the NPY score and ERG score is negative. In other embodiments, the method does not comprise a step of treating the individual if at least one of the NPY score and ERG score is negative. In some embodiments, the method does not comprise a step of treating the individual if both the NPY score and the ERG score are negative.
In some embodiments, a positive NPY score and a positive ERG score together indicate that the individual is in need of active therapy, while at least one of the NPY score and ERG score being negative indicates that the individual is not in need of active therapy. Active therapy includes methods such as, but not limited to, the administration of a medicament, surgical castration, external beam radiation therapy, brachytherapy, radical prostatectomy, hormone therapy, cryotherapy and/or high frequency ultra sound therapy. In some embodiments, active therapy comprises the administration of a medicament, where the medicament is selected from the group consisting of a GnRH-agonist, a GnRH-antagonist, an estrogen, an LHRH agonist, an LHRH antagonist, an androgen synthesis inhibitor and an androgen receptor antagonist. It will be understood that the prognosis as defined above, i.e. risk of prostate cancer- specific death, aggressiveness of the cancer, hazard ratios or need for active therapy, might vary overtime. Thus in some embodiments the present method is performed repeatedly and the levels of NPY and ERG are monitored over time, such as once a year, such as every second year, such as every third year, such as every fifth year.
NPY for use in prognosis
In another aspect, the invention thus relates to NPY for use in the prognosis of prostate cancer-specific mortality. As detailed above, determining the levels of NPY in a sample isolated from an individual suffering from or suspected of suffering from prostate cancer can be used in a method for establishing a prognosis for prostate cancer as disclosed herein. The present methods provide a reliable prognosis independently of the GS, but appear even more reliable when performed on individuals with a GS of 7 or less, or with a GS of 6 or less. The prognostic can also be established by determining not only the level of NPY but also the level of ERG, as detailed above.
Kit
In yet another aspect, the invention relates to a kit for performing the method of the invention, comprising an anti-NPY antibody recognising at least the C-terminal part of NPY, an anti-ERG antibody recognising ERG and instructions for use.
The kit disclosed herein may comprise other reagents and/or materials necessary for performing the method of the invention.
In some embodiments, the kit may also comprise synthetic or recombinant variants of NPY and/or ERG, istopically labelled variants of NPY and/or ERG, chemically modified variants of NPY and/or ERG, fluorescently labelled variants of NPY and/or ERG. Such variants may be used as standard composition in order to allow precise quantification of NPY and/or ERG, respectively, in a sample isolated from an individual.
Examples
Example 1 - Materials and methods
Patient samples
Radical prostatectomy specimens collected at the Umea University Hospital (Ethical permit Dnr 03-482) were frozen or formalin fixed and preserved in paraffin. Paraffin sections were macro-dissected to isolate control tissue (defined as non-malignant tissue without high grade of inflammation, atrophy, or PIN) and prostate cancer of different Gleason scores for mass spectrometry analysis. Epithelial-rich areas (>50 % epithelial cells) were selected, mainly from the peripheral prostate zone. Frozen prostate sections were used for histochemistry. Tissue microarrays (TMAs) from a historical cohort of men with prostate cancer (detected after transurethral resection of the prostate due to voiding symptoms) and followed by watchful waiting were used to evaluate NPY prognostic predictive value. A cohort of 122 patients (Ahlqvist et al., 2013) treated with radical prostatectomy at the Skane University Hospital, Malmo, Sweden was used to study ERG and NPY expression in relation with disease relapse after prostatectomy also known as biochemical recurrence (BCR). The studies were approved by the Ethics Committee, Lund University, Sweden, and the Helsinki Declaration of Human Rights was strictly observed. Cell lines and culture conditions
LNCaP, PC-3, 22Rv1 and WPMY-1 were purchased from LGC standards (Sweden). Cells were maintained in RPMI medium supplemented with 10% FBS. For proteome isotopic labelling (SI LAC), cells were cultured for at least 10 generations in arginine and lysine depleted RPMI medium (Biowest) supplemented with 28 and 48 mg/L Arg10 (13C6; 15N4) and Lys8 (13C6; 15N2) respectively (Cambridge isotope laboratories, Inc) and 10% dialyzed FBS (SIGMA).
Proteomic analysis
Protein extracts of SI LAC labelled LNCaP, PC-3, 22Rv1 and WPMY-1 were mixed in a 27:27:27: 19 ratio and used as spike-in standard in all subsequent mass spectrometry analyses. Whole protein extracts were purified from FFPE specimens (10-20 sections of about 100 mm2 tissue) essentially as described (Ostasiewicz et al., 2010) mixed in equimolar amounts with the isotopically labeled protein standard obtained from the cell lines and trypsin digested following the Filter-Aid Sample Preparation (FASP) methodology. The resulting tryptic peptides were further fractionated by Strong Anion Exchange chromatography (SAX) into six fractions to reduce sample complexity and maximize depth of proteome coverage. Each fraction was then analyzed by LC-MS/MS on a linear ion trap Orbitrap mass spectrometer. Fragment spectra were obtained by Higher Energy Collisional Dissociation (HCD) with high mass accuracy. The obtained mass spectrometric raw data was analyzed in the MaxQuant environment with the integrated Andromeda searching engine and false discovery rate cut-off for peptide identification of 0.1 (Fig. 1A). Normalized light (tissue) to heavy (SILAC standard) intensity ratios were averaged for tumour and control samples. Differences of the mean were evaluated by Student's t test followed by Benjamini-Hochberg correction for multiple testing. False discovery rates (FDR) smaller than 0.1 were considered statistically significant. No correction was applied when tumours were grouped according to their Gleason scores (GS) or ERG status and p values smaller than 0.05 were considered statistically significant. Immunohistochemistry
Tissue microarray (TMA) and whole paired tissue sections were deparaffinized in xylene and rehydrated through graded ethanol. Immunohistochemistry was performed in one batch for each protein and cohort by using the ultraView Universal DAB Detection kit with the CC1 antigen retrieval technique in the automatic VENTANA Benchmark Ultra system, according to manufacturer's description (Roche Diagnostics, Mannheim, Germany). For immunohistochemistry of NPY alone, the primary antibody was anti-NPY (diluted 1 :500, HPA044572, Atlas Antibodies). Immunoreactivity (IR) was scored as 0 (<25 % positive cells) or 1 (>25 % intensely stained cells).
For pro-NPY and ERG evaluation in the radical prostatectomy cohort, consecutive TMA sections, 4 μηι thick, were de-paraffinized with xylene and re-hydrated in graded ethanol solutions, before being subjected to antigen retrieval (PT Link solution, Dako) at 98°C for 40 minutes. Anti-ERG was purchased from Novus biological (rabbit monoclonal: EPR386455). Immunohistochemical staining (IHC) was performed using EnVisionTM Flex, High pH (Dako, code K8010), and visualized with DAB+ (Diaminobenzidine), according to the manufacturer's protocol. Resultant staining was scored as 0 (NPY: detected in less than 25 % cells; ERG: not detected) or 1 (NPY: detected in more than 25 % cells; ERG: detected).
Example 2. Identification of a novel biomarker of disease progression.
Most tumours diagnosed upon PSA testing have low to intermediate histological Gleason grade (GG) (Cooperberg et al., 2003). Although localized tumours of all grades are potentially lethal, several studies have demonstrated that patients with GG ≥ 4 at diagnosis have a more aggressive disease course than those with predominant GG 3 or less (Stark et al., 2009; Popiolek et al., 2013; Wright et al., 2009). In order to be able to validate candidate biomarkers using IHC analysis, we compared the proteomes of tumours with low and high GG to identify proteins with large expression differences. As shown in Fig. 1A and table 1 , only a small number of proteins are differentially expressed (p < 0.05; fold change > 1.7) in tumours with a predominant GG of 4 against tumours with a predominant GG of 3, including pro-NPY, PSMA (FOLH1), NCOA7 and CD276.
Table 1 Fold change
Gene Symbol Uniprot Ttest (GG4 vs GG3)
GG4 vs GG3
NPY P01303 3,818038785 0,034900945
ASB9 Q96DX5 2,620513122 0,005552396
FOLH1 Q04609 2,566086198 0,009655289
CRIPl P50238 2,553975194 0,007601337
TMC4 Q7Z404 2,340073306 0,027111593
NCOA7 Q8NI08 2,261347175 0,03494838
CD14 P08571 2,194026792 0,015002772
ASRGL1 Q7L266 2,159151645 0,00487443
TSC22D2 075157 2,158505135 0,031250501
TOE1 Q96GM8 2,132167722 0,015867601
DUS2L Q9NX74 2,09176004 0,04295551
CD276 Q5ZPR3 2,036736094 0,013846827 mm P19827 1,980428855 0,041100865
VWF P04275 1,94924948 0,03470613
KLC1 Q07866 1,914611335 0,007750082
CDKN2A P42771 1,855839065 0,00074006
DGCR14 Q96DF8 1,852724785 0,005894061
PHLDB2 Q86SQ0 1,850880236 0,034935089
MEA1 Q16626 1,842798411 0,03133391
LCLAT1 Q6UWP7 1,834349765 0,006346267
NNMT P40261 1,820225959 0,02106651
CHAC2 Q8WUX2 1,784989816 0,028821526
THEM4 Q5T1C6 1,778644795 0,008002535
GMPR P36959 -1,749588857 0,008946429
COL6A3 P12111 -1,753529711 0,045422033
TXNIP Q9H3M7 -1,755247963 0,01005012
CFL2 Q9Y281 -1,755396071 0,043056602
SRFBP1 Q8NEF9 -1,766026357 0,016513165
DBT P11182 -1,767758293 0,019187838
ABCC4 015439 -1,76882948 0,021007341
IGF2BP2 F8W930 -1,771889435 0,031214144
AZI1 Q9UPN4 -1,775621794 0,046728396
SH3RF1 Q7Z6J0 -1,78068209 0,020006623
KDSR Q06136 -1,783430307 0,048465593
TPM2 P07951 -1,786713779 0,026395008
CD63 P08962 -1,79063895 0,009750561
EHHADH Q08426 -1,791745056 0,049164739
MYH11 P35749 -1,799274382 0,038080168 CHDH Q8NE62 -1,807625446 0,021542133
PYGB P11216 -1,809884461 0,001150922
IRAKI P51617 -1,810192511 0,002161253
ALDH2 P05091 -1,810397242 0,018207326
AIF1 Q5STX8 -1,821553245 0,040924408
SCPEP1 Q9HB40 -1,824056813 3,5094E-05
TSPAN6 043657 -1,834709626 0,005776187
JUP F5GWP8 -1,85941869 0,01099687
SFXN2 Q96NB2 -1,862107048 0,009897934
HAUS6 Q7Z4H7 -1,872416002 0,01300613
CSRP1 P21291 -1,884374656 0,016734007
PIGO Q8TEQ8 -1,885695393 0,007606899
EHD2 Q9NZN4 -1,912797744 0,004584884
MAP1A E9PGC8 -1,926044051 0,021201833
MYL9 P24844 -1,933392544 0,015864941
MT-ND2 P03891 -1,946439756 0,008563141
SMTN P53814 -1,954692496 0,008281822
COL6A2 P12110 -1,975626191 0,013789816
FLNA P21333 -1,980892829 0,003785024
ABAT H3BRN4 -1,986804439 0,02108119
DBI P07108 -1,998296479 0,037270458
TSPAN8 P19075 -2,00101054 0,002620991
TMEM87A Q8NBN3 -2,004479355 0,000745666
RNASE4 P34096 -2,022316978 0,028016328
CTBS Q01459 -2,024104728 0,007639588
DPP4 P27487 -2,035953754 0,039618647
FLNC Q14315 -2,058563925 0,001272953
PAM P19021 -2,125529379 0,009900742
CLIC6 Q96NY7 -2,161031941 0,035847617
IFT88 Q13099 -2,276927165 0,025290102
RACGAP1 Q9H0H5 -2,364103176 0,012289331
TPPP 094811 -2,371740771 0,038202138
MT-C03 P00414 -2,457762907 0,019909359
AZGP1 P25311 -2,460976773 0,036161013
SEMA3C F5H1Z7 -2,56202095 0,00090526
TMBIM1 Q969X1 -2,637682274 0,004157795
ST6GAL1 P15907 -2,760530581 0,008128551
FABP3 P05413 -3,157137476 0,009573204
KCNN4 015554 -3,547816918 0,029343813
DES P17661 -3,611822722 0,001420518
C2orf43 B5MDU6 -3,973964542 0,01002372 We then ranked proteins for their capacity to separate the GG high and low groups using the Support Vector Machine derived weights in a Recursive Feature Elimination (RFE-SVM) procedure. We performed a cross validation procedure using 15% of the data as test set and repeating the procedure 250 times. A classification error rate of 28.6% was observed when the 56 top ranked features were used in the validation procedure (Table 2). Importantly, pro-NPY is part of the top performing features that give minimun error rates. In addition, we also observed a significant up-regulation of pro-NPY in localized tumours in comparison to benign tissue (fold change=3.82, p< 0.05)
Table 2
Gene Symbol Uniprot
0 TPPP3 Q9BW30
1 NPY P01303
2 NAA38 095777
3 APOE P02649
4 CKM P06732
5 ACTA2 P62736
6 YME1L1 Q96TA2
7 LTBP4 Q8N2S1
8 DPYSL5 Q9BPU6
9 KHDRBS3 075525
10 NDUFB7 P17568
11 ENPP1 P22413
12 ABCC4 015439
13 ECHDC2 Q86YB7
14 TC2N Q8N9U0
15 C17orfl01 Q6PK18
16 FAM82A1 Q96LZ7
17 AGT P01019
18 LSM3 P62310
19 AN07 Q6IWH7
20 BASP1 P80723
21 IGHG2 P01859
22 MALSU1 Q96EH3 23 CHMP7 Q8WUX9
24 TYMP P19971
25 ABRACL Q9P1F3
26 OSBPL10 Q9BXB5
27 ACSM3 Q53FZ2
28 EFCAB4B Q9BSW2
29 HLA-A Q5SRN5
30 HPGD P15428
31 ST6GAL1 P15907
32 KLK11 Q9UBX7
33 P06309
34 QRSL1 Q9H0R6
35 CRISPLD1 Q9H336
36 HDGFRP3 Q9Y3E1
37 GSTM5 P46439
38 C9 P02748
39 BCL7C I3L1Q2
40 DMD P11532
41 CDKN1B P46527
42 SPON2 Q9BUD6
43 PAGE4 060829
44 GNE Q9Y223
45 LSP1 P33241
46 ACAD8 Q9UKU7
47 OSCP1 Q8WVF1
48 UBE2E3 Q969T4
49 AOC3 Q16853
50 ITGA5 P08648
51 GCDH Q92947
52 SNCG 076070
53 COX7A2L 014548
54 TMEM87A Q8NBN3
55 HIST1H2BA Q96A08
The most abundant pro-NPY peptide identified by mass spectrometry corresponded to a portion of the protein C-terminal end (amino acid residues 68 to 97 of SEQ ID NO: 1), which is normally proteolytically processed to generate mature NPY (amino acid residues 1 to 67 of SEQ ID NO: 1) (Fig. 1 B). The most abundant peptide corresponds to residues 68 to 80 of NPY (SEQ ID NO: 1). Therefore, an antibody generated against the C-terminal domain of pro-NPY was used to assess its expression levels by IHC analysis in a cohort of 289 prostate cancer specimens treated with watchful waiting, of which 197 had associated benign prostate tissue. The samples were obtained from transurethral prostate resection (TURP) procedures from a population that has not been screened for PSA and has been followed up for median of 22 years. Pro-NPY immunoreactivity (IR) was stratified as negative (Fig. 4A, upper panels) or positive (Fig. 4B, lower panels). The overall inspection of IHC data revealed that 40% of the tumours exhibit moderate (>25% stained cells) or strong staining (>75% stained cells) for pro- NPY (corresponding to a positive NPY score NPY+) and significant differences in expression levels of pro-NPY between normal and tumour tissues were observed (Fig. 1 C). Tumours with GS > 6 showed significantly increased expression of pro-NPY than tumours with GS≤ 6, confirming the findings obtained by mass spectrometry analysis (Fig. 1 C).
Example 3. NPY as prognostic marker
First, we observed that positive staining for pro-NPY is mainly observed in prostate cancer. In a panel of 400 surgical samples from 10 tumour types (prostate, breast, colorectal, pancreatic, lung, liver, uterus, oral, stomach and ovarian), only the prostate tumours displayed a positive NPY score (Fig. 4B). Patients with a positive NPY score in prostate tumour tissue exhibited a significantly increased risk [HR: 2.13, 95%CI: 1.21-3.73] of prostate cancer-specific death (Fig. 2A). Interestingly, when samples were dichotomized based on their histological score, pro- NPY levels were no longer predictive of death for patients with high Gleason score tumours (GS > 6) but an increased mortality was observed for patients carrying low Gleason tumours (GS ≤ 6) exhibiting high levels of pro-NPY [HR: 5.2 (1.6-16.84)], indicating that pro-NPY levels could be particularly useful for the identification of aggressive tumours at an early stage (Fig. 2B). When tumours with Gleason tumours GS ≤ 7 were evaluated, we found that those with high levels of pro-NPY exhibit increased risk of prostate cancer specific mortality HR: 2.51 (1.08-5.81).
Example 4. NPY and ERG as prognostic markers
ERG expression has been previously analyzed in this cohort and demonstrated to be related to increased risk of disease related mortality as well as to other factors of prognostic significance, such as cell proliferation and angiogenesis (Hagglof et al., 2014).
We analyzed whether pro-NPY expression correlated with ERG expression in our sample cohort. Of the 282 tumours included in the analysis 44% were positive for Erg expression and of them, 52% of the tumours also showed high pro-NPY levels, a statistically significant finding (Fisher's exact test, p=0.0007).
Univariate Cox regression analysis surprisingly demonstrated that tumours with positive staining for ERG (i.e. ERG is detected in the sample) and high pro-NPY levels (staining in more than 25% of the sample) had a significantly increased risk of disease- related mortality (HR: 5.05 (CI: 2.64 - 9.65)) when compared to tumours that were negative for either pro-NPY or ERG (Fig. 3A). This effect was even more pronounced if the analysis was limited to tumours with low Gleason score (HR: 131.82, 95%CI: 23.98 - 724.11) (Fig. 3B).
In multivariate analysis both ERG and pro-NPY independently contributed to prediction of disease mortality for low Gleason tumours (Table 1). In line with its increased aggressiveness, this subgroup of tumours also exhibited significantly increased expression of markers of cell proliferation (Ki67) and angiogenesis (data not shown).
In conclusion, our data show that NPY and ERG can be used in combination as prognostic markers for evaluating the aggressiveness of prostate tumours, in particular in tumours with low Gleason scores.
The identification of prognostic biomarkers that can identify aggressive tumours among those normally deemed to exhibit low to intermediate risk based on Gleason grading can provide physicians with better tools to select patients that will benefit from active therapy more accurately. Here, we identify that pro-NPY levels in prostate tissue samples are predictive of prostate cancer-specific mortality in a watchful waiting cohort, and show that this is especially true for patients with low-grade tumours. Patients bearing Gleason 6 tumours and high levels of NPY have 5-fold increased risk of dying from prostate cancer. Moreover, the combined assessment of ERG and pro-NPY identified a subset of Gleason 6 tumours with a dramatically increased risk (HR: 131.8, 95%CI: 24-724) of PCa-specific mortality comparable to the increased risk imparted by the presence of a high (GS>7) Gleason score (HR=128.7, 95%CI: 17.6-939.5) (Hagglof et al., 2014). Positive staining for both ERG and pro-NPY identified lethal Gleason 6 tumours in this cohort with an accuracy of 92%. Given the excellent outcome for Gleason 6 patients after prostatectomy (Eggener et al., 201 1), this shows that after accounting for age and comorbidities this subgroup of Gleason 6 patients with high NPY/ERG expression levels would benefit from active treatment. Interestingly neither pro-NPY IR nor its combination with ERG correlate with biochemical recurrence after radical prostatectomy (Fig. 6A), suggesting that clinical intervention is beneficial for these patients.
Example 5. Measuring NPY and CPON secreted from prostate cancer cells.
C-flanking peptide of NPY (CPON) and pro-NPY secreted by VCaP prostate cancer cells were analysed by capillary electrophoresis (Fig. 9). The CPON was detected by an anti-proNPY antibody. In the figure, results using the anti-proNPY antibody from Atlas antibodies (HPA044572) are shown. Recombinant pro-NPY fragment can be detected by antibodies against mature NPY. In the figure, results using the Millipore AB1583 against NPY are shown.
References
Ahlqvist, K., et al. Oncogene 32, 1601-1608 (2013).
Cooperberg, M.R., et al. J Urol 170, S21-25; discussion S26-27 (2003).
Eggener, S.E., et al. J Urol 185, 869-875 (2011).
Hagglof, C, et al. PLoS One 9, e86824 (2014).
Massoner, P., et al. PLoS One 8, e55207 (2013).
Ostasiewicz, P., et al. J Proteome Res 9, 3688-3700 (2010).
Popiolek, M., et al. Eur Urol 63, 428-435 (2013).
Schroder, F.H., et al. N Engl J Med 360, 1320-1328 (2009).
Stark, J.R., et al. J Clin Oncol 27, 3459-3464 (2009).
Uhlen, M., et al. Nat Biotechnol. 28(12): 1248-50 (2010)
Wright, J.L, et al. J Urol 182, 2702-2707 (2009). Sequences
SEQ ID NO: 1 pro-NPY
MLGNKRLGLS GLTLALSLLV CLGALAEAYP SKPDNPGEDA PAEDMARYYS ALRHYINLIT RQRYGKRSSP ETLISDLLMR ESTENVPRTR LEDPAMW
SEQ ID NO: 2 ERG
MIQTVPDPAA HIKEALSVVS EDQSLFECAY GTPHLAKTEM TASSSSDYGQ TSKMSPRVPQ QDWLSQPPAR VTIKMECNPS QVNGSRNSPD ECSVAKGGKM VGSPDTVGMN YGSYMEEKHM PPPNMTTNER RVIVPADPTL WSTDHVRQWL EWAVKEYGLP DVNILLFQNI DGKELCKMTK DDFQRLTPSY NADILLSHLH YLRETPLPHL TSDDVDKALQ NSPRLMHARN TGGAAFIFPN TSVYPEATQR ITTRPDLPYE PPRRSAWTGH GHPTPQSKAA QPSPSTVPKT EDQRPQLDPY QILGPTSSRL ANPGSGQIQL WQFLLELLSD SSNSSCITWE GTNGEFKMTD PDEVARRWGE RKSKPNMNYD KLSRALRYYY DKNIMTKVHG KRYAYKFDFH GIAQALQPHP PESSLYKYPS DLPYMGSYHA HPQKMNFVAP HPPALPVTSS SFFAAPNPYW NSPTGGIYPN TRLPTSHMPS HLGTYY
SEQ ID NO: 3 NPY
AEAYPSKPDN PGEDAPAEDM ARYYSALRHY INLITRQRY

Claims

Claims
A method for establishing a prognosis in an individual suffering from or at risk of suffering from prostate cancer, said method comprising the steps of:
determining the level of NPY in a sample isolated from said individual;
assigning an NPY score to said level of NPY;
establishing the prognosis based on said NPY score.
The method according to claim 1 , wherein the sample is a prostate tissue sample, a blood sample or a urine sample.
The method according to any one of the preceding claims, wherein the NPY level in said blood sample is determined by measuring the plasma level of mature NPY with an analytic biochemistry assay such as ELISA optionally combined with capillary electrophoresis.
The method according to claim 3, wherein the ELISA is performed with an anti- NPY antibody recognising at least the C-terminal part of NPY.
The method according to any one of the preceding claims, wherein a plasma NPY level of 160 pg/mL plasma or more, such as 170 pg/mL plasma or more, such as 180 pg/mL plasma or more, such as 190 pg/mL plasma or more, such as 200 pg/mL plasma or more, such as 210 pg/mL plasma or more, such as 220 pg/mL plasma or more, such as 230 pg/mL plasma or more, such as 240 pg/mL plasma or more, such as 250 pg/mL plasma or more, such as 260 pg/mL plasma or more, such as 270 pg/mL plasma or more, such as 280 pg/mL plasma or more, such as 290 pg/mL plasma or more, such as 300 pg/mL plasma or more, such as 310 pg/mL plasma or more, such as 320 pg/mL plasma or more, such as 330 pg/mL plasma or more, such as 340 pg/mL plasma or more, indicates that the individual is at increased risk of prostate cancer-specific mortality compared to an individual with a plasma level of less than 160 pg/mL plasma.
6. The method according to any one of the preceding claims, wherein: if the plasma NPY level is less than a cut-off value, the NPY score is negative; if the plasma NPY level is equal to or more than said cut-off value, the NPY score is positive.
The method according to any one of the preceding claims, wherein the cut-off value is 160 pg NPY/mL plasma.
The method according to any one of the preceding claims, wherein the level of NPY is determined by measuring the level of pro-NPY.
The method according to any one of the preceding claims, wherein the level of NPY is determined by measuring the immunoreactivity of NPY in the prostate tissue sample.
10. The method according to any one of the preceding claims, wherein the
immunoreactivity (IR) of NPY is determined by immunohistochemistry, wherein NPY is detected with an anti-NPY antibody recognising at least the C-terminal part of NPY.
1 1. The method according to any one of the preceding claims, wherein:
if NPY is detected in less than 25% of the sample, the NPY score is negative; if NPY is detected in 25% of the sample or more, the NPY score is positive.
12. The method according to any one of the preceding claims, wherein the
individual has a Gleason score GS≤ 7, such as GS=2, GS=3, GS=4, GS=5, GS=6 or GS=7.
13. The method according to any one of the preceding claims, wherein the
individual has a Gleason score GS≤ 6, such as GS=2, GS=3, GS=4, GS=5 or GS=6.
14. The method according to any one of the preceding claims, wherein a negative NPY score reflects a good prognosis and a positive NPY score reflects a bad prognosis, wherein if the prognosis is good, said individual is not at risk of dying of prostate cancer within 20 years and if the prognosis is bad, said individual is at risk of dying of prostate cancer within 20 years.
15. The method according to any one of the preceding claims, wherein a negative NPY score indicates that the prostate cancer is not progressing or progressing slowly and a positive NPY score indicates that the prostate cancer is aggressive.
16. The method according to any one of the preceding claims, wherein a negative NPY score indicates that the individual does not need active therapy and a positive NPY score indicates that the individual needs active therapy.
17. The method according to any one of the preceding claims, wherein a positive NPY score is predictive of high prostate-cancer specific mortality of said individual compared to an individual with a negative NPY score.
18. The method according to any one of the preceding claims, wherein if the NPY score is positive, the method further comprises treating said individual for prostate cancer.
19. The method according to any one of the preceding claims, wherein the method further comprises the steps of:
determining the level of ERG in said sample;
assigning to said level of ERG an ERG score, where the ERG score is positive if ERG is expressed and negative if ERG is not expressed.
20. The method according to any one of the preceding claims, wherein ERG is determined by measuring the immunoreactivity of ERG in the prostate tissue sample.
21. The method according to any one of the preceding claims, wherein the
immunoreactivity (IR) of ERG is determined by immunohistochemistry, wherein ERG is detected with an anti-ERG antibody.
22. The method according to any one of the preceding claims, wherein:
if ERG is not detected in the sample, the ERG score is negative;
if ERG is detected in the sample, the ERG score is positive.
23. The method according to any one of the preceding claims, wherein a positive NPY score and a positive ERG score together are predictive of prostate-cancer specific mortality of said individual.
24. The method according to any one of the preceding claims, wherein the
individual has a Gleason score GS≤ 7, such as GS≤ 6.
25. The method according to any one of the preceding claims, wherein:
a negative NPY score and a negative ERG score indicates that the individual does not need active therapy;
a negative NPY score and a positive ERG score indicates that the individual does not need active therapy;
a positive NPY score and a negative ERG score indicates that the individual does not need active therapy;
a positive NPY score and a positive ERG score indicates that the individual needs active therapy.
26. The method according to any one of the preceding claims, wherein the
treatment is active monitoring, watchful waiting or active therapy.
27. The method according to any one of the preceding claims, wherein active
therapy comprises the administration of a medicament, surgical castration, external beam radiation therapy, brachytherapy, radical prostatectomy, hormone therapy, cryotherapy and/or high frequency ultra sound therapy.
28. The method according to any one of the preceding claims, wherein the
medicament is selected from the group consisting of a GnRH-agonist, a GnRH- antagonist, an estrogen, an LHRH agonist, an LHRH antagonist, an androgen synthesis inhibitor and an androgen receptor antagonist.
29. A method for establishing a prognosis of prostate-cancer specific mortality in an individual suffering from or at risk of suffering from prostate cancer, said method comprising:
determining the level of NPY in a prostate tissue sample isolated from said individual by immunohistochemistry;
assigning to said level of NPY a positive or negative NPY score, where a negative NPY score corresponds to staining in less than 25% of the sample and a positive NPY score corresponds to staining in more than 25% of the sample; or said method comprising:
- determining the plasma level of NPY in a blood sample isolated from said
individual by an analytical biochemistry assay such as ELISA optionally combined with capillary electrophoresis;
assigning to said level of NPY a positive or negative NPY score, where a negative NPY score corresponds to plasma NPY levels lower than 160 pg/mL plasma and a positive NPY score corresponds to plasma NPY levels of 160 pg/mL plasma or more;
wherein an individual with a negative NPY score is not at risk of dying of prostate cancer within 20 years and an individual with a positive NPY score is at risk of dying of prostate cancer within 20 years.
30. The method according to any one of the preceding claims, further comprising the steps of:
determining the level of ERG in said prostate tissue sample;
assigning to said level of ERG an ERG score, where the ERG score is positive if ERG is expressed and negative if ERG is not expressed,
wherein:
a negative NPY score and a negative ERG score is predictive of low prostate cancer-specific mortality;
a negative NPY score and a positive ERG score is predictive of low prostate cancer-specific mortality;
a positive NPY score and a negative ERG score is predictive of low prostate cancer-specific mortality;
a positive NPY score and a positive ERG score is predictive of high prostate cancer-specific mortality, wherein if the prostate cancer-specific mortality is low, said individual is not at risk of dying of prostate cancer within 20 years, and if the prostate cancer- specific mortality is high, said individual is at risk of dying of prostate cancer.
31. NPY for use in the prognosis of prostate-cancer specific mortality.
32. The use according to any one of the preceding claims, wherein the prognosis i established by the method defined in any one of claims 1 to 30.
33. A kit for performing the method according to any one of claims 1 to 30,
comprising:
an anti-NPY antibody recognising at least the C-terminal part of NPY;
an anti-ERG antibody recognising ERG; and
instructions for use.
34. The kit according to claim 33, further comprising:
a recombinant or a synthetic fragment of NPY ;
at least one isotopically labelled variant of NPY;
at least one chemically modified variant of NPY.
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