Patent Publication Number: US-7910318-B2

Title: Methods of diagnosing ovarian cancer and kits therefor

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a National Entry Application of PCT application no PCT/CA2006/001536 filed on Sep. 15, 2006 and published in English under PCT Article 21(2), which itself claims priority on U.S. provisional application Ser. No. 60/716,941, filed on Sep. 15, 2005. All documents above are incorporated herein in their entirety by reference. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates to methods of diagnosing ovarian cancer and kits therefor. More particularly, the present invention relates to the identification of markers associated with ovarian cancer and their use to detect ovarian cancer. The invention further relates to methods and reagents for the diagnosis of ovarian cancer. 
     SEQUENCE LISTING 
     This application contains a Sequence Listing in computer readable form entitled 14257 — 13.5T25, created Jan. 5, 2007 having a size of 408 Kb. The computer readable form is incorporated herein by reference. 
     BACKGROUND OF THE INVENTION 
     Epithelial ovarian carcinoma (EOC) is the most common malignant ovarian tumor, representing 80% of all ovarian malignancies (1). EOCs are thought to originate from either the normal ovarian surface epithelium (OSE) itself or from the crypts and inclusion cysts located in the stroma (1). EOCs are heterogeneous and are designated according to their histological subtype: serous, endometrioid, mucinous, clear cell, Brenner, undifferentiated or mixed (association of two or more sub-types) (2, 3). This cancer is often asymptomatic where over 70% of patients with ovarian cancer are diagnosed at an advanced stage of the disease. While up to 80% of the patients will initially respond to treatment, recurrence is generally observed within variable time intervals. Although 10-15% of the patients achieve and maintain a complete response to therapy, the remaining patients show persistent disease or eventually relapse thus requiring additional treatment. In contrast, borderline or low malignant potential (LMP) tumors, which represent 10-20% of all EOCs, have a more favorable prognosis compared to the invasive form of the disease, where the 5-year survival rate falls below 30% (1, 4). 
     Currently, there is no reliable method for screening early stage ovarian cancer. The clinically used CA125 serum marker (5) combined with trans-vaginal sonography, 3-dimensional ultrasound or power Doppler have yielded only minimal results (6). The reduced efficacy of CA125 for screening is largely related to its poor specificity. While elevated levels of CA125 are generally associated with the malignant disease, increased serum CA125 levels have also been observed with benign conditions (7), non-neoplastic conditions such as first trimester of pregnancy, menstruation, endometriosis, uterine fibrosis, acute salphingitis, hepatic diseases and inflammation of peritoneum, pericardium or pleura as well as with cancers of other sites. In addition, CA125 levels generally fail to rise in early stage disease, and lower levels are also associated with endometrioid and mucinous ovarian tumors (8). Thus, there is a need to develop reliable screening tools for EOC as these would be extremely valuable for improving cancer detection, clinical management and subsequently impact positively on survival. 
     Microarray technology is a powerful method for the analysis of cancer-specific gene expression by measuring tumor-specific expression of thousands of genes in hundreds of tumors (9), which can then be associated with specific clinical parameters. Candidate genes for diagnostic markers can further be characterized in combination with a large-scale quantitative polymerase chain reaction (Q-PCR) of RNA and immunohistochemical (IHC) analysis of protein expression using tissue arrays. However, such diagnostic techniques are difficult to implement since they require surgery to obtain the epithelial ovarian samples. Alternatively, if the differentially expressed gene encodes for a secreted protein circulating in peripheral blood, such a protein represents a potential serum based marker. The most common approach for testing such peripheral blood markers is through an enzyme-linked immunosorbent assay (ELISA). Although previous studies have investigated the potential of prostasin, osteopontin, mesothelin and HE4 (10-13) as diagnostic markers of EOC, no single marker has been shown to be sufficiently sensitive nor specific for proper diagnosis of ovarian cancer. Various combinations of different tumor markers have shown a higher specificity in differentiating benign from malignant disease (13, 14). However the efficacy and/or sensitivity of these markers were limited to advanced stage serous subtype tumors. 
     Therefore, ovarian cancer still remains a major source of morbidity and mortality and there is a clear need for the development of novel diagnosis method having the required sensitivity and specificity for early and reliable detection of ovarian cancer. 
     The present description refers to a number of documents, the content of which is herein incorporated by reference in their entirety. 
     Other objects, advantages and features of the present invention will become more apparent upon reading of the following non-restrictive description of specific embodiments thereof, given by way of example only with reference to the accompanying drawings. 
     SUMMARY OF THE INVENTION 
     The invention relates to markers associated with ovarian cancer and corresponding methods, uses and products (e.g. probes, collections, kits, etc.) for the diagnosis of ovarian cancer. 
     Accordingly, in a first aspect, the invention provides a method comprising:
         (a) providing a biological sample from a subject (subject sample); and   (b) detecting the expression level of each of the markers FGF-2 and CA125 in the subject sample.       

     In an embodiment, the above-mentioned subject is susceptible of having ovarian cancer. 
     In an embodiment, the above-mentioned subject is asymptomatic for ovarian cancer. 
     In an embodiment, the above-mentioned method further comprises:
         (c) comparing the expression level of each of the markers in the subject sample to corresponding pre-determined threshold expression levels for each of the markers, wherein an expression level of each of the markers in the subject sample that is higher than the pre-determined threshold expression levels for each of the markers is an indication that the subject is affected by ovarian cancer.       

     In an embodiment, the above-mentioned method further comprises:
         (c) comparing the expression level of each of the markers in the subject sample to the expression level of each of the markers in a control sample, wherein an expression level of each of the markers that is higher in the subject sample than in the control sample is an indication that the subject is affected by ovarian cancer       

     In an embodiment, the above-mentioned method further comprises:
         (c) comparing the expression level of each of the markers in the subject sample to the expression level of each of the markers in a sample from the subject at an earlier time, wherein an expression level of each of the markers that is higher in the subject sample than in the sample from the subject at an earlier time is an indication that the subject is affected by ovarian cancer.       

     In an embodiment, the above-mentioned method further comprises:
         (c) comparing the expression level of each of the markers in the subject sample to the expression level of each of the markers in a non-cancerous sample from the subject, wherein an expression level of each of the markers that is higher in the subject sample than in the non-cancerous sample from the subject is an indication that the subject is affected by ovarian cancer.       

     In an embodiment, the above-mentioned threshold expression level for each of the markers is determined by Receiver Operator Curves comparing the concentration of each of the markers in an ovarian cancer-free control population with that in a population affected by ovarian cancer. 
     In an embodiment, the above-mentioned expression is determined at the polypeptide level. In a further embodiment, the expression is determined using an immunoassay. In a further embodiment, the immunoassay is enzyme-linked immunosorbent assay (ELISA). 
     In an embodiment, the expression level of each of the above-mentioned markers is above the following pre-determined threshold expression levels: 50 U/ml for CA125 and 37 pg/ml for FGF-2. 
     In an embodiment, step (b) of the above-mentioned further comprises detecting the concentration of marker IL-18 in the sample. 
     In an embodiment, step (b) of the above-mentioned further comprises detecting the concentration of marker IL-18 in the sample, and the expression level of IL-18 in the sample is above the pre-determined threshold expression level of 215 pg/ml for this marker. 
     In an embodiment, the above-mentioned subject sample is a body fluid sample. In a further embodiment, the above-mentioned subject sample is selected from the group consisting of blood, plasma and serum. In a further embodiment, the above-mentioned subject sample is serum. 
     In an embodiment, the above-mentioned subject sample is primary culture cells derived from an ovarian tumor sample from the subject. 
     In an embodiment, the above-mentioned method is in vitro. 
     In an other aspect, the present invention provides a kit comprising means for detection of an expression level of each of markers CA125 and FGF-2 in a biological sample from a subject (subject sample), and instructions to use said markers in a method as recited above. 
     In an embodiment, the above-mentioned kit further comprises means for detection of an expression level of marker IL-18. 
     In an embodiment, the above-mentioned means for detection of expression level of each of the markers are antibodies. 
     In an other aspect, the invention provides a method of assessing the potential efficacy of a test compound for treating or inhibiting ovarian cancer in a subject, said method comprising determining the expression level of each of markers CA125 and FGF-2 in a biological sample from the subject (subject sample), before and after administration of the test compound to the subject, wherein a decrease in the expression level of the markers after administration of the test compound is indicative that said test compound is effective for treating or inhibiting ovarian cancer. 
     In an other aspect, the invention provides a method of assessing the potential efficacy of a therapy for treating or inhibiting ovarian cancer in a subject, said method comprising determining the expression level of each of markers CA125 and FGF-2 in a biological sample from the subject (subject sample), before and after administration of said therapy in said subject, wherein a decrease in the expression level of said markers after administration of said therapy is indicative that said therapy is effective for treating or inhibiting ovarian cancer. 
     In an embodiment of the above-mentioned methods, the methods further comprise detecting the concentration of marker IL-18 in the sample. In an embodiment, the above-mentioned expression is determined at the polypeptide level. In a further embodiment, the expression is determined using an immunoassay. In a further embodiment, the immunoassay is enzyme-linked immunosorbent assay (ELISA). 
     In an embodiment, the above-mentioned sample is a body fluid sample. In a further embodiment, the above-mentioned sample is selected from the group consisting of blood, plasma and serum. In a further embodiment, the above-mentioned sample is serum. 
     In an embodiment, the above-mentioned subject is a human. 
     In an embodiment, the above-mentioned ovarian cancer is epithelial ovarian carcinoma (EOC). 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       In the appended drawings: 
         FIG. 1  shows validation of gene expression profiles by Q-PCR on primary culture samples. (A) Two micrograms of RNA extracted from 9 NOSE and 8 primary culture cells of EOC were reverse-transcribed and the levels of IL-18 and FGF-2 quantified using specific primers (left hand panels). Each expression level was normalized to that of the control RNA. Relative fold change expression is the ratio of the NOSE 18 gene expression to that of other samples. Three micrograms of RNA extracted from 12 BOT (benign ovarian tumor) tissues and 22 EOC tissues were reverse-transcribed and the levels of IL-18 and FGF-2 quantified as in the left hand panels (right hand panels). Each expression level was normalized to that of the control RNA. Relative fold change expression is the ratio of the BOT142 gene expression to that of other samples; (B) shows the expression of IL-18 and FGF-2 in normal ovarian surface epithelial (NOSE) tissues and four histopathologies of EOC tissues. IHC was performed using antibodies against indicated proteins (left). Nuclei are counterstained with hematoxylin (blue). Brown color demonstrates specific peroxidase staining; 
         FIG. 2  shows serum measurement of CA125 (A) IL-18 (B) and FGF-2 (C) by ELISA. Patients sera was tested for all CA125, IL-18 and FGF-2 and threshold levels (dashed lines) were determined for each serum marker. Solid lines show the median level of the serum marker for each group of patients. LMP: low malignant potential tumor patients (n=5). NOSE: normal ovarian surface epithelia patients (n=11). BOT: benign ovarian tumor patients (n=23). TOV: ovarian tumor patients (equivalent to EOC: invasive epithelial ovarian cancer patients) (n=42); 
         FIG. 3  presents nucleic acid (SEQ ID NO: 1) and polypeptide (SEQ ID NO: 2) sequences for CA125; 
         FIG. 4  presents nucleic acid (SEQ ID NO: 3) and polypeptide (SEQ ID NO: 4) sequences for IL-18; and 
         FIG. 5  presents nucleic acid (SEQ ID NO: 5) and polypeptide (SEQ ID NO: 6) sequences for FGF-2. 
     
    
    
     DESCRIPTION OF ILLUSTRATIVE EMBODIMENTS 
     The present invention concerns markers which can be used to diagnose ovarian cancer in subjects. 
     “Selectivity” in the context of the present invention refers to the ability of a marker of the present invention to discriminate between a sample affected by ovarian cancer and one that is not i.e. a marker with high selectivity produces few false positives. 
     “Sensitivity” in the context of the present invention refers to the ability of a marker of the present invention to correctly identify a sample affected by ovarian cancer as such i.e. a marker with high sensitivity produces few false negatives. 
     “Marker” in the context of the present invention refers to, without being so limited, a nucleic acid or a polypeptide (or fragment thereof), which is differentially present in a sample taken from a subject having ovarian cancer as compared to a comparable sample taken from a control subject (e.g., a person with a negative diagnosis or undetectable cancer, normal or healthy subject). 
     “Subject” in the context of the present invention relates to any mammal including a mouse, rat, pig, monkey, horse. In a specific embodiment, it refers to a human. 
     As used herein the terms “sample from the subject at an earlier time is meant to refer to a sample from a subject at a time where it was known that the subject was not affected by ovarian cancer. 
     The articles “a,” “an” and “the” are used herein to refer to one or to more than one (i.e., to at least one) of the grammatical object of the article. 
     The term “including” and “comprising” are used herein to mean, and reused interchangeably with, the phrases “including but not limited to” and “comprising but not limited to”. 
     The term “such as” is used herein to mean, and is used interchangeably with, the phrase “such as but not limited to”. 
     Optionally, a marker can be modified before analysis to improve its resolution or to determine its identity. For example, the markers may be subject to proteolytic digestion before analysis. Any protease can be used. Proteases, such as trypsin, that are likely to cleave the markers into a discrete number of fragments are particularly useful. The fragments that result from digestion function as a fingerprint for the markers, thereby enabling their detection indirectly. This is particularly useful where there are markers with similar molecular masses that might be confused for the marker in question. Also, proteolytic fragmentation is useful for high molecular weight markers because smaller markers are more easily resolved by mass spectrometry. The markers can also be modified by the attachment of a tag of particular molecular weight that specifically bind to molecular markers, further distinguishing them. Optionally, after detecting such modified markers, the identity of the markers can be further determined by matching the physical and chemical characteristics of the modified markers in a protein database (e.g., SwissProt™). 
     Expression levels may in general be detected by either detecting mRNA from the cells and/or detecting expression products, such as polypeptides and proteins. Expression of the transcripts and/or polypeptides encoded by the nucleic acids described herein may be measured by any of a variety of known methods in the art. In general, the nucleic acid sequence of a nucleic acid molecule (e.g., DNA or RNA) in a subject sample can be detected by any suitable method or technique of measuring or detecting gene sequence or expression. Such methods include, but are not limited to, polymerase chain reaction (PCR), reverse transcriptase-PCR (RT-PCR), in situ PCR, quantitative PCR (q-PCR), in situ hybridization, Southern blot, Northern blot, sequence analysis, microarray analysis, detection of a reporter gene, or other DNA/RNA hybridization platforms. For RNA expression, preferred methods include, but are not limited to: extraction of cellular mRNA and Northern blotting using labeled probes that hybridize to transcripts encoding all or part of one or more of the genes of this invention; amplification of mRNA expressed from one or more of the genes of this invention using gene-specific primers, polymerase chain reaction (PCR), quantitative PCR (q-PCR), and reverse transcriptase-polymerase chain reaction (RT-PCR), followed by quantitative detection of the product by any of a variety of means; extraction of total RNA from the cells, which is then labeled and used to probe cDNAs or oligonucleotides encoding all or part of the genes of this invention, arrayed on any of a variety of surfaces; in situ hybridization; and detection of a reporter gene. The term “quantifying” or “quantitating” when used in the context of quantifying transcription levels of a gene can refer to absolute or to relative quantification. Absolute quantification may be accomplished by inclusion of known concentration(s) of one or more target nucleic acids and referencing the hybridization intensity of unknowns with the known target nucleic acids (e.g., through generation of a standard curve). Alternatively, relative quantification can be accomplished by comparison of hybridization signals between two or more genes, or between two or more treatments to quantify the changes in hybridization intensity and, by implication, transcription level. 
     As used herein, “control sample” refers to a sample of the same type, that is, obtained from the same biological source (e.g. body fluid, tissue, etc.) as the tested sample but from a healthy subject, (i.e. who is not afflicted by ovarian cancer, and preferably who is not afflicted by any cancer). The control sample can also be a standard sample that contains the same concentration of the above-mentioned markers that are normally found in a corresponding biological sample obtained from a healthy subject. For example, there can be a standard control sample for the amounts of CA125, IL-18 and FGF-2 normally found in biological samples such as tissue, blood, plasma and serum. 
     The methods of the invention can also be practiced, for example, by selecting a combination of the above-mentioned markers and one or more additional markers for which increased or decreased expression correlates with ovarian cancer, such as CA72-4, hK6, hK10, HSCCE, kallikrein 4, kallikrein 5, kallikrein 6, kallikrein 8, kallikrein 9, kallikrein 11, CA15-3, CA19-9, OVX1, lysophosphatidic acid (LPA) or carcinoembryonic antigen (CEA), as well as other markers specific for other types of cancer. Those skilled in the art will be able to select useful diagnostic markers for detection in combination with CA125, IL-18 and FGF-2. Similarly, four or more or five or more or a multitude of markers can be used together for determining a diagnosis of a patient. 
     In an embodiment, the expression level of the above-mentioned markers is determined at the polypeptide level. 
     Methods to measure polypeptide expression levels of the markers of this invention, include, but are not limited to: Western blot, immunoblot, enzyme-linked immunosorbant assay (ELISA), radioimmunoassay (RIA), immunoprecipitation, surface plasmon resonance, chemiluminescence, fluorescent polarization, phosphorescence, immunohistochemical analysis, matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry, microcytometry, microarray, microscopy, fluorescence activated cell sorting (FACS), flow cytometry, and assays based on a property of the protein including but not limited to DNA binding, ligand binding, or interaction with other protein partners. 
     The terms “polypeptide,” “peptide” and “protein” are used interchangeably herein to refer to a polymer of amino acid residues. The terms apply to amino acid polymers in which one or more amino acid residue is an artificial chemical mimetic of a corresponding naturally occurring amino acid, as well as to naturally occurring amino acid polymers, those containing modified residues, and non-naturally occurring amino acid polymers. 
     In an embodiment, the expression level of the above-mentioned markers is determined using an immunoassay. 
     An immunoassay is an assay that uses an antibody to specifically bind an antigen (e.g., a marker). The immunoassay is characterized by the use of specific binding properties of a particular antibody to isolate, target, and/or quantify the antigen. The phrase “specifically (or selectively) binds” to an antibody or “specifically (or selectively) immunoreactive with,” when referring to a protein or peptide, refers to a binding reaction that is determinative of the presence of the protein in a heterogeneous population of proteins and other biologics. Thus, under designated immunoassay conditions, the specified antibodies bind to a particular protein at least two times the background and do not substantially bind in a significant amount to other proteins present in the sample. Specific binding to an antibody under such conditions may require an antibody that is selected for its specificity for a particular protein. For example, polyclonal antibodies raised to a marker from specific species such as rat, mouse, or human can be selected to obtain only those polyclonal antibodies that are specifically immunoreactive with that marker and not with other proteins, except for polymorphic variants and alleles of the marker. This selection may be achieved by subtracting out antibodies that cross-react with the marker molecules from other species. 
     Using the purified markers or their nucleic acid sequences, antibodies that specifically bind to a marker can be prepared using any suitable methods known in the art. See, e.g., Harlow &amp; Lane, Antibodies: A Laboratory Manual (1988) and Goding, Monoclonal Antibodies: Principles and Practice (2d ed. 1986). Such techniques include, but are not limited to, antibody preparation by selection of antibodies from libraries of recombinant antibodies in phage or similar vectors, as well as preparation of polyclonal and monoclonal antibodies by immunizing rabbits or mice. 
     Generally, a sample obtained from a subject can be contacted with the antibody that specifically binds the marker. Optionally, the antibody can be fixed to a solid support to facilitate washing and subsequent isolation of the complex, prior to contacting the antibody with a sample. Examples of solid supports include glass or plastic in the form of, e.g., a microtiter plate, a stick, a bead, or a microbead. The sample is preferably a biological fluid sample taken from a subject. The sample can be diluted with a suitable eluant before contacting the sample to the antibody. 
     After incubating the sample with antibodies, the mixture is washed and the antibody-marker complex formed can be detected. This can be accomplished by incubating the washed mixture with a detection reagent. This detection reagent may be, e.g., a second antibody which is labeled with a detectable label. Exemplary detectable labels include magnetic beads (e.g., DYNABEADS™), fluorescent dyes, radiolabels, enzymes (e.g., horse radish peroxidase, alkaline phosphatase and others commonly used in an ELISA), and colorimetric labels such as colloidal gold or colored glass or plastic beads. Alternatively, the marker in the sample can be detected using an indirect assay, wherein, for example, a second labeled antibody is used to detect bound marker-specific antibody, and/or in a competition or inhibition assay wherein, for example, a monoclonal antibody which binds to a distinct epitope of the marker is incubated simultaneously with the mixture. 
     Methods for measuring the amount of, or presence of, antibody-marker complex include, for example, detection of fluorescence, luminescence, chemiluminescence, absorbance, reflectance, transmittance, birefringence or refractive index (e.g., surface plasmon resonance, ellipsometry, a resonant mirror method, a grating coupler waveguide method or interferometry). Optical methods include microscopy (both confocal and non-confocal), imaging methods and non-imaging methods. Electrochemical methods include voltametry and amperometry methods. Radio frequency methods include multipolar resonance spectroscopy. Methods for performing these assays are readily known in the art. Useful assays include, for example, an enzyme immune assay (EIA) such as enzyme-linked immunosorbent assay (ELISA), a radioimmune assay (RIA), a Western blot assay, or a slot blot assay. These methods are also described in, e.g., Methods in Cell Biology: Antibodies in Cell Biology, volume 37 (Asai, ed. 1993); Basic and Clinical Immunology (Stites &amp; Terr, eds., 7th ed. 1991); and Harlow &amp; Lane, supra. 
     In a further embodiment, the above-mentioned immunoassay is an enzyme-linked immunosorbant assay (ELISA). 
     The markers can be measured in different types of biological samples. The sample is preferably a biological fluid sample such as blood, plasma and serum. Other typical biological samples include, but are not limited to, tissue biopsy from ovarian tumor, sputum, lymphatic fluid, blood cells (e.g., peripheral blood mononuclear cells), tissue or fine needle biopsy samples, urine, peritoneal fluid, colostrums, breast milk, fetal fluid, tears, pleural fluid, or cells therefrom. Because all of the markers are found in blood serum, blood serum is a preferred sample source for embodiments of the invention. 
     If desired, the sample can be prepared to enhance detectability of the markers. For example, to increase the detectability of markers, a blood serum sample from the subject can be preferably fractionated by, e.g., Cibacron™ blue agarose chromatography and single stranded DNA affinity chromatography, anion exchange chromatography, affinity chromatography (e.g., with antibodies) and the like. The method of fractionation depends on the type of detection method used. Any method that enriches for the protein of interest can be used. Sample preparations, such as pre-fractionation protocols, are optional and may not be necessary to enhance detectability of markers depending on the methods of detection used. For example, sample preparation may be unnecessary if antibodies that specifically bind markers are used to detect the presence of markers in a sample. 
     Typically, sample preparation involves fractionation of the sample and collection of fractions determined to contain the markers. Methods of pre-fractionation include, for example, size exclusion chromatography, ion exchange chromatography, heparin chromatography, affinity chromatography, sequential extraction, gel electrophoresis and liquid chromatography. The analytes also may be modified prior to detection. These methods are useful to simplify the sample for further analysis. For example, it can be useful to remove high abundance proteins, such as albumin, from blood before analysis. Examples of methods of fractionation are described in WO/2003/057014. 
     The methods for detecting these markers in a sample have many applications. For example, one or more markers can be measured to aid human cancer diagnosis. In another example, the methods for detection of the markers can be used to monitor responses in a subject to cancer treatment. In another example, the methods for detecting markers can be used to assay for and to identify compounds that modulate expression of these markers in vivo or in vitro. 
     In an embodiment, the subject is a human. 
     The present invention also relates to a kit for determining the likelihood of ovarian cancer in a subject, said kit comprising means for detection of expression of the markers CA125 and FGF-2 and, in more specific embodiments, the marker IL-18, in a biological sample from said subject together with instructions setting forth the above-mentioned method. Means for detection include probe, primer (or primer pair), or immunological reagent (e.g. antibody) in accordance with the present invention. For example, a compartmentalized kit in accordance with the present invention includes any kit in which reagents are contained in separate containers. Such containers include small glass containers, plastic containers or strips of plastic or paper. Such containers allow the efficient transfer of reagents from one compartment to another compartment such that the samples and reagents are not cross-contaminated and the agents or solutions of each container can be added in a quantitative fashion from one compartment to another. Such containers may for example include a container which will accept the test sample (DNA, protein or cells), a container which contains the primers used in the assay, containers which contain enzymes, containers which contain wash reagents, and containers which contain the reagents used to detect the indicator products. 
     Kits for evaluating expression of nucleic acids can include, for example, probes or primers that specifically bind a nucleic acid of interest (e.g., a nucleic acid, the expression of which correlates with increased likelihood of ovarian cancer). The kits for evaluating nucleic acid or polypeptide expression can provide substances useful as standard (e.g., a sample containing a known quantity of a nucleic acid or polypeptide to which test results can be compared, with which one can assess factors that may alter the readout of a diagnostic test, such as variations in an enzyme activity or binding conditions). Kits for assessing nucleic acid or polypeptide expression can further include other reagents useful in assessing levels of expression (e.g. buffers and other reagents for performing amplification reactions, or for detecting binding of a probe to a nucleic acid or binding of an antibody to a polypeptide). The kits can provide instructions for performing the assay used to evaluate gene/polypeptide expression for determining likelihood of ovarian cancer based on the results of the assay. For example, the instructions can indicate that levels of expression of a gene of interest (e.g., relative to a standard or a control), correlate with increased likelihood for ovarian cancer. 
     The invention further provides a method of assessing the potential efficacy of a test compound for treating or inhibiting ovarian cancer in a subject, said method comprising determining, in a biological sample from said subject, the expression of the markers CA125 and FGF-2 and, in more specific embodiments, the marker IL-18, before and after administration of said test compound in said subject, wherein a decrease in the expression of said markers after administration of said test compound is indicative that said test compound is effective for treating or inhibiting ovarian cancer. 
     In an other aspect, the invention provides a method of assessing the efficacy of a therapy for treating or inhibiting ovarian cancer in a subject, said method comprising determining, in a biological sample from said subject, the expression of the markers CA125 and FGF-2 and, in more specific embodiments, the marker IL-18, before and after administration of said therapy in said subject, wherein a decrease in the expression of said markers after administration of said therapy is indicative that said therapy is effective for treating or inhibiting ovarian cancer. 
     In an embodiment, the above-mentioned ovarian cancer is epithelial ovarian carcinoma. 
     The present invention is illustrated in further details by the following non-limiting examples. 
     Example 1 
     Clinical Samples 
     Tissue samples and sera were obtained with informed consent from participants. Tumor samples were collected from surgeries performed at the Centre Hospitalier de l&#39;Université de Montréal (CHUM). Histopathology, grade and stage of tumors were assigned according to the International Federation of Gynecology and Obstetrics (FIGO) criteria. Normal controls were defined as tumor-free patients. Primary cell cultures from normal ovarian surface epithelia (NOSE) and EOC samples were established as described (15, 16) and used for microarray analysis. Cells in primary culture were maintained in OSE media consisting of 50:50 medium 199:105 (Sigma) supplemented with 10% fetal bovine serum (FBS), 2.5 μg/mL amphotericin B and 50 μg/mL gentamicin (15). Independent cohorts for microarray, ELISA and tissue array IHC studies were used and are presented in Table 1 below. 
     Quantitative PCR 
     Linear amplification of RNA from primary culture cells was performed as described previously (17). The cDNA synthesis was done according to the protocol of the SuperScript™ First-Strand Synthesis System for Q-PCR (Invitrogen Life Technologies) with a starting amount of 2 mg RNA and reverse transcription performed with random hexamers. The PCR reaction (temperature, specificity) was performed using conventional PCR conditions with a Rotor-gene™ 3000 Real-Time Centrifugal DNA Amplification System (Corbett tumor tissues Research, NSW, Australia). The Quantitect™ SYBR Green PCR (Qiagen Inc., ON, Canada) reaction mixture was used according to the manufacturer instruction. Serial dilutions were performed to generate a standard curve for each gene tested in order to define the efficiency of the Q-PCR reaction and a melt curve was done to confirm the specificity of the reaction. Based on the stability of its expression in microarray experiments, primers for the ERK1 gene were used as an internal control. Experiments were done in duplicate. Positive and negative controls were introduced in all experiments. The sequences for IL-18 primers are: Fwd 5′-CGCTTCCTCTCGCMCAAACTAT-3′ (SEQ ID NO: 7) and Rev 5′-CCGGGGTGCATTATCTCTACAGT-3′ (SEQ ID NO: 8); FGF-2: Fwd 5′-CGCGCAGGAGGGAGGAGA-3′ (SEQ ID NO: 9) and Rev 5′-ACGCCGCCTGGGGAGAG-3′ (SEQ ID NO: 10) and finally ERK1: Fwd 5′-GCGCTGGCTCACCCCTACCT-3′ (SEQ ID NO: 11) and Rev 5′-GCCCCAGGGTGCAGAGATGTC-3′ (SEQ ID NO: 12). The Pfaffl analysis was used method to measure the relative quantity of gene expression (18). 
     RNA Preparation and Microarray 
     Total RNA was extracted with TRIzol™ reagent (Gibco/BRL, Life Technologies Inc., Grand Island, N.Y., USA). RNA was extracted directly from cells grown to 80% confluency. The quality of the RNA was monitored by gel electrophoresis and a 2100 Bioanalyzer using the RNA 6000 Nano LabChip™ kit (Agilent Technologies, Germany). Biotinylated hybridization target was prepared from total RNA as described (19). HuGeneFI™ 6800 GeneChip™ microarray experiments were performed at the McGill University and Genome Quebec Innovation Centre and raw data was processed using the Affymetrix™ MAS4 software. Detailed protocols are known in the art and are available at www.genomequebec.mcgill.ca/center.php. The raw data of each experiment was normalized according to the mean of the global intensity adjusted to 100 units. Arrays with global intensity below 100 were eliminated. After normalization, all values below 20 were considered as technical noise and expression values below this threshold were transformed to this value. All the EST&#39;s were next filtered, which had “A” call (ambiguous signal) across all samples. To detect differentially expressed genes in ovarian tumor samples versus normal ovarian cells, two statistical tests were used to identify classifiers. A parametric and a non-parametric (Mann-Whitney (U)) test were performed using GeneSpring™ software (Silicon Genetics). Candidate genes identified in common in the two analyses were selected for further analysis. 
     Tissue Array and IHC 
     The following monoclonal antibodies were used in immunohistochemistry (IHC): anti-IL-18 (R&amp;D system), anti-FGF-2 (Santa Cruz Biotechnology). A tissue array containing 94 cores of ovarian epithelial tissues (see Table 1 below) was built and used for IHC studies. Briefly, the tissue array was heated at 60° C. for 30 min, deparaffinized in toluene and rehydrated in a gradient of ethanol. To unmask antigen the slides were submerged in 90° C. citrate buffer (0.01 M citric acid+500 ul tween-20/L adjusted to pH 6.0) (J. T. Baker Philipsburg, N.J.) for 15 min. The tissue was blocked with a protein-blocking serum-free reagent (DakoCytomation Inc., Mississauga, ON) and incubated with the different antibodies overnight at 4° C. in a humid chamber. The optimal concentration for each primary antibody was determined by serial dilutions. Subsequently, endogenous peroxidase activity was quenched by treatment with 3% H 2 O 2 . The array was then incubated with a secondary biotinylated antibody (DakoCytomation Inc., Mississauga, ON) for 10 min followed by incubation with a streptavidin-peroxidase complex (Dako Diagnostics Canada Inc.) for 10 min at room temperature. Reaction products were developed using diaminobenzidine (brown stain) containing 0.3% H 2 O 2  as a substrate for peroxidase and nuclei were counterstained with diluted hematoxylin (blue stain). Epithelial zones were scored according to the intensity of staining (value of 0 for absence, 1 for weak, 2 for moderate, 3 for high intensity). Each array was independently analyzed in a blind study by two independent observers. Statistical analyses were performed using the T-test. 
     ELISA 
     Patient&#39;s blood was centrifuged for 30 min at 2500 rpm and the separated serum was immediately frozen at −20° C. until further use. Before measurement, all sera were re-centrifuged for 10 min at 8000 rpm. The sera were further tested by ELISA for CA125 (Panomics BC1013), FGF-2 (R&amp;D System, item DFB50) and IL-18 (R&amp;D System, item 7620) concentration according to the manufacturer&#39;s instructions. The limit of detection for IL-18 was 20 pg/ml, 10 U/ml for CA125 and 20 pg/ml for FGF-2. Independent experiments were calibrated with at least two samples. Statistical analyses were performed using SPSS software. For small sample set sizes (&lt;10) the Mann-Whitney U test was applied, otherwise statistical analysis relied on the T-test. 
     Example 2 
     Identification of Two Genes Up-Regulated in Ovarian Cancer and Encoding for Cytokines 
     Comparative analysis of gene expression profiles of ovarian epithelial cells was performed using 11 primary cultures of normal ovarian epithelial surface (NOSE) samples and 39 primary cultures of EOC samples. The 39 EOC represented different grades, stages and pathologies of ovarian cancer (see Table 1 below). To gain insight into genes exhibiting dominant expression levels in ovarian tumors, the expression profiles were analyzed using two different supervised classification algorithms. Among a total of 177 candidate genes that were common to both supervised analyses, several genes encoding for secreted proteins were identified but only two genes encoding for cytokines, IL-18 and FGF-2, were present. In order to maximize the chance of sampling differential gene expression in serum, these latter two genes were selected for further study. 
     
       
         
           
               
             
               
                 TABLE 1 
               
             
            
               
                   
               
               
                 SAMPLE SETS USED IN EACH EXPERIMENT 
               
            
           
           
               
               
               
               
            
               
                   
                 Sample 
                 Tumor grade 
                 Tumor stage 
               
            
           
           
               
               
               
               
               
               
               
               
               
            
               
                 Histopathology 
                 size 
                 B 
                 1 
                 2 
                 3 
                 Mixed 
                 Low 
                 high 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
            
               
                 Microarray set 
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 (n = 50) 
               
               
                 Normal 
                 11 
               
               
                 Serous 
                 29 
                 6 
                 1 
                 7 
                 15 
                   
                 4 
                 25 
               
               
                 Endometroid 
                 7 
                   
                   
                 3 
                 4 
                   
                   
                 7 
               
               
                 Mixed 
                 1 
                   
                   
                   
                 1 
                   
                   
                 1 
               
               
                 Clear cell 
                 2 
                   
                   
                   
                 2 
                   
                   
                 2 
               
               
                 Total tumors 
                 39 
                 6 
                 1 
                 10 
                 22 
                   
                 4 
                 35 
               
               
                 Tissue array 
               
               
                 (n = 114) 
               
               
                 Normal 
                 20 
                   
                   
                   
                   
                   
                 NA 
                 NA 
               
               
                 Serous 
                 21 
                 4 
                 5 
                 5 
                 7 
                   
                 NA 
                 NA 
               
               
                 Endometroid 
                 27 
                   
                 13 
                 7 
                 5 
                 2 
                 NA 
                 NA 
               
               
                 Clear cell 
                 17 
                   
                   
                 5 
                 9 
                 3 
                 NA 
                 NA 
               
               
                 Mixed 
                 5 
                   
                   
                   
                 3 
                 2 
                 NA 
                 NA 
               
               
                 Mucinous 
                 24 
                 21 
                 3 
                   
                   
                   
                 NA 
                 NA 
               
               
                 Total tumors 
                 94 
                 25 
                 18 
                 17 
                 24 
                 6 
                 NA 
                 NA 
               
               
                 ELISA set (n = 70) 
               
               
                 Normal and 
                 25 
               
               
                 benign 
               
               
                 Serous 
                 29 
                 3 
                 2 
                 3 
                 20 
                 1 
                 3 
                 26 
               
               
                 Endometrioid 
                 3 
                   
                 3 
                   
                   
                   
                 2 
                 1 
               
               
                 Clear cell 
                 5 
                   
                   
                   
                 4 
                 1 
                 3 
                 2 
               
               
                 Mixed 
                 3 
                   
                 1 
                 1 
                 1 
                   
                 0 
                 3 
               
               
                 Brenner 
                 2 
                   
                   
                   
                   
                 2 
                 1 
                 1 
               
               
                 Mucinous 
                 3 
                 2 
                 1 
                   
                   
                   
                 2 
                 1 
               
               
                 Total tumors 
                 45 
                 5 
                 7 
                 4 
                 25 
                 4 
                 11 
                 34 
               
               
                 PCR tissues 
               
               
                 (n = 34) 
               
               
                 Normal and 
                 12 
               
               
                 benign 
               
               
                 Serous 
                 6 
                 1 
                   
                 1 
                 2 
                   
                 2 
                 4 
               
               
                 Endometrioid 
                 5 
                   
                 1 
                   
                 4 
                   
                   
                 5 
               
               
                 Clear cell 
                 7 
                   
                   
                   
                 5 
                 2 
                 1 
                 6 
               
               
                 Mucinous 
                 4 
                 2 
                 1 
                   
                 1 
                   
                 1 
                 2 
               
               
                 Total tumors 
                 22 
                 3 
                 2 
                 3 
                 12 
                 2 
                 4 
                 18 
               
               
                   
               
               
                 Grade B are low malignant potential tumors. 
               
               
                 Low stage: stage I and II tumors; 
               
               
                 high stage: stage III and IV tumors. 
               
            
           
         
       
     
     Example 3 
     Validation of the Differential Gene Expression of IL-18 and FGF-2 
     Q-PCR was used to validate the differential expression of the IL-18 and FGF-2 RNA as observed in the microarray analysis. For this purpose, 9 NOSEs and 8 EOCs randomly chosen from the previous set of primary cultures, as well as 12 benign tumors (BOT) and 22 EOCs from fresh tissues, were compared and their expression levels correlated with the results obtained by microarray analysis ( FIG. 1A , left hand panels). IL-18 and FGF-2 RNA were weakly detectable in NOSE samples while they were readily detectable in the majority of malignant samples serving as an independent confirmation of their differential expression in EOC. To determine IL-18 and FGF-2 expression in tissues, RNAs isolated from 12 benign and 22 malignant ovarian tumor tissues were also tested (Table I). Most malignant tissues, with the exception of two mucinous and one serous tumor, showed an overexpression of IL-18 ( FIG. 1A , right hand panels). Highest FGF-2 RNA expression was seen in endometroid tissues, although the difference between benign and malignant tissues was less striking ( FIG. 1A , right hand panels). 
     Example 4 
     Protein Expression of IL-18 and FGF-2 in Ovarian Tissue Specimens 
     To address the expression of FGF-2 and IL-18 in EOC, IHC was performed with IL-18 and FGF-2 specific antibodies on ovarian tissues using a tissue array containing 20 NOSE and 94 EOC tissue cores from 114 independent patients. The 94 EOC cores represented the different grades and pathologies of ovarian cancer with the exception of Brenner tumors (see Table 1 above). Scoring results from the IHC analyses are summarized in Table 2 below. IL-18 and FGF-2 were expressed in NOSE as well as EOC tissues. In NOSE tissues, heterogeneity of staining intensity was observed among the different cores (see Table 2 below). In addition, IL-18 and FGF-2 staining was also present in the stroma of NOSE tissues, which may be due to their direct expression by stromal cells or to the secretion of these cytokines by adjacent epithelial cells. EOC tissues showed a slightly more marked staining of IL-18 and FGF-2. The staining was a significantly stronger for IL-18 in serous, endometrioid and clear cells tumors (p&lt;0.05) and for endometrioid and clear cell tumors with FGF-2 ( FIG. 1B  and Table 2). 
     
       
         
           
               
             
               
                 TABLE 2 
               
             
            
               
                   
               
               
                 INTENSITY OF IMMUNOSTAINING OF TISSUE ARRAY 
               
               
                 WITH ANTI-IL-18 AND ANTI-FGF-2 ANTIBODIES 
               
            
           
           
               
               
               
            
               
                   
                 Staining intensity 
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                   
                 Histopathology 
                 p 
                 0 
                 1+ 
                 2+ 
                 3+ 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                   
                 Antibody anti-IL-18 
                   
                   
                   
                   
                   
               
               
                   
                 Normal 
                   
                 3 
                 13 
                 4 
                 0 
               
               
                   
                 Clear cells 
                 &lt;0.001 
                 0 
                 1 
                 14 
                 2 
               
               
                   
                 Endometrioid 
                 0.001 
                 1 
                 9 
                 15 
                 2 
               
               
                   
                 Serous 
                 0.03 
                 0 
                 13 
                 8 
                 0 
               
               
                   
                 Mixed 
                 0.05 
                 0 
                 2 
                 3 
                 0 
               
               
                   
                 Mucinous 
                 0.20 
                 8 
                 11 
                 5 
                 0 
               
               
                   
                 Total tumors 
                 0.005 
                 12 
                 36 
                 45 
                 4 
               
               
                   
                 Antibody anti-FGF-2 
               
               
                   
                 Normal 
                   
                 5 
                 7 
                 5 
                 3 
               
               
                   
                 Clear cells 
                 &lt;0.001 
                 0 
                 2 
                 12 
                 3 
               
               
                   
                 Endometrioid 
                 0.01 
                 1 
                 6 
                 15 
                 5 
               
               
                   
                 Serous 
                 0.45 
                 7 
                 1 
                 13 
                 0 
               
               
                   
                 Mixed 
                 0.33 
                 2 
                 0 
                 3 
                 0 
               
               
                   
                 Mucinous 
                 0.08 
                 11 
                 8 
                 6 
                 0 
               
               
                   
                 Total tumors 
                 0.14 
                 21 
                 17 
                 49 
                 8 
               
               
                   
                   
               
               
                   
                   a 0, absence; 1, weak; 2, moderate; 3, for high intensity. 
               
            
           
         
       
     
     Example 5 
     Serum IL-18 and FGF-2 Proteins as Markers of EOC 
     IL-18 and FGF-2 were studied as individual markers in comparison to CA125. For this purpose a total of 72 patients was selected: 25 patients were free of cancer and 47 patients had ovarian cancer (see Table 1 above). Among the cancer-free patients, six presented with benign ovarian (BOV) or (benign) tumors. Among the 47 ovarian cancers, five were low malignant potential (LMP) tumors, eight grade 1, four grade 2, and 26 grade 3 tumors (see Table 1 above). Six different pathologies were represented in the set of selected patients with EOC (serous, endometrioid, clear cells, Brenner, mucinous and mixed). 
     CA125 was significantly elevated in patients with EOC (p&lt;0.001) (see Table 3 below). No significant difference was observed in patients with or without benign tumors (p=0.31). Patients with LMP tumors showed a lower level of CA125 (median 75 U/ml) than malignant EOC (median level 350 U/ml) (see  FIG. 2  and Table 3 below). This observation was consistent with the increased levels of CA125 which correlated with increased tumor grade (r=0.33, p=0.004) and stage in independent studies (8). The increased level of CA125 also correlated with the histopathology (Spearman&#39;s Rho test p=0.002) where CA125 was more elevated in serous tumors than in endometrioid and clear cell tumors (see Table 3 below). 
     While IL-18 was also significantly more elevated in EOC patients (median level pg/ml p=0.003) it was correlated with tumor grade (Spearman&#39;s Rho test, p=0.172). Serous tumors showed the highest level of IL-18 expression (median level 305 pg/ml) but no significant correlation was observed between IL-18 and pathology disease (Spearman&#39;s Rho test, p=0.173). As observed with CA125, there was no significant difference between patients with or without benign tumors (p=0.99) (see Table 3 below). 
     FGF-2 levels were higher in EOC patients compared to cancer free patients although with a weaker significance compared to CA125 or IL-18 (p=0.04). In accordance with the results obtained in tissue arrays, serum FGF-2 levels were highest in association with clear cell tumors. A correlation between increased FGF-2 serum levels and tumor grade was also detected (Spearman&#39;s Rho test p=0.02) (Table 3). 
     
       
         
           
               
             
               
                 TABLE 3 
               
             
            
               
                   
               
               
                 EXPRESSION LEVEL OF MARKERS CA125, IL-18 AND 
               
               
                 FGF-2 IN SERUM 
               
            
           
           
               
               
               
               
            
               
                   
                 CA125 (U/ml) 
                 IL-18 (pg/ml) 
                 FGF-2 (pg/ml) 
               
               
                   
                 [Median/ 
                 [Median/ 
                 [Median/ 
               
               
                   
                 average (p*)] 
                 average (p*)] 
                 average (p*)] 
               
               
                   
                   
               
            
           
           
               
               
               
               
            
               
                 NOSE + 
                 37/92 
                 204/215 
                 29/35 
               
               
                 benign 
               
               
                 All EOC 
                 306/474 (&lt;0.001) 
                 264/315 (0.001) 
                 39/50 (0.037) 
               
               
                 Normal 
                 44/114 
                 203/212 
                 34/43 
               
               
                 Benign 
                  32/63 (0.31) 
                 207/219 (0.99) 
                 27/25 (0.31) 
               
               
                 LMP 
                  75/100 (0.30) 
                 236/257 (0.31) 
                 68/21 (0.175) 
               
               
                 Invasive EOC 
                 350/545 (&lt;0.001) 
                 258/327 (0.003) 
                 49/56 (0.006) 
               
               
                 Grade 1 
                 339/336 (0.03) 
                 282/267 (0.04) 
                 31/31 (0.70) 
               
               
                 Grade 2 
                 260/285 (0.04) 
                 251/283 (0.008) 
                 43/36 (0.011) 
               
               
                 Grade 3 
                 484/683 (&lt;0.001) 
                 307/370 (0.003) 
                 66/68 (0.002) 
               
               
                 Low stage 
                  75/419 (0.18) 
                 233/239 (0.62) 
                 39/47 (0.65) 
               
               
                 High stage 
                 350/450 (&lt;0.001) 
                 281/282 (&lt;0.001) 
                 44/42 (0.016) 
               
               
                 Serous 
                 419/544 (&lt;0.001) 
                 305/358 (&lt;0.001) 
                 44/54 (0.11) 
               
               
                 Endometrioid 
                 339/380 (0.16) 
                 281/252 (0.37) 
                 23/23 (0.63) 
               
               
                 Mucinous 
                  38/46 (0.79) 
                 263/247 (0.29) 
                 21/32 (0.68) 
               
               
                 Clear cells 
                  34/492 (0.55) 
                 242/330 (0.30) 
                 69/49 (0.10) 
               
               
                   
               
               
                 NOSE, normal ovarian surface epithelia; 
               
               
                 EOC, epithelial ovarian cancer; 
               
               
                 LMP, low malignant potential tumor; 
               
               
                 low stage, stage I and II; 
               
               
                 high stage, stage III and IV. 
               
               
                 p* Mann-Whitney test. 
               
            
           
         
       
     
     Example 6 
     Diagnostic Potential of Serum CA125, IL-18 and FGF-2 as Markers 
     Receiver Operator Curves were used to determine threshold values for the three serum markers to compare the diagnostic potential of the individual cytokine markers with CA125. The greatest accuracy in differential diagnosis of malignant tumors was achieved with a threshold of 50 U/ml for CA125, 215 pg/ml for IL-18 and 37 pg/ml for FGF-2. Sensitivity, namely the fraction of patients correctly diagnosed with ovarian cancer, was more accurate when considering CA125 or IL-18, as individual markers. Sensitivity as determined by CA125 and IL-18 was 82% and 78% respectively, compared to 58% with FGF-2 (Table 4). To ensure that there was no difference in sensitivity between CA125 and IL-18 the number of samples was increased to 97 (data not shown). In this larger set, CA125 and IL-18 sensitivity levels remained similar (75% and 74%, respectively). 
     Specificity was defined as the fraction of samples correctly diagnosed as non-malignant, including serum from patients with normal ovaries or benign disease. Individual analysis of patients with either normal ovaries or benign disease gave similar results (data not shown). Specificity was best provided by FGF-2 (72%). CA125 and IL-18 showed relative low similar specificities of 60% and 64% respectively (Table 4). In the larger set, CA125 and IL-18 specificity levels remained similar (61% and 64% respectively, data not shown). 
     
       
         
           
               
             
               
                 TABLE 4 
               
             
            
               
                   
               
               
                 SPECIFICITY AND SENSITIVITY OF CA125, IL-18 AND 
               
               
                 FGF-2 IN UNIVARIATE OR MULTIVARIATE ANALYSIS 
               
            
           
           
               
               
               
               
               
            
               
                   
                   
                   
                   
                 CA125 + 
               
               
                   
                   
                   
                   
                 IL-18 + 
               
               
                   
                 CA125 (U/ml) 
                 IL-18 (pg/ml) 
                 FGF-2 (pg/ml) 
                 FGF2 
               
            
           
           
               
               
               
               
               
               
               
               
               
            
               
                 Patient type 
                 n &gt; 50 U/ml 
                 %+ 
                 n &gt; 215 pg/ml 
                 %+ 
                 n &gt; 37 pg/ml 
                 %+ 
                 n 
                 %+ 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
            
               
                 Specificity 
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 NOSE + 
                 10/25 
                 60 
                  9/25 
                 64 
                  7/25 
                 72 
                  5/25 
                 80 
               
               
                 benign 
               
               
                 Sensitivity 
               
               
                 All EOC 
                 37/45 
                 82 
                 35/45 
                 78 
                 26/45 
                 58 
                 35/45 
                 78 
               
               
                 LMP 
                 3/5 
                 60 
                 3/5 
                 60 
                 1/5 
                 20 
                 3/5 
                 60 
               
               
                 Invasive EOC 
                 34/42 
                 81 
                 34/42 
                 81 
                 25/42 
                 60 
                 32/42 
                 76 
               
               
                 Low stage 
                  6/11 
                 55 
                  6/11 
                 55 
                  7/11 
                 64 
                  7/11 
                 64 
               
               
                 High stage 
                 31/34 
                 91 
                 29/34 
                 85 
                 20/34 
                 59 
                 28/34 
                 73 
               
               
                 Serous 
                 28/29 
                 97 
                 26/29 
                 90 
                 19/29 
                 66 
                 27/29 
                 93 
               
               
                 Endometroide 
                 2/3 
                 67 
                 2/3 
                 67 
                 1/3 
                 33 
                 1/3 
                 33 
               
               
                 Clear cell 
                 1/5 
                 20 
                 3/5 
                 60 
                 4/5 
                 80 
                 3/5 
                 60 
               
               
                 Mucinous 
                 1/3 
                 33 
                 2/3 
                 67 
                 1/3 
                 33 
                 1/3 
                 33 
               
               
                 Brenner 
                 2/2 
                 100 
                 0/2 
                 0 
                 0/2 
                 0 
                 1/2 
                 50 
               
               
                 Mixed 
                 3/3 
                 100 
                 2/3 
                 67 
                 1/3 
                 33 
                 2/3 
                 67 
               
               
                   
               
               
                 EOC, Epithelial ovarian cancer; 
               
               
                 LMP, low malignant potential tumor; low stage, stage I-II; high stage, stage III-IV; 
               
               
                 %+, corresponds to percentage of NOSE + benign which do not score above the threshold (specificity). 
               
            
           
         
       
     
     Example 7 
     Diagnostic Potential of Serum IL-18 and FGF-2 as Combined Markers with CA125 
     The estimated correlation among the three serum markers (IL-18, FGF-2 and CA125) were low suggesting that they were complementary to each other and that a multivariate approach might outperform the CA125 assay alone. To validate this hypothesis a multivariate analysis was performed using a logistic binary regression algorithm. As shown in Table 5, FGF-2, but not IL-18, increased the diagnosis potential of CA125 (Odd Ratio from 5.24 to 6). However addition of both FGF-2 and IL-18 achieved a superior diagnostic potential (Odd Ratio=6.94, 0.95 (1.99-24.39), p=0.002) suggesting that the combination of both IL-18 and FGF-2 with CA125 allows a better sensitivity and specificity. 
     Scoring samples as malignant was also tested based on whether ELISA values were above the threshold for at least two of the three markers. In this analysis (Table 4), a sensitivity of 78% was achieved which was similar to that obtained with CA125 or IL-18 alone, but the specificity of diagnosis was dramatically increased from CA125 (60%), IL-18 (64%) or FGF-2 (72%) alone to 80% the combination of these serum markers (Table 4). Similar result was obtained in a larger set of samples (77%, data not shown). 
     
       
         
           
               
             
               
                 TABLE 5 
               
             
            
               
                   
               
               
                 LOGISTIC BINARY REGRESSION (LBR) ANALYSIS OF 
               
               
                 MULTIVARIATE ANALYSIS OF CA125, IL-18 AND FGF-2 
               
            
           
           
               
               
               
               
            
               
                   
                 p 
                 OR 
                 CI 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
            
               
                 LBR 
                 CA125 
                 &lt;0.001 
                 5.24 
                 2.07-13.33 
               
               
                   
                 CA125 + IL-18 
                 0.002 
                 4.78 
                 1.81-12.66 
               
               
                   
                 CA125 + FGF-2 
                 0.002 
                 6 
                 1.93-18.61 
               
               
                   
                 IL-18 + FGF-2 
                 0.014 
                 2.25 
                 0.726-6.96  
               
               
                   
                 CA125 + IL-18 + FGF 
                 0.002 
                 6.94 
                 1.99-24.39 
               
               
                   
               
               
                 OR+: odd ratio. 
               
               
                 CI: confidence interval 95% 
               
            
           
         
       
     
     Although the present invention has been described hereinabove by way of specific embodiments thereof, it can be modified, without departing from the spirit and nature of the subject invention as defined in the appended claims. Throughout this application, various references are referred to describe more fully the state of the art to which this invention pertains. The disclosures of these references are hereby incorporated by reference into the present disclosure. 
     REFERENCES 
     
         
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         6. Modugno, F. Ovarian cancer and high-risk women-implications for prevention, screening, and early detection. Gynecol Oncol, 91: 15-31, 2003. 
         7. Woolas, R. P., Xu, F. J., Jacobs, I. J., Yu, Y. H., Daly, L., Berchuck, A., Soper, J. T., Clarke-Pearson, D. L., Oram, D. H., and Bast, R. C., Jr. Elevation of multiple serum markers in patients with stage I ovarian cancer. J Natl Cancer Inst, 85: 1748-1751, 1993. 
         8. Meyer, T. and Rustin, G. J. Role of tumour markers in monitoring epithelial ovarian cancer. Br J Cancer, 82:1535-1538, 2000. 
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         10. Mok, S. C., Chao, J., Skates, S., Wong, K., Yiu, G. K., Muto, M. G., Berkowitz, R. S., and Cramer, D. W. Prostasin, a potential serum marker for ovarian cancer: identification through microarray technology. J Natl Cancer Inst, 93: 1458-1464, 2001. 
         11. Kim, J. H., Skates, S. J., Uede, T., Wong, K. K., Schorge, J. O., Feltmate, C. M., Berkowitz, R. S., Cramer, D. W., and Mok, S. C. Osteopontin as a potential diagnostic biomarker for ovarian cancer. Jama, 287: 1671-1679, 2002. 
         12. McIntosh, M. W., Drescher, C., Karlan, B., Scholler, N., Urban, N., Hellstrom, K. E., and Hellstrom, I. Combining CA 125 and SMR serum markers for diagnosis and early detection of ovarian carcinoma. Gynecol Oncol, 95: 9-15, 2004. 
         13. Hellstrom, I., Raycraft, J., Hayden-Ledbetter, M., Ledbetter, J. A., Schummer, M., McIntosh, M., Drescher, C., Urban, N., and Hellstrom, K. E. The HE4 (WFDC2) protein is a biomarker for ovarian carcinoma. Cancer Res, 63: 3695-3700, 2003. 
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