# Patent

## Title
Methods for predicting survival in cancer patients

## Abstract

A method for survival prediction in cancer patients is provided. In one embodiment, the survival prediction is determined by the presence or absence of KRAS gene region deletion and/or loss of Chromosome 12 (Ch. 12) in cancer tumor tissue. In another embodiment, the presence or absence of KRAS gene region deletion and/or loss of Ch. 12 in cancer tumor tissue is used to predict survival in non-small-cell lung cancer (NSCLC) patients.

## Background
PRIORITY CLAIM
This application claims priority to U.S. Provisional Application No. 61/314,511, filed Mar. 16, 2010, the subject matter of which is hereby incorporated by reference as if fully set forth herein.


STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH
The invention was made with Government support under Grant No. CA138359 Awarded by the National Cancer Institute (NCI), division of the National Institutes of Health (NIH). The Government has certain rights in the invention.


BACKGROUND
Non-small-cell lung cancer (NSCLC), accounting for about 85% of all lung cancers, is the leading cause of cancer deaths in the United States (Jemal et al., 2008) and worldwide. Despite advances in early detection and surgical resection, NSCLC often has a high recurrence.
KRAS is an oncogene located on Chromosome 12 (Ch. 12), with a cytogenic location of Ch. 12p12.1. KRAS encodes a protein called K-Ras that is involved in regulating cell division. The K-Ras protein has guanosinenucleotide-binding activity and intrinsic guanosine triphosphatase (GTPase) activity. K-Ras is downstream of epidermal growth factor receptor (EGFR), which signals through the PI3K/AKT/mTOR and STAT pathways involved in cell survival, and the RAS/RAF/MEK/MAPK pathway involved in cell proliferation.
The genetic code is a set of rules by which a gene is translated into a functional protein. Each gene includes a specific sequence of nucleotides encoded in a DNA (or sometimes RNA) strand. The four nucleotides are named for the heterocyclic base associated with them: adenine (“A”), cytosine (“C”), guanine (“G”), and thymine (“T”). The nucleotides polymerize to form a single strand of DNA, then two single strands interact by hydrogen bonding between complementary nucleotide, A being complementary with T and C being complementary with G, to form base pairs with results in the formation of a DNA double helix. RNA is similar to DNA except that the base thymine is replaced with uracil (“U”) and does not form double strands.
A gene can contain coding and/or non-coding DNA sequences that are transcribed into RNA. RNA sequences that are transcribed by coding sequences of a gene are known as messenger RNA (mRNA). mRNA sequences in turn encode for a particular proteins by the process of translation. Proteins produced from genes then perform a specific biochemical or structural function. A correspondence between nucleotides, the basic building blocks of genetic material, and amino acids, the basic building blocks of proteins, must be established for genes to be successfully translated into functional proteins. Sets of three nucleotides, known as codons, each correspond to a specific amino acid or to a signal; three codons are known as “stop codons” wherein, instead of specifying a new amino acid, alert the translation machinery that the end of the gene has been reached. There are 64 possible codons (four possible nucleotides at each or three positions) and only 20 standard amino acids. Thus, the code is redundant and multiple codons can specify the same amino acid.
RNA sequences that are transcribed by non-coding sequences of a gene are known as non-coding RNA (ncRNA), and are not translated into proteins. There are several types of ncRNA that are involved in various cellular functions. For example, transfer RNA (tRNA) and ribosomal RNA (rRNA) are involved in protein assembly, small nuclear RNA (snRNA) and ribozymes are involved in post-transcriptional processing and splicing of mRNA, and MicroRNAs (miRNA), Piwi-interacting RNA (piRNA) and small interfering RNA (siRNA) are involved in gene regulation by acting via the RNA interference (RNAi) system. The RNAi system involves miRNA, siRNA, piRNA or other RNA molecules that are complementary to a target DNA and/or RNA sequence, and regulates gene expression in several ways. For example, an miRNA, siRNA or piRNA may bind to and effect or accelerate the degradation of a target mRNA, or may bind to a target DNA or RNA sequence to block or enhance transcription or translation, respectively.
A variance, also known as a polymorphism or mutation, in the genetic code for any coding or non-coding gene sequence may result in the production of a gene product, usually a protein or an RNA molecule, with altered biochemical activity or with no activity at all, or may influence the function of that gene or locus. This can result from as little change as an addition, deletion, or substitution of a single nucleotide in the DNA comprising a particular gene that is sometimes referred to as a single nucleotide polymorphism (SNP).
Somatic mutations in the KRAS gene are involved in the development of many types of cancer, including NSCLC. When mutated in codon 12, 13 or 61, the KRAS genes encode a constitutively active K-Ras protein that continuously activate transducer signals by linking tyrosine kinases to downstream serine and threonine kinases. Activating point mutations have been found in various malignancies, including NSCLC. In advanced NSCLC, tumors that harbor KRAS point mutations have been correlated with progression of the disease, but not with survival (Massarelli et al., 2007). While the EGFR tyrosine kinase inhibitors, gefitinib and erlotinib can be beneficial for some NSCLC patients, the presence of KRAS mutations predicts primary resistance to these drugs (Massarelli et al., 2007; Zhu et al., 2008; Herbst et al., 2008).
In addition, variations in gene dosage, the number of copies of a gene that are present in a cell, can be clinically significant indicators of disease states. Such variations arise from errors in DNA replication and can occur in germ line cells (leading to congenital defects and even embryonic demise), or in somatic cells. These replication anomalies can cause deletion or duplication of parts of genes, full-length genes and their surrounding regulatory regions, megabase-long portions of chromosomes, or entire chromosomes.
Chromosomal abnormalities affect gene dosage on a larger scale and can affect either the number or structure of chromosomes. Conditions wherein cells, tissues, or individuals have one or more whole chromosomes or segments of chromosomes either absent, or in addition to the normal euploid complement of chromosomes can be referred to as aneuploidy.
Chromosomal aberrations in somatic cells, such as large deletions, insertions or amplifications that are the result of acquired mutations such as loss of heterozygosity (LOH) or gene duplication are associated with many diseases, including many types of cancer. Because somatic KRAS gene mutations have been associated with the development of many types of cancer, including NSCLC, chromosomal aberrations of the KRAS gene are also likely to be clinically relevant in cancer research. Detection of such chromosomal aberrations may have therapeutic, diagnostic or prognostic implications in cancer patients.
Methods for the detection of point mutations and small deletions or insertions in genomic DNA have been well established, however, detection of larger genomic deletions or other aberrations is more complicated. Chromosomal aberrations can be detected in cancer through chromosomal banding (Mertens et al., 1997; Database of Aberrations in cancer, found at http://cgap.nci.nih.gov/Chromosomes/Mitelman), fluorescent in situ hybridization (FISH) (Schrock et al., 1996; Fauth and Speicher, 2001; Speicher and Ward, 1996), and comparative genomic hybridization (CGH) (Kallioniemi et al., 1994; Pinkel et al., 1998). However, early detection of deletions and amplifications are difficult, largely because 1) there is a low frequency of aberrations in early stages of cancer development, 2) tumors often have a multiploid cancer genome, and 3) early stage cancer tissue specimens often have low proportions of tumor cells. Therefore, there is a need to develop more accurate and reliable methods to detect chromosomal deletions and aberrations in early stages of cancer, which may be used in the detection and discovery of predictive biomarkers in cancer.
SUMMARY
A method for survival prediction in cancer patients is provided. In one embodiment, the survival prediction is determined by the presence or absence of a KRAS gene region deletion and/or loss of Chromosome 12 (Ch. 12) in cancer tumor tissue. In another embodiment, the presence or absence of a KRAS gene region deletion and/or loss of Ch. 12 in cancer tumor tissue is used to predict survival in non-small-cell lung cancer (NSCLC) patients.
In some embodiments, samples of cancer tumor tissue and optionally normal marginal tissue are harvested from cancer patients, and a first deletion detection technique is performed to detect gene region deletions in cancer tumor tissue. In one embodiment, the cancer patients are non-small-cell lung cancer (NSCLC) patients. In some embodiments, the first deletion detection technique that is used may be robust dosage-polymerase chain reaction (RD-PCR), fluorescent in situ hybridization (FISH), or comparative genomic hybridization (CGH). The results of the deletion detection technique are analyzed to determine whether a KRAS gene region deletion and/or loss of Chromosome 12 (Ch. 12) is present, wherein the presence of a gene region deletion or loss of Ch. 12 in the cancer tumor tissue that is not present in the normal marginal tissue is associated with a shorter survival.
In one embodiment, the deletion detection technique is RD-PCR, wherein a target gene region and control gene region are simultaneously amplified. The total number and relative ratio of gene or gene region template copies are determined by the ROY and ROT, then the ratio of ROT in tumor tissue to normal marginal tissue is calculated to determine whether a KRAS gene region deletion and/or loss of Ch. 12 is present. The presence of a gene region deletion or loss of Ch. 12 in the tumor tissue that is not present in the normal marginal tissue is associated with shorter survival. In another embodiment, a kit comprising all of the materials necessary to perform the method for predicting survival in NSCLC patients is contemplated.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 illustrates the detection of deletions in the KRAS gene region. Exon 2 of the KRAS gene (target), and exon 1 of the F9 gene (endogenous internal control) were co-amplified from genomic DNA isolated from frozen cancer samples of NSCLC patients.
FIG. 2 is a graph illustrating the correlation between KRAS gene region deletions and survival rate in early stage NSCLC patients as analyzed by a Kaplan-Meier analysis and Cox hazard proportional model.
FIGS. 3A and 3B are representative FISH analyses according to embodiments of the disclosure.
FIGS. 4A and 4B are representative Illumina analyses according to embodiments of the disclosure. Illumina parallel sequencing confirms the presence of KRAS gene region deletions in cancer samples of patients 13 (FIG. 4A) and 19 (FIG. 4B).



DETAILED DESCRIPTION
Methods for predicting survival in cancer patients are provided. In some embodiments, a survival prediction is determined by the presence or absence of KRAS gene region deletions and/or loss of Chromosome 12 (Ch. 12) in cancer tumor tissue compared to normal marginal tissue. In one embodiment, the methods for predicting survival are used to predict survival in early stage non-small-cell lung cancer (NSCLC) patients.
The term “gene region” as used herein refers to a gene, its exons, its introns, and its associated regions flanking it upstream and downstream, e.g., stop and start codons, and regulatory sequences such as promoters and enhances.
The term “gene” refers to a DNA sequence that comprises control and coding sequences necessary for the production of an RNA having a non-coding function (e.g., an rRNA, tRNA, miRNA, siRNA, piRNA, snRNA or ribozyme), or an RNA having a coding function (e.g., an mRNA) for a polypeptide. The RNA or polypeptide can be encoded by a full length coding sequence or by any portion or the coding sequence so long as the desired activity or function is retained.
The term “gene dosage” as used herein refers to the copy number of a gene, a gene region, a chromosome or fragments or portions thereof. Normal individuals carry two copies of most genes or gene regions, one on each of two chromosomes. However, there are certain exceptions, e.g., when genes or gene regions reside on the X or Y chromosomes, or when gene sequences are present in pseudogenes.
The term “aneuploidy” as used herein refers to conditions wherein cells, tissues, or individuals have one or more whole chromosomes or segments of chromosomes either absent, or in addition to the normal euploid complement of chromosomes.
Typically, human solid tumor cells have an aneuploidy, that is, they have an abnormal number of chromosomes or chromosome segments present within an individual cell. Tumor cells have been detected with an aneuploidy of 6n, including those in the studies described herein. When a single gene or gene region is knocked out, the dosage effect may cause a change in the aneuploidy. For example, if a single KRAS gene or gene region is knocked out in a 6n cell, the gene dosage effect is approximately a 15% reduction, and may influence aneuploidy, i.e., changes from 6n to 5n. In the studies described herein, a change in gene dosage of approximately 15% in cells, including aneuploid cells, unexpectedly resulted in an altered survival in oncology patients.
Methods for survival prediction in cancer patients as described herein comprise the use of one or more deletion detection techniques that can detect gene region or chromosomal deletions, the results of which can be used for determining a survival prediction. For example, a KRAS gene region deletion and/or loss of Chromosome 12 (Ch. 12) in tumor tissue that is not found in normal marginal tissue is associated with a shorter survival in NSCLC patients. In another embodiment, kits for use in predicting survival in early stage NSCLC are provided.
According to some embodiments, a cancer tumor tissue and optionally a normal marginal tissue are harvested from cancer patients undergoing resection surgery. A tissue is then analyzed by performing one or more deletion detection technique for the detection of KRAS gene region deletions and/or loss of Ch. 12. Several deletion detection techniques exist to detect such deletions and losses. The deletion detection technique may be any suitable method for detecting nucleic acids. In some embodiments, the deletion technique may detect alteration in RNA form or expression or alterations in a region of DNA.
In some embodiments, methods for nucleic acid detection described herein include amplification or signal amplification methods. Amplification of target DNA or RNA sequences in a tissue sample may be accomplished by any suitable method known in the art, such as transcription amplification, reverse transcription polymerase chain reaction (RT-PCR) amplification, quantitative PCR or RT-PCR, ligase chain reaction, self-sustained sequence replication, transcriptional amplification system, Q-Beta Replicase, rolling circle replication or any other nucleic acid amplification method, followed by the detection of the amplified molecules using known techniques as described below. Such methods are useful for the detection of nucleic acid molecules if such molecules are present in very low numbers. In some aspects, expression is assessed by quantitative fluorogenic RT-PCR (i.e., the TaqMan® System).
In some embodiments, expression levels of RNA or DNA may be detected using a membrane blot (such as used in hybridization analyses such as Northern, Southern, dot, and the like), or microwells, sample tubes, gels (e.g. electrophoresis), beads or fibers (or any solid support comprising bound nucleic acids). The detection of nucleic acid expression may also include using nucleic acid probes in solution.
In some embodiments, detection of nucleic acids may be accomplished by a sequence-specific probe hybridization technique used in conjunction with or without an amplification step. The term “probe” refers to any molecule that is capable of selectively binding to a specifically intended target biomolecule, for example, a nucleotide transcript or a protein encoded by or corresponding to a biomarker. Examples of molecules that can be utilized as probes include, but are not limited to, RNA, DNA, proteins, antibodies, and organic molecules. Probes and primers for the hybridization techniques described above can be synthesized and labeled by various known techniques. For example, oligonucleotides for use as probes and primers may be chemically synthesized according to the solid phase phosphoramidite triester method or using an automated synthesizing technique. Purification of oligonucleotides can be performed, e.g., by either native acrylamide gel electrophoresis or by anion-exchange HPLC.
In some aspects, the hybridization methods may include, but are not limited to, solution phase, solid phase, oligonucleotide array methods, mixed phase, or in situ hybridization assays. In solution (or liquid) phase hybridizations, both the target nucleic acid and the probe or primers are free to interact in the reaction mixture. Techniques such as real-time PCR systems have also been developed that permit analysis, e.g., quantification of amplified products during a PCR reaction. In this type of reaction, hybridization with a specific oligonucleotide probe occurs during the amplification program to identify the presence of a target nucleic acid. Examples of real-time PCR systems include fluorescence resonance energy transfer hybridization probes, molecular beacons, molecular scorpions, and exonuclease hybridization probes.
Hybridization complexes may be detected according to various techniques. For example, nucleic acid probes capable of specifically hybridizing to a target can be labeled by any one of several methods typically used to detect the presence of hybridized nucleic acids. For example, one common method of detection is the use of autoradiography using probes labeled with 3H, 125I, 15S, 14C, or 32P, or other suitable labels. Alternatively, probes can be conjugated directly with labels such as fluorophores, chemiluminescent agents or enzymes. The choice of label depends on sensitivity required, ease of conjugation with the probe, stability requirements, and available instrumentation.
In one embodiment, the RNA is immobilized on a solid surface and contacted with a probe, for example by running the isolated RNA on an agarose or other gel and transferring the RNA from the gel to a membrane, such as nitrocellulose. In an alternative embodiment, the probe(s) are immobilized on a solid surface and the RNA is contacted with the probe(s), for example, in an Affymetrix gene chip array.
In other embodiments, microarrays are used to detect biomarker expression. DNA microarrays provide one method for the simultaneous measurement of the expression levels of large numbers of genes. Each array consists of a reproducible pattern of capture probes attached to a solid support. Labeled RNA or DNA is hybridized to complementary probes on the array and then detected by laser scanning. Hybridization intensities for each probe on the array are determined and converted to a quantitative value representing relative gene expression levels. High-density oligonucleotide arrays are useful for determining the gene expression profile for a large number of RNAs in a sample.
In some embodiments, the deletion detection technique, includes robust dosage-polymerase chain reaction (RD-PCR), fluorescent in situ hybridization (FISH), and comparative genomic hybridization (CGH).
RD-PCR. In one embodiment, the number of copies of a target or control gene region or a chromosome within a tumor cell may be determined by robust dosage-polymerase chain reaction (RD-PCR). RD-PCR is a duplex quantitative PCR that co-amplifies a target gene, gene region, or locus (“target”) and an endogenous internal control gene, gene region, or locus (“control”) from the same genomic DNA source (Liu et al., 2003; Nguyen et al., 2007). The control has a known gene copy number per cell since it its gender is known, while the target has an unknown dosage number per cell. For example, if the target is autosomal, then the control is X-chromosomal. In one embodiment, the target gene region may be exon 2 or exon 3 of the KRAS gene. In another embodiment, the control gene region is exon 1 of the F9 gene.
In accordance with embodiments of the disclosure, RD-PCR products are analyzed to determine the relative template copy number quantitatively. The target and control genes or gene regions are compared in order to determine whether a KRAS gene region deletion and/or loss of Ch. 12 is present. The ratio of yield (ROY) is directly proportional to the ratio of the target to control product. Thus, the net signal of the target gene region is divided by the net control gene signal to obtain the ratio of yields (ROY). The accuracy of ROY is the degree of conformity of a ROY to its true ROY value. The consistency of ROY is the degree to which further ROY will show the same or similar results, and is characterized in terms of the standard deviation of ROY.
A DNA sample from a NSCLC patient tissue is then tested and its ROY is compared to the expected ratio from a matched gender control tissue to determine the relative template ratio of target to control. For females, the ratio of the template copy number of the autosomal (KRAS) to X chromosomal (F9) locus is 2:2. For males, the ratio of the template copy number of the autosomal (KRAS) to X chromosomal (F9) locus is 2:1, which is functionally equivalent to a heterozygous chromosomal deletion. A blinded analysis with normal male and female samples can be used to validate a given assay when multiple heterozygous deletions are unavailable. Therefore, by using wild-type male and female samples as controls, relative template (or copy) numbers of 2:1 and 2:2 are established, respectively. This relative template ratio of target to control is known as the template copy ratio (ROT). In addition to the ROY and ROT calculations, the percentage of tumor cells within a tissue can be calculated and used as an additional factor in an analyzing whether a KRAS gene region deletion and/or loss of Ch. 12 is present.
Although other polymerase chain reaction (PCR) based methods can be used to detect chromosomal deletions and duplications, these methods have remained a challenge because of small variations in PCR efficiency accumulate exponentially with cycling, and the presence of a terminal plateau phase where PCR yield is saturated. These challenges are potentiated by preferential amplification of one segment over another, especially with high GC contents. In contrast, RD-PCR has advantages over other methods of PCR, such as: 1) high accuracy and consistency, 2) easy calibration of linearity using male and female samples, 3) use of an endogenous internal dosage control to eliminate preparation and manipulation errors, and 4) quantification of gene dosage over a wide dynamic range.
Fluorescent in situ hybridization (FISH). In another embodiment, the number of copies of a target or control gene or gene region or a chromosome within a tumor cell may be determined by FISH. FISH is a cytogenetic technique used to detect and localize the presence or absence of specific DNA sequences on chromosomes. FISH uses fluorescent probes that bind particular genes, gene regions or chromosome loci. The probe or probes are labeled by various methods, such as nick translation, random primed labeling, and PCR. Two labeling strategies are commonly used: indirect labeling, wherein probes are labeled with modified nucleotides that contain a hapten; and direct labeling, wherein nucleotides that have been directly modified to contain a fluorophore are used. The target gene, gene region, or locus and the probe are then denatured with heat or chemicals in order to allow annealing to occur between the complementary target and probe sequences. The probe and target sequences are then combined so that the probe hybridizes to its complementary sequence on the chromosome. In some embodiments, a fluorescent probe can be used to detect the site of hybridization directly. In other embodiments, the probe is not fluorescent, and a secondary fluorescent probe is used to visualize the hybridized probe. Hybrids formed between the probes and their chromosomal targets are then detected using a fluorescent microscope.
Comparative genomic hybridization (CGH). In another embodiment, the number of copies of a target gene or gene region; control gene or gene region; or chromosome within a tumor cell may be determined by CGH. CGH is a molecular-cytogenic method for the analysis of copy number changes in a subject's DNA. DNA from a subject's target tumor tissue and from normal marginal tissue is labeled with different colors. After combining the target tumor tissue and the normal marginal tissue DNA with unlabeled human cot-1 DNA (placental DNA that is enriched for repetitive DNA sequences) to suppress repetitive DNA sequences, the combination is hybridized to normal metaphase chromosomes. For array- or matrix-CGH, the combination is hybridized to a slide containing hundreds or thousands of defined DNA probes. Using epifluorescence microscopy and quantitative image analysis, regional differences in the fluorescence ratio of gains or losses as compared to the control DNA can be detected and used for identifying abnormal regions in the genome.
Gene region deletions and/or loss of Ch. 12 may be verified by performing a first technique described above, then performing a second technique described above to verify the results of the first technique. For example, RD-PCR may be performed first, the results of which may be verified by performing FISH. Alternatively, the gene region deletions detected by one or more of the techniques described above may be verified by a gene sequencing technique such as Illumina parallel sequencing analysis as described in the examples below. Other suitable gene sequencing techniques known in the art may include, but are not limited to, the Sanger method (e.g., chain terminator or dye terminator methods), high-throughput parallelized sequencing, and sequencing by hybridization, ligation, mass spectrometry, or electron microscopy.
The detection of KRAS gene region deletions or loss of Ch. 12 may be used to predict survival in NSCLC patients. Deletions found in cancer tumor tissue, but not in the corresponding normal tissue are associated with a decrease in survival. In one embodiment, a search for predictive survival biomarkers in early stage non-small-cell lung cancer (NSCLC) patients was performed by using the highly quantitative RD-PCR technique described above to detect KRAS gene region deletions or loss of Ch. 12 in cancer tumor tissue as compared to normal marginal tissue. In one embodiment, a KRAS gene region deletion or loss of Ch. 12 was determined to exist in cancer tumor tissue as compared to normal marginal tissue, by dividing the cancer tumor tissue ROT by the normal marginal tissue ROT (T/N ROT). If the T/N ROT falls below a threshold (set at 0.85, see examples below), then it is likely that a KRAS gene region deletion or loss of Chromosome 12 exists in the cancer tumor tissue, but not in the normal marginal tissue. In one example, seven such deletions were found in 28 surgical sectioned cancer tissues but not in their paired normal tissues. These seven patients had a median survival or 35 months after surgery, compared with non-deletion patients of 59 months, showing a 1.7-fold decrease in survival (Long-Rank test; P=0.045).
Having described the invention with reference to the embodiments and illustrative examples, those in the art may appreciate modifications to the invention as described and illustrated that do not depart from the spirit and scope of the invention as disclosed in the specification. The Examples are set forth to aid in understanding the invention but are not intended to, and should not be construed to limit its scope in any way. The examples do not include detailed descriptions of conventional methods. Such methods are well known to those of ordinary skill in the art and are described in numerous publications. Further, all references cited above and in the examples below are hereby incorporated by reference in their entirety, as if fully set forth herein.
EXAMPLE 1
Materials and Methods
NSCLC patients and tissue specimens. Twenty-eight NSCLC patients from Taiwan were diagnosed at an early stage (IA, IB, IIA, or IIB) and were treated with standard adjuvant therapy (Table 1). Tissues were harvested during resection surgery, wherein samples of the cancer tissue and the paired marginal normal tissue were removed form each patient, sectioned, and then immediately frozen at −70° C. The cancer tissues contained sufficient portion of tumor cells, typically ≧40%, and normal tissues had no tumor cells as initially judged by a pathologist.







TABLE 1







Seven deletions and clinical characteristics of early stage NSCLC patients






















Smoking
Follow
Recurrence/




Lymph node
Tumor
KRAS gene


#
Sex
Age
(PPD)
up (M)
Metastasis
Status
Histology
Differentiation
Stage
involved
size
region deletion






















1
F
62
No
53

Alive
Adenoca
Moderate
IB
N0
T2



2
M
65
Yes
47

Alive
Adenoca
Moderate
IA
N0
T1
Del


3
M
74
Yes
22
Brain
Death
Squamous
Poor
IB
N0
T2



4
M
56
Yes
51

Alive
Squamous
Moderate
IB
N0
T2



5
M
76
Yes
26

Loss
Adenoca
Moderate
IB
N0
T2









follow














up








6
M
58
No
48

Alive
Adenoca
Moderate
IA
N0
T1



7
M
70
No
6

Death
Squamous
Moderate
IA
N0
T1



8
M
70
No
27

Death
Adenoca
Moderate
IB
N0
T2
Del


9
M
70
No
48

Alive
Squamous
Moderate
IA
N0
T1



10
M
65
Yes
56
Lung
Death
Squamous
Moderate
IB
N0
T2
Del


11
M
46
No
6

Loss
Squamous
Poor
IB
N0
T2









follow














up








12
F
72
No
38
Mediastinum
Death
Adenoca
Moderate
IA
N0
T1
Del







LN









13
F
80
No
32

Death
Adenoca
Moderate
IB
N0
T2
Del


14
F
71
No
42
Bone
Alive
Adenoca
Moderate
IB
N0
T2



15
M
51
Yes
70

Alive
Squamous
Moderate
IB
N0
T2



16
M
73
No
40

Alive
Adenoca
Moderate
IB
N0
T2



17
M
76
Yes
28

Loss
Squamous
Moderate
IB
N0
T2









follow














up








18
F
36
No
40

Alive
Adenoca
Moderate
IIB
N1
T2



19
M
69
No
24
Lung
Death
Adenoca
Moderate
IA
N0
T1
Del


20
M
63
No
45

Alive
Adenoca
Moderate
IA
N0
T1



21
F
72
No
34

Alive
Adenoca
Moderate
IA
N0
T1



22
M
77
Yes
34

Alive
Squamous
Moderate
IB
N0
T2



23
F
77
No
20

Death
Adenoca
Moderate
IA
N0
T2



24
M
65
Yes
31

Alive
Adenoca
Well
IA
N0
T1



25
F
48
Yes
65
Lung
Death
Adenoca
Well
IB
N0
T2



26
M
81
No
18

Loss
Adenoca

IA
N0
T1
Del








follow














up








27
M
71
No
53

Alive
Adenoca
Moderate
IA
N0
T1



28
M
62
No
39
Brain
Death
Squamous
Poor
IB
N0
T2









Extraction of genomic DNA from frozen tissues. The genomic DNA was extracted from frozen tissue using DNeasy Mini Kit according to manufacturer's protocol (Qiagen). The concentrations were measured by NanoDrop-1000 spectrophotometer at 260 nm (NanoDrop).
RD-PCR for chromosomal deletions. Each assay co-amplified a KRAS segment as a target and an X-Chromosome segment as an endogenous internal control. Primers were designed according to Liu et al. 2003 and Nguyen et al., 2007 (Nguyen et al., 2007; Langmead et al. 2009), the details of which are shown in Table 2 below.







TABLE 2







Primers for RD-PCR












3′ gene specific region





 of the primer
Core segment













Gene and


Tm
Size
Tm
GC


exon
Name
Sequence (5′-3′)
(° C.)
(bp)
(° C.)
(%)





F9 exon 1 on
F9(2724)D
ATGTAGCCACTATGCCTATC
64.4
486
83.0
40.7


Ch.X (Control)

(SEQ ID NO: 2)







F9(3210)U
CTGGCTGTTAGACTCTTCAA
61.7







(SEQ ID NO: 3)






 


KRAS exon 2
RAS(5445)D
CTGGTGGAGTATTTGATAGTGT
61.9
413
80.4
34.9


on autosome

(SEQ ID NO: 4)






12p12.1
RAS(5857)U
GAACATCATGGACCCTGACA
67.9







(SEQ ID NO: 5)






 


KRAS exon 3
RAS(23351)D
AGTGGCCATTTGTCCGTCAT
71.1
418
81.3
36.8


on autosome

(SEQ ID NO: 6)






12p12.1
RAS(23768)U
GCATGGCATTAGCAAAGACT
66.4







(SEQ ID NO: 7)









The primers are named according to the following protocol: gene(starting nucleotide # of gene)direction of transcription. For example, for the primer named F9(2724)D, F9 is the human coagulation factor IX gene, (2724) means that the 5′ end of the 3′ gene-specific region of the primer begins at nucleotide 2724 (according to GenBank accession K02402), and D means that the direction of the transcription is downstream. The precise sizes and locations of the PCR fragment can be obtained from the informative names. The KRAS sequence is from Genbank accession NG—007524 (SEQ ID NO:1). The sequence of the 3′ gene-specific region of each primer is shown. A 10-nucleotide universal tail for KRAS primers (5′ggccaagtga3′; SEQ ID NO:8) was attached to the 5′ end of each primer.
Oligo 5 calculates the melting temperature of a primer by the nearest neighbor method at 50 mM KCl, 0.7 mM free Mg, and 200 nm DNA. The melting temperature of a PCR product The Tm value of each PCR segment was estimated under the above salt conditions by the formula:

Tmproduct=31.5+16.6 log {[K+]/(1+0.7[K+])}+0.41(% G+% C)−500/length.

Before RD-PCR, genomic DNA samples were incubated at 95° C. in 1×Expand High Fidelity buffer #3 without MgCl2 (Roche) for 10 minutes in order to completely denature the genomic DNA and minimize RD-PCR bias (Langmead et al., 2009).
Each RD-PCR reaction contained a total volume of 25 μl containing the following: 1×Expand High Fidelity buffer #3 (Roche), 4.5 mM MgCl2, 200 μM each dNTP, 0.1 μM each primer of the F9 gene (internal control), 0.3 μM each primer for exon 2 or 0.2 μM each primer for exon 3 (target), 1U of Platinum Taq DNA polymerase and 1U of Platinum Taq DNA polymerase High Fidelity (Invitrogen), and 60 ng of genomic DNA. The reaction was first incubated at 94° C. for 2 minutes to denature the sample followed by the cycling phase, wherein each cycle follows a protocol of denaturation at 94° C. for 15 seconds, annealing at 55° C. for 30 seconds, and elongation at 72° C. for 90 seconds, repeated for 23 cycles.
Following the RD-PCR reaction, 15 μl of each reaction sample was loaded onto and electrophoresed through a 3% agarose gel. The gel was then stained with 0.5 μg/mL ethidium bromide for 1 hour, then scanned with a TyphoonTM 9410 Variable Mode Imager (GE healthcare) with the following parameter settings: 532 nm laser wavelength, 610 BP 30 emission filter, 550 photolnultiplier voltage, normal sensitivity, +3 mm focal plane, and 50 μm resolution.
The image of the gel was then analyzed using ImagerQuantTM software to quantify product yield. The net signal of a product was obtained by subtracting local background signal from total signal. The product yield ratio (ROY) of the KRAS gene to the F9 gene of a sample is the net signal of the target segment divided by the net signal of the control segment.
For normal samples, ROY was correlated with the template copy ratio (ROT) of the KRAS gene to the F9 gene (normal male ROT=2 and female ROT=1) and regressed according to the following linear equation:

ROY=m·ROT+b. 

The linear equation was then used to convert ROY of an unknown sample to its ROT. A threshold ROT value of ≦85% for a cancer sample was set by comparison with its paired normal marginal sample, equivalent to when 30% of diploid cells lose one copy of the KRAS gene.
Fluorescence in situ hybridization (FISH) analysis. Hematoxylin and eosin (H&E) stained frozen tissue sections were analyzed. Cover slips were removed in xylene and slides were fixed in Carnoy's fixative (3:1; methanol:acetic acid) for 30 min. Slides were then placed in 2×SSC for 10 min. followed by 0.05% pepsin in 10 mM HCl at 37° C. for 10 min.
After dehydration through an ethanol series, a Vysis EGFR/CEP 7 probe (cat# 30-191053) (Abbott Molecular, Abbott Park, Ill.) was applied. The probe and section were co-denatured at 80° C. for 5 minutes. A post-wash overnight incubation at 37° C. was then performed according to the manufacturer's instructions.
KRAS copy number was determined using the bacterial artificial chromosome (BAC) clone RP11-295i5 (Rosewell Park Microarray Core Facility). KRAS was nick translated with digoxigenin and detected with rhodamine anti-dig. This probe was combined with a Vysis CEP12 (cat# 32-132012) (Abbott Molecular, Abbott Park, Ill.) probe for an internal control. Hybridization was performed as described above.
Images were acquired using Bioview D3 image analyzer (Bioview) to capture the cell morphology. For each probe set, sixty cells were examined for each case by two independent scorers. Their average copies per tumor cell were normalized by positive normal standards, and then rounded to the nearest integer.
Pathological analysis. Frozen tissues were formalin fixed and paraffin embedded, then 5 μm thick sections were cut and placed on slides. The sections were then stained with hematoxylin and eosin (H&E). Morphological analyses were performed to determine the ratio of tumor area to the total area (% tumor cells) on slides by two investigators.
Illumina parallel sequencing analysis. Genomic DNA library preparation and high throughput sequencing were performed using the Solexa sequencing technology (GenomeAnalyzer, Illumina) according to the manufacturer's instructions. Five micrograms (μg) of genomic DNA was sheared using the bioruptor (Diagenode). The fragmented DNA was end-repaired using T4 DNA polymerase and Klenow polymerase with T4 polynucleotide kinase to phosphorylate the 5′ ends. A 3′ overhang was created using a 3′-5′ exonuclease-deficient Klenow fragment, and Illumina paired-end adaptor oligonucleotides were ligated to the sticky ends thus created. The ligation mixture was amplified for 18 cycles with Solexa primers followed by electrophoresis on an agarose gel and 400±25 bp fragments were selected and purified using a QIAGEN Gel Extraction Kit. The same libraries were used for both single read and paired-end sequencing. Clusters were generated on the Illumina Cluster station according to the manufacturer's protocol. Clusters of PCR colonies were then sequenced on the Genome Analyzer II platform. FASTQ sequence files were generated using the Illumina pipeline 1.3.2 for images processing and base calling.
Raw sequences from Illumina GAII sequencer were trimmed to the first 45 high quality bases and aligned to human genome build (using NCBI Build 36.1 of the human genome) using Bowtie aligner with default settings (Langmead et al. 2009). Briefly, reads are considered mapped to the genome when there are less than 2 mismatches in the first 28 bases, and the maximum quality score of mismatched bases is less than 70. Only one alignment belonging to the best stratum is reported when a read can be aligned to multiple locations. All of the following analyses were done in R statistical environment. Each chromosome was divided into non-overlapping 50 kb windows and the number of aligned tags within each window were counted and compared between cancer and normal samples. The log2 ratio for each window was calculated as the log2 transformed ratio between tumor counts and normal counts, offset by 1. The log2 ratio data were then mean centered and segmented using a circular binary segmentation (CBS) algorithm implemented in the Bioconductor package “DNAcopy” to detect copy number abnormalities (CNA) with default settings (Venkatraman & Olshen 2007). Only segments with more than 10 windows and an absolute log2 ratio>=0.1 were selected as candidate CNAs. Due to the polyploidy nature of these samples, the normalization approach will result in regions with high gains (e.g. EGFR) having a log2 ratio close to 0.
PCR and Sanger sequencing for point mutations. The following primers were designed to amplify and sequence exons 2 and 3 of the KRAS gene:









Exon 2 Forward:



(SEQ ID NO: 9)



5′-CTGGTGGAGTATTTGATAGTGT-3′



 



Exon 2 Reverse:



(SEQ ID NO: 10)



5′-ACTCCCAAGGAAAGTAAAGTT-3′;



 



Exon 3 Forward



(RAS(23351)D; SEQ ID NO: 6)



5′-AGTGGCCATTTGTCCGTCAT-3′ 



 



Exon 3 Reverse



(RAS(23768)U; SEQ ID NO: 7)



5′-GCATGGCATTAGCAAAGACT-3′ 






Each PCR sample reaction mixture contained a total volume of 25 μl of the following: 50 mM KCl, 10 mM Tris/HCl (pH 8.3), 1.5 mM MgCl2, 200 μM each dNTP, 0.1 μM each primer listed above, 1U of TaqGold DNA polymerase (Invitrogen), and 20 ng of genomic DNA. Before cycling, the samples were incubated at 94° C. for 10 minutes to activate the TaqGold DNA polymerase. Each cycle sample was then cycled, wherein each cycle followed a protocol of denaturation at 94° C. for 15 seconds, annealing at 55° C. for 30 second, and elongation at 72° C. for 1 minute, repeated for 35 cycles.
The PCR product was purified using Amocon50 to remove the unincorporated primers and dNTPs. Two nanograms (ng) of the PCR product were sequenced using ABI 3730 fluorescent DNA sequencer and BigDye terminator chemistry V1.1 (Applied Biosystems) with the above PCR primers. Sequencher software (Gene Codes) was used to identify a point somatic mutation when its mutant peak had ≧18% of the wild-type peak height, which is the equivalent to when 30% of diploid cells contain a copy of the mutation.
Statistical analysis. Data was analyzed using the JMP Statistical Discovery Software version 7.0 (SAS Institute, Cary, N.C.). Group comparisons for continuous data were performed using t-tests for independent means or one-way analyses of variance. A Kaplan-meier analysis was employed to estimate survival of patients. Cox proportional Hazard models were used to adjust for covariate effects on the risk ratio. Statistical significance was set at P<0.05.
EXAMPLE 2
Detection of Seven Large KRAS Gene Region Deletions or Loss of Chromosome 12 (Ch. 12) by RD-PCR
The use of highly quantitative RD-PCR to measure the gene copies in genomic DNA in 28 early stage NSCLC patients (as described above) reliably detected very small changes in the number of copies of the KRAS gene (i.e. “gene dosage”) at a high linearity and correlation between the copy number of the input template and the yield of the output product. Measurement of the gene dosage of any other portion of the KRAS gene or gene region may also be attained in this manner. Changes in gene dosage as small as 10% were obtained in a large-scale validation of 110 successive RD-PCR assays (Liu et al., 2003; Nguyen et al., 2007).
RD-PCR was used to examine the ratio of gene copies between exon 2 or 3 of the KRAS gene (the target), and exon 1 of the F9 gene (the endogenous internal control) from the genomic DNA pool with high accuracy and consistency. As shown in FIG. 1, exon 2 of the KRAS gene and exon 1 of the F9 gene were co-amplified from genomic DNA isolated from the frozen cancer samples of NSCLC patients. After being electrophoresed on an agarose gel, the relative product ratio of target to control (ROY) was calculated. Comparison of a ROY between a cancer sample and its paired normal tissue of a given patient is one factor used to determine whether a KRAS gene region deletion (D) was present. The linear function and correlation determinant were obtained from 12 male and 6 female normal samples (ROY=0.961·ROT−0.042, R2=0.973) showing high linearity and correlation. A normal male (M) has two copies of the KRAS gene and one copy of the F9 gene per cell, a normal female (F) has two copies of the KRAS gene and two copies of the F9 gene per cell.
The product yield ratio (ROY) of the KRAS gene to the F9 gene was then converted to the corresponding template copy ratio (ROT) (see Table 3, Table 4, below). A threshold for the presence of deletions was set to a 15% deviation from cancer sample ROT values as compared to their paired normal samples. This threshold is 3 times higher than its coefficient variance (CV). Analyzed in this manner, RD-PCR can detect one copy of deletions in 6-ploid tumor cells, accounting for ≧70% of cellular population.
To compare RD-PCR results on different gels, ROY of a sample was converted to its ROT based on a linear regression equation as described above. ROY was regressed and correlated with its ROT among 54 normal male samples (ROT=2, because there are two copies of the KRAS gene and one copy of the F9 gene in a male cell) and 27 female (ROT=1) samples. In the linear regression equation of ROY=m·ROT+b, the average coefficient m was 1.12 and 1.05 for exons 2 and 3, showing a high correlation.
In addition, ROT was further statistically analyzed (Table 3). Coefficient variance of ROT among the normal samples was from 0.054 to 0.061. In other words, if an unknown ROT is ≦85% of the normal value, we have more than 99% confidence to detect a KRAS deletion. CV of ROT from the 7 tumor tissues is 0.32, an even smaller number.







TABLE 3







ROT statistics of the two RD PCR assays from normal samples










Normal sample













Sex
Statistics
Exon 2
Exon 3
















Female
Average ROT
0.995
1.020




Standard Deviation of ROT
0.055
0.055




Coefficient Variance
0.055
0.054




Number of sample
19
8



Male
Average ROT
2.041
2.016




Standard Deviation of ROT
0.109
0.124




Coefficient Variance
0.054
0.061




Number of sample
37
17










To exclude possible bias of the F9 gene dosage, its copies were calibrated by four additional RD-PCR assays that targeted four loci on Chromosome 7 (Ch. 7) within the EGFR and MET genes. In addition, the percentage of tumor cells within the cancer tissues was also measured.
Seven large KRAS gene region deletions or loss of the locus on Chromosome 12 (Ch. 12) were found in the frozen cancer tissues ( ̃25% of cases), but not in their paired normal tissues. Specifically, in tumor cells, one to three copies of the KRAS gene were deleted from 4 or 6-ploid genome, such as in regions of the EGFR gene and Chromosome 7 centromere, likely due to cell fusion (Duelli & Lazebnik 2003). Table 4 shows the relevant calculations in patients with KRAS gene region deletions that led to this conclusion. Analysis of any given sample was repeated up to 4 times on the average. The presence of KRAS gene region deletions was estimated from the results of RD-PCR, % tumor cells within tissue specimen, and copies of the F9 gene per tumor cell, assuming that each tumor cell has the identical genomic pattern as well as each normal cell does. The results of the RD-PCR include the following measurements: ROT of KRAS to F9, which is the copy number ratio of the KRAS gene to the F9 gene; and T/N ROT which is the ratio between the ROT of the tumor tissue to the ROT of its paired normal tissue. A threshold of T/N ROT was set to be 0.85. This means that a T/N ROT for exon 2 or exon 3 that is 0.85 or lower indicates that a KRAS gene region deletion is likely present. The percentage of tumor cells in each sample (% tumor cells) was measured by dividing the tumor area by the total tissue area on slides. The number of copies of EGFR and KRAS genes (EGFR and KRAS) as well as the number of Ch. 7 and Ch. 12 (Ch. 7 Centromere and Ch. 12 Centromere) per tumor cell were initially estimated by FISH (see Example 3 below).







TABLE 4







Seven KRAS gene region deletions














RD-PCR


















Exon 2
Exon 3






















ROT of

ROT of



FISHe






















KRAS to

KRAS to

% tumor
KRAS

Ch. 7

Ch. 12


Patient#
Sex
Tissue
F9a
T/N ROTb
F9
T/N ROTb
cellsc
deletiond
EGFR
Centro-mere
KRAS
Centro-mere






















2
Male
Cancer
1.73
0.81
1.66
0.84
60-70%
Yes
8
6
2
3




Normal
2.14

1.99









8
Male
Cancer
1.70
0.85
1.61
0.87
60-70%
Yes
4
4
2
2




Normal
1.98

1.84









10
Male
Cancer
1.61
0.81
1.75
0.81
   80%
Yes
4
4
2
3




Normal
1.99

2.15









12
Female
Cancer
0.82
0.79
0.88
0.79
   60%
Yes
6
3
3
3




Normal
1.03

1.11









13
Female
Cancer
0.80
0.74
0.79
0.69
   80%
Yes
6
6
2
3




Normal
1.07

1.15









19
Male
Cancer
0.96
0.48
0.77
0.43
50-60%
Yes
6
6
3
3




Normal
2.01

1.79









26
Male
Cancer
1.18
0.58
1.32
0.64
   60%
Yes
5
4
2
3




Normal
2.02

2.05









The NSCLC patients had over 5 years of clinical follow-up after surgery. The seven NSCLC patients with the KRAS gene region deletions had for a median survival of 35 months, while the remaining patients who did not have KRAS gene region deletions have a median survival of 59 months. (FIG. 2, Long-Rank test P=0.045). These results show a strong association between KRAS-gene region deletions and length of survival period, and suggest that the number of copies of the KRAS gene region (i.e. “gene dosage”) is a predictive biomarker for survival in early stage NSCLC patients.
FIG. 2 is a graph illustrating that KRAS gene region deletions are correlated with a lower survival rate in early stage NSCLC patients. Kaplan-Meier analysis and Cox hazard proportional models were applied to the above data for survival analysis. The solid line indicates the NSCLC patients with the KRAS gene region deletions (N=7), and dashed line indicates the NSCLC patients without KRAS gene region deletions (N=21).
EXAMPLE 3
KRAS Gene Region Deletions as Detected by FISH and Illumina Analyses
The KRAS gene region deletions were verified by FISH by the use of an individual tumor cell as a unit to measure the copy ratio between the KRAS gene and Ch. 12 centromere. Deletions of any portions of the KRAS gene or gene region may be verified in this manner. FIGS. 3A and 3B are representative FISH analyses according to embodiments of the disclosure. FIG. 3A is an EGFR/CEP7 FISH image from patient 2 cancer tissue. The VYSIS EGFR probe was labeled in Spectrum orange (gray dots) and the CEP 7 centromere probe was labeled in Spectrum green (bright white spots). The cell on the lower left (arrow (1)) has a 5R/5G signal pattern. The cell in the middle right (arrow (2)) has a 6R/6G signal pattern.
FIG. 3B is a KRAS/CEP 12 FISH image from patient 13 cancer tissue. KRAS is labeled with Digoxigenin and detected with Rhodamine Anti Dig (red signal). The VYSIS CEP12 probe for the Ch. 12 centromere is labeled with Spectrum Green. The cell (arrow (3)) shows a 2R/3G pattern indicating a loss of 1 copy of the KRAS gene. (also see Table 4). This is based on the following reasons. First, tumor cells contained multi-copies of the genome, (commonly 4 or 6-ploid), such as in the EGFR gene and Ch. 7 centromere. Second, the KRAS gene showed two copies but Ch. 12 centromere had three copies in four cancer tissues, which directly implicates KRAS gene region deletions. In the other three cases, copies of the KRAS gene and Ch. 12 centromere were greatly reduced relative to those of the EGFR gene and Ch. 7 centromere, which indirectly implicates KRAS gene region deletions.
Although both RD-PCR and FISH show KRAS gene region deletions, there may be a difference in terms of the exact number of the KRAS genes deleted or lost (Table 4) presumably due to technical limitations. Because FISH examines tumor cells on slides with a thickness of 5 μm and not within the tumor as a whole, the number of signals may be underestimated. For example, if a large deletion spans the KRAS gene region and Ch. 12 centromere, the ratio may still remain normal.
The KRAS gene region deletions were also verified by Illumina paired-end parallel sequencing as described above. About 20 million reads were scored from tumor and normal samples of patients 13 and 19 using a fixed window approach (Chiang et al., 2009) and CBS segmentation method. As shown in FIGS. 4A and 4B, Illumina parallel sequencing confirms the presence of KRAS gene region deletions in cancer samples of patients 13 and 19. Using a 50 kb non-overlapping window along the entire genome, the number of counts was scored for each window as a log2 function and then compared to that of the relative normal control. The log2 ratio data were then mean centered and segmented, represented by short red lines. Deletion within the KRAS locus is noted. The blue horizontal line at zero means that there is no change in the number of copies. Patient 13 had a large KRAS gene region deletion almost covering the entire short arm of Chromosome 12, while patient 19 has many more break points and hence a relatively small KRAS gene region deletion. The average log2 ratios at these deleted regions are −0.16 and −0.14 respectively, which is consistent with an estimation of a one copy loss in the 6-ploid genome.
EXAMPLE 4
Somatic KRAS Point Mutations Are Likely Not Predictive of Survival
Applying PCR and Sanger sequencing of exons 2 and 3 to patient 25 (Table 1), a G5571C somatic missense mutation (Gly to Ala at codon 12) was identified in the cancer tissue but not in the paired normal tissue. In addition, this patient did not harbor any KRAS gene region deletions.
In statistical analysis, if this patient is excluded from statistical analyses, the KRAS gene region deletion effect results in the same conclusion using only the data from the other patients. However, if the patient with a somatic KRAS point mutation is placed in the same category as a KRAS gene region deletion and transferred to the KRAS gene region deletion group, there would be no significant difference between the two groups (Long-Rank test, P=0.11). This suggests that KRAS point mutations are not necessarily predictive of survival, and that deletions and point mutations likely play different roles in the development of NSCLC.
KRAS point mutations are found much more frequently in advanced NSCLC or their cell lines. This difference may be caused by staged mutagenesis in cancer development. Furthermore, it has also been observed that the number of deletions typically is small in premalignant, hyperproliferative lesions but become substantially larger in more advanced lesions. For example, KRAS mutations can occur in atypical hyperplasias of the lung (Sakuma et al., 2007), but their number is 20-30% higher in advanced NSCLC (Salgia and Skarin, 1998).
References
The references listed below, and all references cited in the specification are hereby incorporated by reference in their entirety, as if fully set forth herein.

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## Claims

1. A method for predicting survival in a cancer patient comprising:
(a) performing a first deletion detection technique on a cancer tumor tissue sample from a cancer patient, wherein the first deletion detection technique is robust dosage-polymerase chain reaction (RD-PCR) comprising:
amplifying a target gene region comprising one or more exons of a Kirsten rat sarcoma viral oncogene homolog (KRAS) gene region to produce DNA molecules that are complementary to the sequence of the one or more exons using one or more set of primers selected from:
a set of primers to amplify exon 2 of the KRAS gene region comprising the sequences of CTGGTGGAGTATTTGATAGTGT (SEQ ID NO:4) and GAACATCATGGACCCTGACA (SEQ ID NO:5), and
a set of primers to amplify exon 3 of the KRAS gene region comprising the sequences of AGTGGCCATTTGTCCGTCAT (SEQ ID NO:6) and GCATGGCATTAGCAAAGACT(SEQ ID NO:7);


(b) determining whether a KRAS gene region deletion is present; and
(c) predicting about a 1.7-fold decrease in survival for a patient having a KRAS gene region deletion in the cancer tumor tissue.

2. The method of claim 1, wherein the cancer patient has non-small-cell lung cancer (NSCLC).

3. The method of claim 1, wherein the RD-PCR technique comprises co-amplifying the target gene region and a control gene region from the cancer tumor tissue sample.

4. The method of claim 3, wherein the control gene region is exon 1 of the F9 gene.

5. The method of claim 3, wherein the RD PCR results are quantified by determining the target gene region to control gene template copy ratio (ROT).

6. The method of claim 1, wherein the method further comprises a second deletion detection technique to verify the results of the first deletion detection technique.

7. The method of claim 6, wherein the second deletion detection technique is selected from the group consisting of robust dosage-polymerase chain reaction (RD-PCR), fluorescent in situ hybridization (FISH), and comparative genomic hybridization (CGH).

8. The method of claim 1, wherein the method further comprises performing a gene sequencing technique to verify the results of the first deletion detection technique.

9. The method of claim 2, wherein the patient has early stage NSCLC (IA, IB, IIA, or IIB).