Patent Publication Number: US-9416404-B2

Title: Quantitative multiplex methylation-specific PCR

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a divisional application of U.S. application Ser. No. 13/224,024 filed Sep. 1, 2011; which is a continuation application of U.S. application Ser. No. 10/976,932 filed Oct. 28, 2004, now issued as U.S. Pat. No. 8,062,849; which claims the benefit under 35 USC §119(e) to U.S. Application Ser. No. 60/515,100 filed Oct. 28, 2003. The disclosure of each of the prior applications is considered part of and is incorporated by reference in the disclosure of this application. 
    
    
     GRANT INFORMATION 
     This invention was made with government support under Grant No. DAMD 17-01-1-0286 awarded by the Department of Defense and Grant No. P50CA88843 awarded by the National Institutes of Health, National Cancer Institute. The government has certain rights in the invention. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The invention relates generally to cancer markers and more specifically to a method of evaluating gene methylation within a sample, referred to herein as quantitative multiplex methylation-specific PCR (QM-MSP), in order to detect conditions associated with methylation status of genes. 
     2. Background Information 
     Epigenetic alterations including hypermethylation of gene promoters are proving to be consistent and early events in neoplastic progression (Hanahan D. and Weinberg R. A.  Cell  (2000) 100:57-70; Wamecke P. M. and Bestor T. H.  Curr Opin Oncol  (2000) 12:68-73; Yang X. et al.  Endocr Relat Cancer  (2001) 8:115-127; and Widschwendter M. and Jones P. A.  Oncogene  (2002) 211:5462-5482). Such alterations are thought to contribute to the neoplastic process by transcriptional silencing of tumor suppressor gene expression, and by increasing the rate of genetic mutation (Wajed S. A. et al.  Ann Surg  (2001) 234:10-20 and Jones P. A. and Baylin S. B.  Nat Rev Genet  (2002) 3: 415-428). DNA methylation is reversible, since it does not alter the DNA sequence; however, it is heritable from cell to cell. Methylated genes can serve as biomarkers for early detection of cancer for risk assessment and for predicting response to therapy. 
     Widschwendter and Jones (supra) reviewed over 40 genes whose expression is lost in breast cancer due to promoter hypermethylation, and others have studied hypermethylation of genes including NES-1 (Goyal J. et al.  Cancer Res  (1998) 58:4782-4786; Dhar S. et al.  Clin Cancer Res  (2001) 7:3393-3398; Li B. et al.  Cancer Res  (2001) 61:8014-8021; and Yunes M. J. et al.  Int J Radiat Oncol Biol Phys  (2003) 56:653-657) APC (Kashiwaba M. et al.  J Cancer Res Clin Oncol  (1994) 120:727-731; Virmani A. K. et al.  Clin Cancer Res  (2001) 7:1998-2004; and Sarrio D. et al.  Int J Cancer  (2003) 106:208-215),  Cyclin D 2 (Evron E. et al.  Cancer Res  (2001) 61:2782-2787 and Lehmann U. et al.  Am J Pathol  (2002) 160:605-612),  RARB  (Widschwendter M. et al.  J Natl Cancer Inst  (2000) 92:826-832; Yan L. et al.  J Mammary Gland Biol Neoplasia  (2001) 6:183-192; and Sirchia S. M. et al.  Cancer Res  (2002) 62: 2455-2461), TWIST (Evron E. et al.  Lancet  (2001) 357:1335-1336),  RASSF 1 A  (Lehmann U. et al.  Cancer Res  (2001) 61:8014-8021; Burbee D. G. et al.  J Natl Cancer Inst  (2001) 93:691-699; and Dammann R. et al.  Cancer Res  (2001) 61:3105-3109), and  HIN 1 (Krop I. E. et al.  Proc Natl Acad Sci USA  (2001) 98:9796-9801) in tissue, blood and ductal fluids. Since methylation changes often appear early in disease, detection of hypermethylated genes could identify tissues derived from subjects with increased risk. Furthermore, the reversible nature of methylation offers the potential to revert aspects of the cancer phenotype with the appropriate therapy (Fackler M. J. et al.  J Mammary Gland Biol Neoplasia  (2003) 8:75-89). 
     Tumor DNA can be found in various body fluids and these fluids can potentially serve as diagnostic material. Evaluation of tumor DNA in these fluids requires methods that are specific as well as sensitive. For instance, a PCR-base technique called methylation-specific PCR (MSP) is reported to detect one copy of methylated genomic DNA in one-thousand unmethylated copies of genomic DNA (Herman J. G. et al.  Proc Natl Acad Sci USA  (1996) 93:9821-9826). This approach has been modified in order to co-amplify several genes simultaneously in a nested or multiplex MSP assay (Palmisano W. A. et al.  Cancer Res  (2000) 60:5954-5958; Buller A. et al.  Mol Diagn  (2000) 5:239-243; and Brock M. V. et al.  Clin Cancer Res  (2003) 9:2912-2919). The read out is gel-based and qualitative (“all or nothing”). This method has been used to establish the frequency of gene promoter hypermethylation among subjects with bronchial and esophageal carcinoma. However, the method cannot quantitatively measure the levels of gene methylation. 
     Quantitative real time PCR (Q-PCR) allows a highly sensitive quantification of transcriptional levels or levels of the DNA of the gene of interest in a few hours with minimal handling the samples (Heid C. A. et al.  Genome Res  (1996) 6:986-994 and Gibson U. E. et al.  Genome Res  (1996) 6:995-1001). cDNA or genomic copies of the gene of interest are quantitated by detecting PCR products as they accumulate using an optically detectable polynucleotide probe. This technique is widely used. 
     Quantitative MSP (Q-MSP) allows highly sensitive detection of gene promoter methylation levels by real time PCR with methylation-specific primers probes (Lo Y. M. et al.  Cancer Res  (1999) 59:3899-3903; Trinh B. N.  Methods  (2001) 25:456-462; Wong I. H. et al.  Clin Cancer Res  (2003) 9:1047-1052). 
     The advantage of fluorogenic probes over DNA binding dyes (e.g. syber green for real time PCR) is that specific hybridization between probe and target is required to generate fluorescent signal. Thus, with fluorogenic probes, non-specific amplification due to mis-priming or primer-dimer artifact does not generate signal. However, Q-MSP analysis of multiple genes requires additional quantities of template DNA. Therefore, new and better methods are needed to increase the amount of available DNA and to quantitate detection of gene methylation status for several genes. 
     SUMMARY OF THE INVENTION 
     The invention is based on the discovery of a method for evaluating the degree of gene methylation within a single DNA sample, referred to herein as quantitative multiplex methylation-specific PCR (QM-MSP), to co-amplify many genes from amounts of sample previously used for just one or two genes. The invention provides a basis to define the extent of gene promoter hypermethylation across a panel of genes, enhancing the discriminatory power of this test to distinguish between normal and altered condition(s). Determination of hypermethylation as compared with normal methylation of samples may help to stratify different types or stages of conditions, such as cancer, associated with gene hypermethylation. The QM-MSP method is based on real-time PCR that uses one or more distinguishable optically detectable probes to increase the assay specificity and the sensitivity such that one to ten copies of the desired methylated gene among 100,000 unmethylated copies of the gene can be detected (Fackler M. J. et al.  Cancer Res  (2004) 64:4442-4452). QM-MSP is more economical in time and materials, is more informative, quantitative, and suitable for clinical format than MSP, multiplex MSP or Q-MSP. The invention methods solve the dilemma of how best to distribute the available DNA to allow robust quantitative analyses of many different genes from precious small samples. 
     In one embodiment, the invention provides methods for determining the methylation status of DNA in a sample by co-amplifying a plurality of DNA sequences using a mixture of DNA sequence-specific, methylation status-independent outer primer pairs that selectively hybridize to their cognate DNA sequences under conditions that allow generation of a first amplification product containing first amplicons. Real time PCR is then used to amplify unmethylated and/or methylated DNA from the first amplicons under conditions that allow generation of second amplification products for one or more genes, using two sets of primers comprising a DNA sequence-specific, methylation status-dependent (unmethylated or methylated) inner primer pair and a (unmethylated or methylated) DNA sequence-specific probe. Second amplicons are detected by using one or more distinguishable optically detectable labels per reaction. A combination of inner primer pair and probe selectively hybridizes to one first amplicon, and the sets of inner primer pairs and probes collectively hybridize to a plurality of first amplicons in the first amplification product. Signal intensities of the one or more distinguishable labels in the second amplification products are detected to determine the amount of methylation in a gene. A combined methylation value is derived for the methylation in the DNA sequences in the test sample from amounts of methylation determined for the second amplification products across a panel of genes. For the purposes of determining whether the gene amplicon is hyper- or hypo-methylated, the combined methylation value of the test sample is compared with the combined methylation value in a series of comparable normal DNA samples. 
     In yet another embodiment, the invention provides methods of diagnosing development of a condition associated with aberrant methylation of DNA in tissue of a subject by co-amplifying a plurality of DNA sequences using a mixture of DNA sequence-specific, methylation status-independent outer primer pairs that selectively hybridize to their cognate DNA sequences under conditions that allow generation of a first amplification product containing first amplicons. Real time PCR is then used to amplify unmethylated and/or methylated DNA from the first amplicons under conditions that allow generation of second amplification products for one or more genes, using for a gene two sets primers comprising a DNA sequence-specific, methylation status-dependent (unmethylated or methylated) inner primer pair and a (unmethylated or methylated) DNA sequence-specific probe. Second amplicons are detected by using one or more distinguishable optically detectable labels per reaction. A combination of inner primer pair and probe selectively hybridizes to one first amplicon, and the sets of inner primer pairs and probes collectively hybridize to a plurality of first amplicons in the first amplification product. Signal intensities of the one or more distinguishable labels in the second amplification products are detected to determine the amount of methylation in a gene. A combined methylation value is derived for the methylation in the DNA sequences in the test sample from amounts of methylation determined for the second amplification products across a panel of genes. For the purposes of determining whether the gene amplicon is hyper- or hypo-methylated, the combined methylation value of the tissue of the subject is compared with the combined methylation value in a series of comparable normal DNA samples to diagnose the state of development of the condition in the subject. 
     In still another embodiment, the invention provides methods for diagnosing development of a cancer associated with hypermethylation of CpG island DNA in carcinoma-associated tissue of a subject by co-amplifying CpG islands in a subject sample comprising several different DNA sequences isolated from the carcinoma-associated tissue using a mixture of DNA sequence-specific, methylation status-independent outer primer pairs that selectively hybridize to one or more of the DNA sequences under conditions that allow generation of a first amplification product containing first amplicons. Then, real time PCR is used to co-amplify the CpG islands in the first amplicons under conditions that allow generation of one or more second amplification products, using one or more members of a set of DNA sequence-specific probes comprising distinguishable fluorescent moieties and one or more members of a set of DNA sequence-specific methylation status-dependent inner primer pairs that selectively hybridize to one or more first amplicon, wherein the sets of probes and inner primer pairs collectively hybridize to a plurality of different first amplicons in the first amplification product. Fluorescence due to the presence of distinguishable fluorescent moieties in the second amplification products are detected to determine the amount of methylation of the CpG islands therein; and a combined methylation value for the methylation in the tissue of the subject is derived from the amounts of methylation determined for the second amplification products as compared with a combined methylation value in comparable normal tissue to diagnose the state of development of the cancer in the subject. 
     In yet another embodiment, the invention provides methods for diagnosing the state of development of a condition associated with hypermethylation of a gene in a mammalian subject by co-amplifying a plurality of different DNA sequences isolated from tissue of the subject associated with the condition using a mixture of DNA sequence-specific, methylation status-independent outer primer pairs that selectively hybridize to one or more of the DNA sequences under conditions that allow generation of a first amplification product containing first amplicons. Real time PCR is then used to co-amplify the first amplicons under conditions that allow generation of one or more second amplification products using one or more members of a set of DNA sequence-specific probes comprising distinguishable optically detectable labels and one or more members of a set of DNA sequence-specific methylation status-dependent inner primer pairs that selectively hybridize to a cognate first amplicon, wherein the sets of probes and inner primer pairs collectively amplify a plurality of different first amplicons in the first amplification product. Signal intensity of the distinguishable labels in the second amplification products is detected to determine the amount of methylation of the second amplification products. A combined methylation value is derived for the methylation in the DNA sequences from amounts of methylation determined for the second amplification products in the DNA of the subject as compared with the combined methylation value in a comparable normal DNA sample to indicate the state of development of the condition in the subject. 
     In another embodiment, the invention provides kits for determining the methylation status of a plurality of DNA sequences in a DNA sample. The invention kits include a set of DNA sequence-specific, methylation status-independent outer primer pairs that selectively hybridize to cognate DNA sequences under conditions that allow generation of a first amplification product containing first amplicons; a set of DNA sequence-specific, methylation status-dependent inner primer pairs; and a set of DNA sequence-specific probes with one or more distinguishable optically detectable labels. A combination of inner primer pair and probe selectively hybridizes to one or more first amplicon, and the sets of inner primer pairs and probes collectively hybridize to a plurality of first amplicons in the first amplification product. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1A  is a schematic representation of the protocol for quantitative multiplex methylation-specific PCR (QM-MSP) as used in the invention methods. In reaction #1 (RXN 1) a cocktail of gene-specific primer pairs is used to co-amplify DNA for a plurality of genes independent of their DNA methylation status. In reaction #2 (RXN 2) quantitative real-time PCR is performed with gene-specific primers using the DNA template derived from RXN 1 (diluted between 1:5 to 1:10 4 ). Unmethylated (U) and methylated (M) DNA were quantitated separately using methylation-status specific primers and a probe conjugated with the 6FAM label and TAMRA quencher. The probe is progressively degraded with each cycle of PCR and the fluorescence signal generated by FAM is directly proportional to the extent of DNA amplification. To perform methylation analyses on two genes simultaneously, RXN 2 also can contain a second set of gene-specific internal methylation-dependent primers in combination with a probe conjugated with a different label, such as VIC™, as indicated by the schematic and amplification plots for U RASSF1A and U RARβ ( FIG. 1B ). 
         FIGS. 2A-B  are graphs showing validation of QM-MSP using RASSF1A unmethylated (U) and methylated (M) primer sets to amplify serially diluted fragments of multiplexed standard stock HSD/231 DNA. The cycle threshold (C T ) was determined for each dilution of DNA.  FIG. 2A  shows a plot of ΔC T  (ΔC T =C T M−C T U) versus dilution.  FIG. 2B  shows standard curve plots (C T  vs Quantity) of serially diluted DNA. A slope of −3.33 reflects a 2-fold amplification of DNA per cycle. The correlation coefficient (R2) shows linearity (0.999) over the range of DNA concentrations. 
         FIGS. 3A-B  are graphs showing PCR cycles (X axis) plotted against the fluorescence intensity of the probe (Y axis) for multiplexed human sperm DNA (HSD) ( FIG. 3B ) or MDA-MB231 ( FIG. 3A ) template tested with unmethylated (U) and methylated (M) primers for RASSF1A. The unmethylated and methylated reactions were 100% specific since U primers did not cross-react with MDA-MB231 DNA (100% methylated) and M primers did not cross-react with HSD (100% unmethylated) DNA. 
         FIGS. 4A-B  are graphs showing PCR cycles (X axis) plotted against the fluorescence intensity of the probe (Y axis) indicating detection of hypermethylated genomic RASSF1A DNA in 1500-fold excess of unmethylated DNA. Mixed, bisulfite-treated genomic HSD and 231 DNA ( FIG. 4A : 600 pg HSD DNA and 40 pg MDA-MB231 DNA;  FIG. 4B : 60 ng HSD DNA and 40 pg 231 DNA) were subjected to QM-MSP. 
         FIGS. 5A-B  are scatter plots show the level of gene promoter hypermethylation in normal and malignant breast tissues as determined by the invention methods employing QM-MSP on normal tissues RASSF1A (n=28), TWIST (n=18) ( FIG. 5A ), Cyclin D2 (n=16), and HIN1 (n−14) ( FIG. 5B ) and DNA derived from individuals with invasive ductal carcinoma RASSF1A (n=19), TWIST (n=21), Cyclin D2 (n=21), and HIN1 (n=21) compared to leukocyte (Leuk) DNA derived from normal individuals (n=25). Displayed is the Ln e  (% M+1). A bar indicates the median of each group. 
         FIGS. 6A-B  are bar graphs showing cumulative promoter hypermethylation of RASSF1A, TWIST, Cyclin D2, and HIN1 in normal and malignant breast tissues as determined by the invention methods as described in Table 5.  FIG. 6A  represents cumulative methylation in normal mammoplasty and tumor in a subgroup of samples from  FIG. 5  where results were available for all four genes in the panel, normal (Mam; n=9) and tumor (n=19) were scored for cumulative methylation by adding the % M for all four genes within each sample. A maximum of 400 relative methylation units was possible (e.g. MDA-MB231 control DNA is 100% methylated for each of the four genes). The bar height reflects total cumulative methylation, while the segments correspond to the relative amounts of methylation of each gene indicated.  FIG. 6B  shows mean cumulative methylation in normal mammoplasty versus tumor as determined by the unpaired t test (untransformed p=0.0002; transformed p=0.0001). Plotted is the mean (±standard error of the mean) amount of cumulative methylation. 
         FIGS. 7A-B  are bar graphs showing cumulative promoter hypermethylation of RASSF1A, TWIST, Cyclin D2, and HIN1 in adjacent normal and malignant breast tissues as described in Table 6.  FIG. 7A  shows the cumulative methylation in paired samples of adjacent normal and tumor tissue (n=6) as quantitated by QM-MSP. Total possible units=400 (4 genes×100%). The mean of normal mammoplasty (n=9) samples (Mam) from  FIG. 6B  is shown at left.  FIG. 7B  shows mean cumulative methylation in adjacent normal versus tumor (compared to normal mammoplasty). Differences between normal mammoplasty samples (median=0) and adjacent normal tissue samples (median=9 units) were significant (p=0.01; based on the Mann-Whitney test). Plotted is the mean (±standard error of the mean) amount of cumulative methylation found above in adjacent normal tissues (mean 11.7±4.07) and the nearby tumor (mean 129±39.9), compared to normal mammoplasty ( FIG. 7B ) (mean 2.61±2.05; as shown in  FIG. 6B ). The percentage of methylation by gene as well as the extent of cumulative methylation is indicated in the table ( FIG. 7C ) below the bar graphs. 
         FIG. 8  is a bar graph showing cumulative promoter hypermethylation in ductal cells obtained by ductal lavage for RARB, RASSF1A, TWIST, Cyclin D2, and HIN1 genes determined using the invention methods as described in Table 7. Shown is the cumulative methylation of 50-1000 cells found in cytologically benign (n=7) and pre-invasive (DCIS; n=4) samples. For each patient sample the cytology was graded as having mild, moderate or marked atypia, or was found inadequate if fewer than 10 epithelial cells were observed. The relative level of methylation of each gene is indicated by the height of the bar. Total possible units=500 (5 genes×100%). 
         FIG. 9  is a bar graph showing cumulative promoter hypermethylation in ductal cells obtained within nipple aspiration fluid for RARβ, RASSF1A, TWIST, Cyclin D2, HIN1, and ESR1 genes. The cumulative methylation of the 50-1000 cells is indicated. Cells showed either mild atypia (n=3) or appeared malignant (n=1) by cytology. The relative level of methylation of each gene is indicated by the height of the bar. Total possible units=600 (6 genes×100%). 
         FIG. 10  is a bar graph showing cumulative promoter hypermethylation in serum derived from patients (n=5) with metastatic breast cancer. Shown is the cumulative methylation of RARβ, RASSF1A, TWIST, Cyclin D2, HIN1, and ESR1 genes. The relative level of methylation of each gene is indicated by the height of the bar. Total possible units=600 (6 genes×100%). 
         FIGS. 11A-B  show the level of gene promoter hypermethylation in DNA from a series of patients (n=10) at high risk of developing breast cancer, but who are not know to have cancer. Paired samples of DNA isolated from serum and from cells obtained by fine needle aspiration (FNA) and ductal lavage (DL) (50-1000 cells) of each patient were analyzed by QM-MSP.  FIG. 11A  shows the cumulative methylation of RARβ, RASSF1A, TWIST, Cyclin D2, HIN1, ESR1, APC1, BRCA1 and BRCA2 genes. The relative level of methylation of each gene is indicated by the height of the bar. Total possible units=900 (9 genes×100%).  FIG. 11B  shows the percentage of methylation of HIC1 determined by QM-MSP in the patient samples. Gene promoter hypermethylation of HIC1 was found to be significantly higher in FNA and DL samples than for other genes within the panel. For this reason, HIC1 was analyzed separately from the other genes rather than include HIC1 in the cumulative total for each patient. 
         FIG. 12  is a bar graph showing the level of gene promoter hypermethylation in cells derived from ductal lavage fluid from a series of patients (n=7) at high risk of developing breast cancer, but who are not know to have cancer. In most individuals, ducts (D1-D4) from both breasts were serially sampled at 6-9 month intervals (left to right, respectively). Shown is the cumulative methylation of RARβ, RASSF1A, TWIST, Cyclin D2, HIN1, ESR1, APC1, BRCA1, BRCA2, and p16 (CDKN2A) genes within the DNA sample. The relative level of methylation of each gene is indicated by the height of the bar. Total possible units=1000 (10 genes×100%). 
         FIGS. 13A-B  are bar graphs showing the level of gene promoter hypermethylation in cells derived from nipple aspiration fluid (n=10) from a series of patients (n=7) at high risk of developing breast cancer, but who are not know to have cancer.  FIG. 13A  shows the cumulative methylation of RARβ, RASSF1A, TWIST, Cyclin D2, HIN1, ESR1, APC1, BRCA1, and BRCA2 genes within the DNA sample. The relative level of methylation of each gene is indicated by the height of the bar. Total possible units=900 (9 genes×100%).  FIG. 13B  shows high levels of HIC1 methylation were discovered these cytologically benign samples, as indicated by the bar graph showing % methylation within each sample. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     In the invention methods employing a two-step quantitative multiplex-methylation specific PCR (QM-MSP), many genes can be co-amplified from amounts of sample previously used for just one gene and a combined methylation score can be generated for the panel of genes. The QM-MSP technique combines the sensitivity of multiplex PCR with the quantitative features of quantitative methylation-specific PCR (Q-MSP) in such a way that a panel of genes whose hypermethylation is associated with a type of carcinoma can be co-amplified from limiting amounts of DNA derived from tissue or samples sources of the subject being tested. The invention methods also provide quantitative definition of the extent of gene hypermethylation in normal appearing tissues on a gene-by-gene basis. Thus, the invention methods may be used to more powerfully discriminate between normal or benign tissues and malignant tissues and to monitor or assess the course of cancer development in a subject. 
     The invention methods are also broadly applicable to evaluation of any of hundreds of genes from hypermethylated regions of genomic DNA derived from but not limited to human or non-human mammals, plants and insects. For example in mammals, such as humans, samples may be derived from different tissue sources and bodily fluids, including one or more selected from tumor-associated tissue, normal tissue, blood, serum, plasma, ductal lavage fluid, nipple aspiration fluid, lymph, duct cells, lymph nodes, and bone marrow of the subject being tested. In mammals, conditions associated with aberrant methylation of genes that can be detected or monitored include, but are not limited to, carcinomas and sarcomas of all kinds, including one or more specific types of cancer, e.g., breast cancer, an alimentary or gastrointestinal tract cancer such as colon, esophageal and pancreatic cancer, a liver cancer, a skin cancer, an ovarian cancer, an endometrial cancer, a prostate cancer, a lymphoma, hematopoietic tumors, such as a leukemia, a kidney cancer, a lung cancer, a bronchial cancer, a muscle cancer, a bone cancer, a bladder cancer or a brain cancer, such as astrocytoma, anaplastic astrocytoma, glioblastoma, medulloblastoma, and neuroblastoma and their metastases. Suitable pre-malignant lesions to be detected or monitored using the invention include, but are not limited to, lobular carcinoma in situ and ductal carcinoma in situ. The invention methods can be used to assay the DNA of any mammalian subject, including humans, pet (e.g., dogs, cats, ferrets) and farm animals (meat and dairy), and race horses. 
     Samples obtained from other multicellular organisms, such as insects and plants, may also be evaluated for gene methylation status using the invention methods. For example, the methylation status of genes may serve as an indicator of heritability and flexibility of epigenetic states in such subjects. Thus, gene methylation is linked to acquisition of different characteristics in the organism (Frank Lyko  Trends in Gen  (2001) 17:169-172, Finnegan E. J. et al.  Annu Rev Plant Physiol Plant Mol Biol  (1998) 49:223-247). 
     In one embodiment, the invention provides methods for determining the methylation status of a DNA sample by co-amplifying a plurality of DNA sequences using a mixture of DNA sequence-specific, methylation status-independent outer primer pairs that selectively hybridize to their cognate DNA sequences under conditions that allow generation of a first amplification product containing first amplicons. Real time PCR is then used to amplify unmethylated and/or methylated DNA from the first amplicons under conditions that allow generation of second amplification products for one or more genes, using for a gene two sets of primers comprising a DNA sequence-specific, methylation status-dependent (unmethylated or methylated) inner primer pair and a (unmethylated or methylated) DNA sequence-specific probe. Second amplicons are detected by using one or more distinguishable optically detectable labels per reaction. A combination of inner primer pair and probe selectively hybridizes to one first amplicon, and the sets of inner primer pairs and probes collectively hybridize to a plurality of first amplicons in the first amplification product. Signal intensities of the one or more distinguishable labels in the second amplification products are detected to determine the amount of methylation in a gene. A combined methylation value is derived for the methylation in the DNA sequences in the test sample from amounts of methylation determined for the second amplification products in a panel of genes, as compared with the combined methylation value in comparable normal DNA samples to determine the methylation status of the DNA sample. 
     In yet another embodiment, the invention provides methods of diagnosing development of a condition such as pregnancy, preeclampsia, or eclampsia associated with aberrant methylation of DNA in tissue of a subject. In this embodiment, the invention methods comprise co-amplifying a plurality of DNA sequences using a mixture of DNA sequence-specific, methylation status-independent outer primer pairs that selectively hybridize to their cognate DNA sequences under conditions that allow generation of a first amplification product containing first amplicons. Real time PCR is then used to amplify unmethylated and/or methylated DNA from the first amplicons under conditions that allow generation of second amplification products for one or more genes, using for a gene two sets of primers, comprising a DNA sequence-specific, methylation status-dependent (unmethylated or methylated) inner primer pair and a (unmethylated or methylated) DNA sequence-specific probe. Second amplicons are detected by using one or more distinguishable optically detectable labels per reaction. A combination of inner primer pair and probe selectively hybridizes to one first amplicon, and the sets of inner primer pairs and probes collectively hybridize to a plurality of first amplicons in the first amplification product. Signal intensities of the one or more distinguishable labels in the second amplification products are detected to determine the amount of methylation in a gene. A combined methylation value is derived for the methylation in the DNA sequences in the test sample from amounts of methylation determined for the second amplification products across a panel of genes as compared with a combined methylation value in comparable normal tissues to diagnose the state of development of the condition in the subject. 
     In still another embodiment, the invention provides methods for diagnosing development of a carcinoma associated with hypermethylation of CpG island DNA in carcinoma-associated tissue of a subject by co-amplifying CpG islands in a subject sample comprising several different DNA sequences isolated from the carcinoma-associated tissue using a mixture of DNA sequence-specific, methylation status-independent outer primer pairs that selectively hybridize to one or more of the DNA sequences under conditions that allow generation of a first amplification product containing first amplicons. Then, real time PCR is used to co-amplify the CpG islands in the first amplicons under conditions that allow generation of one or more second amplification products, using one or more members of a set of DNA sequence-specific probes comprising distinguishable fluorescent moieties and one or more members of a set of DNA sequence-specific methylation status-dependent inner primer pairs that hybridize to one first amplicon, wherein the sets of probes and inner primer pairs collectively hybridize to a plurality of different first amplicons in the first amplification product. Fluorescence due to the presence of distinguishable fluorescent moieties in the second amplification products is detected to determine the amount of methylation of the CpG islands therein. The combined amount of hypermethylation in CpG islands in the tumor-related tissue compared with a combined amount of methylation in comparable normal tissue is evaluated to diagnose the state of development of the cancer in the subject. For example, the sum of the extent (e.g. percentage) of methylation of the second amplification products across a panel of genes can be used to measure a cumulative amount of hypermethylation in CpG islands in the tumor-related tissue as compared with a cumulative amount of methylation in comparable normal tissue to diagnose the state of development of the carcinoma in the subject. 
     In yet another embodiment, the invention methods can be used for diagnosing the state of development of a condition, such as any cancer and metastases thereof, associated with hypermethylation or aberrant methylation of a gene in a mammalian subject by co-amplifying a plurality of different DNA sequences isolated from tissue of the subject associated with the condition co-amplifying a plurality of DNA sequences using a mixture of DNA sequence-specific, methylation status-independent outer primer pairs that selectively hybridize to their cognate DNA sequences under conditions that allow generation of a first amplification product containing first amplicons. Real time PCR is then used to amplify unmethylated and/or methylated DNA from the first amplicons under conditions that allow generation of second amplification products for one or more genes, using for a gene two sets of primers comprising a DNA sequence-specific, methylation status-dependent (unmethylated or methylated) inner primer pair and a (unmethylated or methylated) DNA sequence-specific probe. Second amplicons are detected by using one or more distinguishable optically detectable labels per reaction. A combination of inner primer pair and probe selectively hybridizes to one first amplicon, and the sets of inner primer pairs and probes collectively hybridize to a plurality of first amplicons in the first amplification product. Signal intensities of the one or more distinguishable labels in the second amplification products are detected to determine the amount of methylation in a gene. A combined methylation value is derived for the methylation in the DNA sequences in the test sample from amounts of methylation determined for the second amplification products in a panel of genes, as compared with the combined methylation value in comparable normal tissue sample to indicate the state of development of the condition in the subject. 
     Optionally, in any of the invention methods, a single combination of inner primer pair and probe may be used for amplification using real time PCR in separate aliquots of the first amplification product. In any case, the sets of probes and inner primer pairs collectively amplify a plurality of different first amplicons in the first amplification product. 
     In another embodiment, the invention provides kits for determining the methylation status of a plurality of DNA sequences in a DNA sample. The invention kits include a set of DNA sequence-specific, methylation status-independent outer primer pairs that selectively hybridize to one or more of the plurality of DNA sequences under conditions that allow generation of a first amplification product containing first amplicons, a set of DNA sequence-specific, methylation status-dependent inner primer pairs, and a set of DNA sequence-specific probes with one or more distinguishable optically detectable labels. A combination of inner primer pair and probe selectively hybridizes to one or more first amplicon, and the sets of inner primer pairs and probes collectively hybridize to a plurality of first amplicons in the first amplification product. The invention kits may include two sets of the set of DNA sequence-specific, methylation status-dependent inner primer pairs, a subset that specifically hybridizes to methylated first amplicons and a subset that specifically hybridizes to unmethylated first amplicons. Illustrative primers are exemplified in the Examples herein. In certain embodiments, the kit may further provide a set of instructions for performing the invention methods using the contents of the kit. 
     The invention methods combine the principles of MSP, multiplex MSP, quantitative real-time PCR (Q-PCR) with quantitative MSP (Q-MSP) in a procedure referred to herein as quantitative multiplex methylation-specific PCR (QM-MSP) ( FIGS. 1 and 2 ). The studies described herein have shown that this combination of procedures can detect as few as 1-10 methylated copies of DNA in a mixture of about 100,000 copies of unmethylated DNA (Table 3 and  FIG. 3 ) and 40 pg of methylated genomic DNA in up to 1500-fold excess unmethylated DNA ( FIG. 4 ). This outcome compares favorably to Q-MSP with a sensitively of 1:10,000 (Trinh B. N. et al., supra) and conventional MSP with a sensitivity of 1:1000 (Herman J. G. et al., supra). In addition, reactions are specific since no cross-reactivity was observed between methylated and unmethylated primers even in mixtures consisting of more than 10 5 -fold excess of one or the other DNA (Table 3,  FIG. 3 ). Also, it has been demonstrated that using the level of unmethylated product for each gene as the internal control for assessing the extent of methylated gene product present provides accurate quantitation (Table 4). 
     Quantitative Real-Time PCR (Q-PCR) 
     The ability to monitor the real-time progress of the PCR changes the way one approaches PCR-based quantification of DNA and RNA. Reactions are characterized by the point in time during cycling when amplification of a PCR product is first detected rather than the amount of PCR product accumulated after a fixed number of cycles. The higher the starting copy number of the nucleic acid target, the sooner a significant increase in fluorescence is observed.  FIGS. 3 and 4  show representative amplification plots. An amplification plot is the plot of fluorescence signal versus cycle number. In the initial cycles of PCR, there is little change in fluorescence signal. This defines the baseline for the amplification plot. An increase in fluorescence above the baseline indicates the detection of accumulated PCR product. A fixed fluorescence threshold can be set above the baseline. The parameter C T  (threshold cycle) is defined as the fractional cycle number at which the fluorescence passes the fixed threshold. For example, the PCR cycle number at which fluorescence reaches a threshold value of 10 times the standard deviation of baseline emission may be used as C T  and it is inversely proportional to the starting amount of target cDNA. A plot of the log of initial target copy number for a set of standards versus C T  is a straight line. Quantification of the amount of target in unknown samples is accomplished by measuring C T  and using the standard curve to determine starting copy number. 
     The entire process of calculating C T s, preparing a standard curve, and determining starting copy number for unknowns can be performed by software, for example that of the 7700 system or 7900 system of Applied Biosystems. Real-time PCR requires an instrumentation platform that consists of a thermal cycler, computer, optics for fluorescence excitation and emission collection, and data acquisition and analysis software. These machines, available from several manufacturers, differ in sample capacity (some are 96-well standard format, others process fewer samples or require specialized glass capillary tubes), method of excitation (some use lasers, others broad spectrum light sources with tunable filters), and overall sensitivity. There are also platform-specific differences in how the software processes data. Real-time PCR machines are available at core facilities or labs that have the need for high throughput quantitative analysis. 
     Briefly, in the Q-PCR method the number of target gene copies can be extrapolated from a standard curve equation using the absolute quantitation method. For each gene, cDNA from a positive control is first generated from RNA by the reverse transcription reaction. Using about 1 μl of this cDNA, the gene under investigation is amplified using the primers by means of a standard PCR reaction. The amount of amplicon obtained is then quantified by spectrophotometry and the number of copies calculated on the basis of the molecular weight of each individual gene amplicon. Serial dilutions of this amplicon are tested with the Q-PCR assay to generate the gene specific standard curve. Optimal standard curves are based on PCR amplification efficiency from 90 to 100% (100% meaning that the amount of template is doubled after each cycle), as demonstrated by the slope of the standard curve equation. Linear regression analysis of all standard curves should show a high correlation (R 2  coefficient≧0.98). Genomic DNA can be similarly quantified. 
     When measuring transcripts of a target gene, the starting material, transcripts of a housekeeping gene are quantified as an endogenous control. Beta-actin is one of the most used nonspecific housekeeping genes. For each experimental sample, the value of both the target and the housekeeping gene are extrapolated from the respective standard curve. The target value is then divided by the endogenous reference value to obtain a normalized target value independent of the amount of starting material. 
     Primer Acid Probe Design for QM-MSP 
     In practice of the invention methods, the above-described quantitative real-time PCR methodology has been adapted to perform quantitative methylation-specific PCR (QM-MSP) by utilizing the external primers pairs in round one (multiplex) PCR and internal primer pairs in round two (real time MSP) PCR. Thus each set of genes has one pair of external primers and two sets of three internal primers/probe (internal sets are specific for unmethylated or methylated DNA). The external primer pairs can co-amplify a cocktail of genes, each pair selectively hybridizing to a member of the panel of genes being investigated using the invention method. Primer pairs are designed to exclude CG dinucleotides, thereby rendering DNA amplification independent of the methylation status of the promoter DNA sequence. Therefore methylated and unmethylated DNA sequences internal to the binding sites of the external primers are co-amplified for any given gene by a single set of external primers specific for that gene. The external primer pair for a gene being investigated is complementary to the sequences flanking the CpG island that is to be queried in the second round of QM-MSP. For example, the sequences of external primers set forth in Table 1 below are used for multiplex PCR (first round PCR) of genes associated with primary breast cancer (Fackler M. J. et al,  Int. J. Cancer  (2003) 107:970-975; Fackler M. J. et al.  Cancer Res  (2004) 64:4442-4452). 
     Internal PCR primers used for quantitative real-time PCR of methylated and unmethylated DNA sequences (round two QM-MSP) are designed to selectively hybridize to the first amplicon produced by the first round of PCR for one or more members of the panel of DNA sequences being investigated using the invention method and to detect the methylation status, i.e., whether methylated (M) or unmethylated (U), of the CpG islands in the first amplicons to which they bind. Thus for each member of the starting panel of promoter DNA sequences used in an invention assay, separate QM-MSP reactions are conducted to amplify the first amplicon produced in the first round of PCR using the respective methylation-specific primer pair and using the respective unmethylated-specific primer pair. 
     In round two of QM-MSP a single gene or a cocktail of two or more genes can be co-amplified using distinguishable fluorescence labeled probes. The probes used in the round two QM-MSP of the invention method are designed to selectively hybridize to a segment of the first amplicon lying between the binding sites of the respective methylation-status specific internal PCR primer pair. Polynucleotide probes suitable for use in real-time PCR include, but are not limited to, a bilabeled oligonucleotide probe, such as a molecular beacon or a TaqMan™ probe, which include a fluorescent moiety and a quencher moiety. In a molecular beacon the fluorescence is generated due to hybridization of the probe, which displaces the quencher moiety from proximity of the fluorescent moiety due to disruption of a stem-loop structure of the bilabeled oligonucleotide. Molecular beacons, such as Amplifluor™ or TriStar™ reagents and methods are commercially available (Stratagene; Intergen). In a TaqMan™ probe, the fluorescence is progressively generated due to progressive degradation of the probe by Taq DNA polymerase during rounds of amplification, which displaces the quencher moiety from the fluorescent moiety. Once amplification occurs, the probe is degraded by the 5′-3′ exonuclease activity of the Taq DNA polymerase, and the fluorescence can be detected, for example by means of a laser integrated in the sequence detector. The fluorescence intensity, therefore, is proportional to the amount of amplification product produced. 
     In one embodiment, fluorescence from the probe is detected and measured during a linear amplification reaction and, therefore, can be used to detect generation of the linear amplification product. 
     Amplicons in the 80-150 base pair range are generally favored because they promote high-efficiency assays that work the first time. In addition, high efficiency assays enable quantitation to be performed using the absolute quantitation method. Quantitation of the copy number of unmethylated (U) and methylated (M) DNA amplicons for a specific gene eliminates the need to use actin as an estimate of DNA input, since U+M is taken to approximate the total number of copies of DNA amplicons for any given gene in the first amplicon product (derived from round one, multiplex PCR of QM-MSP). 
     Whenever possible, primers and probes can be selected in a region with a G/C content of 20-80%. Regions with G/C content in excess of this may not denature well during thermal cycling, leading to a less efficient reaction. In addition, G/C-rich sequences are susceptible to non-specific interactions that may reduce reaction efficiency. For this reason, primer and probe sequences containing runs of four or more G bases are generally avoided. A/T-rich sequences require longer primer and probe sequences in order to obtain the recommended TMs. This is rarely a problem for quantitative assays; however, TaqMan™ probes approaching 40 base pairs can exhibit less efficient quenching and produce lower synthesis yields. 
     For example, external primer pairs, internal primer pairs and gene-specific probes for determining the methylation and unmethylation status of certain genes associated with primary breast cancer, RASSF1A, TWIST, Cyclin D2, and HIN1, are set forth in Tables 1 and 2 below. 
     
       
         
           
               
             
               
                 TABLE 1  
               
             
            
               
                   
               
               
                 Sequence of Multiplex External Primers 
               
               
                 (Used in Round 1 PCR of QM-MSP) 
               
            
           
           
               
               
               
               
            
               
                 Primer Name 
                 Primer Sequence 
                 Orientation 
                 SEQ ID NO. 
               
               
                   
               
               
                 Cyclin D2 Ext F 
                 Tattttttgtaaagatagttttgat 
                 Forward 
                 SEQ ID NO: 1 
               
               
                   
               
               
                 Cyclin D2 Ext R 
                 Tacaactttctaaaaaataaccc 
                 Reverse 
                 SEQ ID NO: 2 
               
               
                   
               
               
                 RASSF1A Ext F(2) 
                 Gttttatagtttttgtatttagg 
                 Forward 
                 SEQ ID NO: 3 
               
               
                   
               
               
                 RASSF1A Ext R(2) 
                 Aactcaataaactcaaactccc 
                 Reverse 
                 SEQ ID NO: 4 
               
               
                   
               
               
                 TWIST Ext R(4) 
                 Cctcccaaaccattcaaaaac 
                 Forward 
                 SEQ ID NO: 5 
               
               
                   
               
               
                 TWIST Ext F(3) 
                 Gagatgagatattatttattgtg 
                 Reverse 
                 SEQ ID NO: 6 
               
               
                   
               
               
                 RARB Ext F 
                 Gtaggagggtttattttttgtt 
                 Forward 
                 SEQ ID NO: 7 
               
               
                   
               
               
                 RARB Ext R(2) 
                 Aattacattttccaaacttactc 
                 Reverse 
                 SEQ ID NO: 8 
               
               
                   
               
               
                 HIN1 Ext F(2) 
                 Gtttgttaagaggaagtttt 
                 Forward 
                 SEQ ID NO: 9 
               
               
                   
               
               
                 HIN1 Ext R 
                 Ccgaaacatacaaaacaaaaccac 
                 Reverse 
                 SEQ ID NO: 10 
               
               
                   
               
               
                 ACTB Ext F 
                 Tatataggttggggaagtttg 
                 Forward 
                 SEQ ID NO: 11 
               
               
                   
               
               
                 ACTB Ext R 
                 Tataaaaacataaaacctataacc 
                 Reverse 
                 SEQ ID NO: 12 
               
               
                   
               
               
                 ESR1 Ext F(2) 
                 Ggtgtatttggatagtagtaag 
                 Forward 
                 SEQ ID NO: 46 
               
               
                   
               
               
                 ESR1 Ext R(3) 
                 Ctccaaataataaaacacctact 
                 Reverse 
                 SEQ ID NO: 47 
               
               
                   
               
               
                 APC1 Ext F(2) 
                 Aaaaccctataccccactac 
                 Forward 
                 SEQ ID NO: 48 
               
               
                   
               
               
                 APC1 Ext R(2) 
                 Ggttgtattaatatagttatatgt 
                 Reverse 
                 SEQ ID NO: 49 
               
               
                   
               
               
                 BRCA1 Ext F 
                 Tattttgagaggttgttgtttag 
                 Forward 
                 SEQ ID NO: 50 
               
               
                   
               
               
                 BRCA1 Ext R 
                 Aaacatcacttaaaccccctat 
                 Reverse 
                 SEQ ID NO: 51 
               
               
                   
               
               
                 BRCA2 Ext F 
                 Gttgggatgtttgataaggaat 
                 Forward 
                 SEQ ID NO: 52 
               
               
                   
               
               
                 BRCA2 Ext R 
                 Atcacaaatctatcccctcac 
                 Reverse 
                 SEQ ID NO: 53 
               
               
                   
               
               
                 P16 Ext F(3) 
                 Aaagaggaggggttggttg 
                 Forward 
                 SEQ ID NO: 54 
               
               
                   
               
               
                 P16 Ext R(5) 
                 Aaccctctacccacctaaat 
                 Reverse 
                 SEQ ID NO: 55 
               
               
                   
               
               
                 HIC1 Ext F 
                 Tttagttgagggaaggggaa 
                 Forward 
                 SEQ ID NO: 56 
               
               
                   
               
               
                 HIC1 Ext R 
                 Aactacaacaacaactacctaa 
                 Reverse 
                 SEQ ID NO: 57 
               
               
                   
               
            
           
         
       
     
     
       
         
           
               
             
               
                 TABLE 2  
               
             
            
               
                   
               
               
                 Sequences of QM-MSP Primers (Used in Round 2 PCR of QM-MSP) 
               
            
           
           
               
               
               
               
               
            
               
                   
                 QM-MSP Primer 
                   
                   
                   
               
               
                 Primer Name 
                 Sequences 
                   
                 Orientation 
                 Status 
               
               
                   
               
               
                 Cyclin D2 RT-FM 
                 tttgatttaaggatgcgttagagtacg 
                 SEQ ID NO: 13 
                 Forward 
                 M 
               
               
                   
               
               
                 Cyclin D2 RT-RM 
                 actttctccctaaaaaccgactacg 
                 SEQ ID NO: 14 
                 Reverse 
                 M 
               
               
                   
               
               
                 Cyclin D2 M Probe 
                 aatccgccaacacgatcgacccta 
                 SEQ ID NO: 15 
                 Reverse 
                 M 
               
               
                   
               
               
                 Cyclin D2 RT-FUM 
                 ttaaggatgtgttagagtatgtg 
                 SEQ ID NO: 16 
                 Forward 
                 U 
               
               
                   
               
               
                 Cyclin D2 RT-RUM 
                 aaactttctccctaaaaaccaactacaat 
                 SEQ ID NO: 17 
                 Reverse 
                 U 
               
               
                   
               
               
                 Cyclin D2 UM Probe 
                 aatccaccaacacaatcaaccctaac 
                 SEQ ID NO: 18 
                 Reverse 
                 U 
               
               
                   
               
               
                 RASSF1A RT-FM 
                 gcgttgaagteggggttc 
                 SEQ ID NO: 19 
                 Forward 
                 M 
               
               
                   
               
               
                 RASSF1A RT-RM 
                 cccgtacttcgctaactttaaacg 
                 SEQ ID NO: 20 
                 Reverse 
                 M 
               
               
                   
               
               
                 RASSF1A M Probe 
                 acaaacgcgaaccgaacgaaacca 
                 SEQ ID NO: 21 
                 Reverse 
                 M 
               
               
                   
               
               
                 RASSF1A RT-FUM 
                 ggtgttgaagttggggtttg 
                 SEQ ID NO: 22 
                 Forward 
                 U 
               
               
                   
               
               
                 RASSF1A RT-RUM 
                 cccatacttcactaactttaaac 
                 SEQ ID NO: 23 
                 Reverse 
                 U 
               
               
                   
               
               
                 RASSF1A UM Probe 
                 ctaacaaacacaaaccaaacaaaacca 
                 SEQ ID NO: 24 
                 Reverse 
                 U 
               
               
                   
               
               
                 TWIST RT-FM 
                 gttagggttcgggggcgttgtt 
                 SEQ ID NO: 25 
                 Forward 
                 M 
               
               
                   
               
               
                 TWIST RT-RM 
                 ccgtcgccttcctccgacgaa 
                 SEQ ID NO: 26 
                 Reverse 
                 M 
               
               
                   
               
               
                 TWIST M-Probe 
                 aaacgatttccttccccgccgaaa 
                 SEQ ID NO: 27 
                 Reverse 
                 M 
               
               
                   
               
               
                 TWIST RT-FUM(3) 
                 ggtttgggggtgttgtttgtatg 
                 SEQ ID NO: 28 
                 Forward 
                 U 
               
               
                   
               
               
                 TWIST-RT-RUM(3) 
                 cccacctcctaaccaccctcc 
                 SEQ ID NO: 29 
                 Reverse 
                 U 
               
               
                   
               
               
                 TWIST UM Probe 
                 aaacaatttccttccccaccaaaaca 
                 SEQ ID NO: 30 
                 Reverse 
                 U 
               
               
                   
               
               
                 RARB RT-FM 
                 agaacgcgagcgattcgagtag 
                 SEQ ID NO: 31 
                 Forward 
                 M 
               
               
                   
               
               
                 RARB RT-RM 
                 tacaaaaaaccttccgaatacgtt 
                 SEQ ID NO: 32 
                 Reverse 
                 M 
               
               
                   
               
               
                 RARB M Probe 
                 atcctaccccgacgatacccaaac 
                 SEQ ID NO: 33 
                 Reverse 
                 M 
               
               
                   
               
               
                 RARB RT-FUM 
                 ttgagaatgtgagtgatttgagtag 
                 SEQ ID NO: 34 
                 Forward 
                 U 
               
               
                   
               
               
                 RARB RT-RUM 
                 ttacaaaaaaccttccaaatacattc 
                 SEQ ID NO: 35 
                 Reverse 
                 U 
               
               
                   
               
               
                 RARB UM Probe 
                 aaatcctaccccaacaatacccaaac 
                 SEQ ID NO: 36 
                 Reverse 
                 U 
               
               
                   
               
               
                 HIN1 RT-FM 
                 tagggaagggggtacgggttt 
                 SEQ ID NO: 37 
                 Forward 
                 M 
               
               
                   
               
               
                 HIN1 RT-RM 
                 cgctcacgaccgtaccctaa 
                 SEQ ID NO: 38 
                 Reverse 
                 M 
               
               
                   
               
               
                 HIN1 M Probe 
                 acttcctactacgaccgacgaacc 
                 SEQ ID NO: 39 
                 Reverse 
                 M 
               
               
                   
               
               
                 HIN1-RT-FUM(2) 
                 aagtttttgaggtttgggtaggga 
                 SEQ ID NO: 40 
                 Forward 
                 U 
               
               
                   
               
               
                 HIN1 RT-RUM(2) 
                 accaacctcacccacactccta 
                 SEQ ID NO: 41 
                 Reverse 
                 U 
               
               
                   
               
               
                 HIN1 UM Probe 
                 caacttcctactacaaccaacaaacc 
                 SEQ ID NO: 42 
                 Reverse 
                 U 
               
               
                   
               
               
                 ACTB F 
                 tggtgatggaggaggtttagtaagt 
                 SEQ ID NO: 43 
                 Forward 
                 Indep 
               
               
                   
               
               
                 ACTB R 
                 aaccaataaaacctactcctcccttaa 
                 SEQ ID NO: 44 
                 Reverse 
                 Indep 
               
               
                   
               
               
                 ACTB Probe 
                 accaccacccaacacacaataacaaacaca 
                 SEQ ID NO: 45 
                 Reverse 
                 Indep 
               
               
                   
               
               
                 ESR1 RT-FUM 
                 tgttgtgtataattattttgagggt 
                 SEQ ID NO: 58 
                 Forward 
                 M 
               
               
                   
               
               
                 ESR1 RT-RUM 
                 ccaatctaaccataaacctacaca 
                 SEQ ID NO: 59 
                 Reverse 
                 M 
               
               
                   
               
               
                 ESR1 UM Probe 
                 caacaaccacaacattaaactcataaac 
                 SEQ ID NO: 60 
                 Reverse 
                 M 
               
               
                   
               
               
                 ESR1 RT-FM 
                 cgtcgtgtataattatttcgagg 
                 SEQ ID NO: 61 
                 Forward 
                 U 
               
               
                   
               
               
                 ESR1 RT-RM 
                 gatctaaccgtaaacctacgcg 
                 SEQ ID NO: 62 
                 Reverse 
                 U 
               
               
                   
               
               
                 ESR1 M Probe 
                 cgacgaccgcgacgttaaactcgt 
                 SEQ ID NO: 63 
                 Reverse 
                 U 
               
               
                   
               
               
                 APC1 RT-FUM 
                 taaatacaaaccaaaacactccc 
                 SEQ ID NO: 64 
                 Forward 
                 M 
               
               
                   
               
               
                 APC1 RT-RUM 
                 gttatatgttggttatgtgtgttt 
                 SEQ ID NO: 65 
                 Reverse 
                 M 
               
               
                   
               
               
                 APC1 UM probe 
                 ttcccatcaaaaacccaccaattaac 
                 SEQ ID NO: 66 
                 Reverse 
                 M 
               
               
                   
               
               
                 APC1 RT-FM 
                 aatacgaaccaaaacgctccc 
                 SEQ ID NO: 67 
                 Forward 
                 U 
               
               
                   
               
               
                 APC1 RT-RM 
                 tatgtcggttacgtgcgtttatat 
                 SEQ ID NO: 68 
                 Reverse 
                 U 
               
               
                   
               
               
                 APC1 M Probe 
                 cccgtcgaaaacccgccgatta 
                 SEQ ID NO: 69 
                 Reverse 
                 U 
               
               
                   
               
               
                 BRCA1 RT-FUM 
                 tggtaatggaaaagtggggaa 
                 SEQ ID NO: 70 
                 Forward 
                 M 
               
               
                   
               
               
                 BRCA1 RT-RUM(4) 
                 cccatccaaaaaatctcaacaaa 
                 SEQ ID NO: 71 
                 Reverse 
                 M 
               
               
                   
               
               
                 BRCA1 UM probe 
                 ctcacaccacacaatcacaattttaat 
                 SEQ ID NO: 72 
                 Reverse 
                 M 
               
               
                   
               
               
                 BRCA1 RT-FM 
                 tttcgtggtaacggaaaagcg 
                 SEQ ID NO: 73 
                 Forward 
                 U 
               
               
                   
               
               
                 BRCA1 RT-RM 
                 ccgtccaaaaaatctcaacgaa 
                 SEQ ID NO: 74 
                 Reverse 
                 U 
               
               
                   
               
               
                 BRCA1 M Probe 
                 ctcacgccgcgcaatcgcaattt 
                 SEQ ID NO: 75 
                 Reverse 
                 U 
               
               
                   
               
               
                 BRCA2 RT-FUM 
                 atttttgggtggtgtgtgtgtt 
                 SEQ ID NO: 76 
                 Forward 
                 M 
               
               
                   
               
               
                 BRCA2 RT-RUM 
                 tcaaaaactcacaccacaaacc 
                 SEQ ID NO: 77 
                 Reverse 
                 M 
               
               
                   
               
               
                 BRCA2 UM Probe 
                 aaccacataacaccataacacaacac 
                 SEQ ID NO: 78 
                 Reverse 
                 M 
               
               
                   
               
               
                 BRCA2 RT-FM 
                 tttgattttcgggtggtgcgt 
                 SEQ ID NO: 79 
                 Forward 
                 U 
               
               
                   
               
               
                 BRCA2 RT-RM 
                 tcaaaaactcgcgccacaaac 
                 SEQ ID NO: 80 
                 Reverse 
                 U 
               
               
                   
               
               
                 BRCA2 M Probe 
                 aaccacgtaacgccgtaacgcga 
                 SEQ ID NO: 81 
                 Reverse 
                 U 
               
               
                   
               
               
                 P16 RT-FUM(2) 
                 ttattagagggtggggtggattgt 
                 SEQ ID NO: 82 
                 Forward 
                 M 
               
               
                   
               
               
                 P16 RT-RUM 
                 caaccccaaaccacaaccataa 
                 SEQ ID NO: 83 
                 Reverse 
                 M 
               
               
                   
               
               
                 P16 UM Probe 
                 ctactccccaccacccactacct 
                 SEQ ID NO: 84 
                 Reverse 
                 M 
               
               
                   
               
               
                 P16 RT-FM(2) 
                 ttattagagggtggggcggatcgc 
                 SEQ ID NO: 85 
                 Forward 
                 U 
               
               
                   
               
               
                 P16 RT-RM 
                 gaccccgaaccgcgaccgtaa 
                 SEQ ID NO: 86 
                 Reverse 
                 U 
               
               
                   
               
               
                 P16 M Probe 
                 agtagtatggagtcggcggcggg 
                 SEQ ID NO: 87 
                 Reverse 
                 U 
               
               
                   
               
               
                 HIC1 RT-FUM 
                 gggttaggtggttagggtgtt 
                 SEQ ID NO: 88 
                 Forward 
                 M 
               
               
                   
               
               
                 HIC1 RT-RUM 
                 taaccaaacacctccatcatatc 
                 SEQ ID NO: 89 
                 Reverse 
                 M 
               
               
                   
               
               
                 HIC1 UM Probe 
                 aaacacacaccaaccaaataaaaaccat 
                 SEQ ID NO: 90 
                 Reverse 
                 M 
               
               
                   
               
               
                 HIC1 RT-FM 
                 ggttaggcggttagggcgtc 
                 SEQ ID NO: 91 
                 Forward 
                 U 
               
               
                   
               
               
                 HIC1 RT-RM 
                 ccgaacgcctccatcgtatc 
                 SEQ ID NO: 92 
                 Reverse 
                 U 
               
               
                   
               
               
                 HIC1 M Probe 
                 cacacaccgaccgaataaaaaccgt 
                 SEQ ID NO: 93 
                 Reverse 
                 U 
               
               
                   
               
            
           
         
       
     
     The TaqMan™ probe used in the Example herein contains both a fluorescent reporter dye at the 5′ end, such as 6-carboxyfluorescein (6-FAM: emission λ max =518 nm) and a quencher dye at the 3′ end, such as 6-carboxytetramethylrhodamine, (TAMRA; emission λ max =582 nm). The quencher can quench the reporter fluorescence when the two dyes are close to each other, which happens in an intact probe. Other reporter dyes include but are not limited to VIC™ and TET™ and these can be used in conjunction with 6-FAM to co-amplify genes by quantitative real time PCR. For instance in round two QM-MSP, unmethylated (using a 6-FAM/TAMRA probe) and unmethylated RARβ (using a VIC/TAMRA probe) either can be co-amplified ( FIG. 1 ) or can be assayed as single genes. 
     Thermal Cycling Parameters 
     The round two QM-MSP reactions are designed to be run as single gene reactions or in multiplex using automated equipment, as are other types of real time PCR. Thermal cycling parameters useful for performing real time PCR are well known in the art and are illustrated in the Examples herein. In certain embodiments, quantitative assays can be run using the same universal thermal cycling parameters for each assay. This eliminates any optimization of the thermal cycling parameters and means that multiple assays can be run on the same plate without sacrificing performance. This benefit allows combining two or more assays into a multiplex assay system, in which the option to run the assays under different thermal cycling parameters is not available. 
     Using the QM-MSP approach, it is possible to compile gene panels that are designed to address specific questions, or to provide intermediate markers or endpoints for clinical protocols. For example, when using de-methylating agents, a panel can be designed to query pathway-specific genes for their use as intermediate markers in specific trials of chemopreventive agents (Fackler M. J. et al.  J Mammary Gland Biol Neoplasia  (2003) 8:75-89). 
     In summary, the invention methods can be used to assess the methylation status of multiple genes, using only picograms of DNA. A cumulative score of hypermethylation among multiple genes better distinguishes normal or benign from malignant tissues. While the studies described herein show that some normal or benign tissue may have low-level gene promoter hypermethylation, it is also shown that distinct differences exist between the levels of normal and malignant tissues. Using QM-MSP, therefore, it is possible to objectively define the range of normal/abnormal DNA sequence hypermethylation in a manner that is translatable to a larger clinical setting. The invention methods may also be used to examine cumulative hypermethylation in benign conditions and as a predictor of conditions, such as various cancers and their metastases that are associated with DNA hypermethylation. The invention method may also predict conditions not associated with cancers, such as pre-eclampsia or eclampsia (Hueller H. M. et al.  M Clin Chem  (2004) 50:1065-1068). 
     In one embodiment, the primer extension reaction is a linear amplification reaction, wherein the primer extension reaction is performed over a number of cycles, and the linear amplification product that is generated is detected. 
     Due to the sensitivity of the invention methods, the first amplification product is optionally diluted from about 1:5 to about 1:10 5  and optionally separate aliquots of the first amplification product are further subjected to QM-MSP as described herein. 
     In real-time PCR, as used in the invention methods, one or more aliquots (usually dilute) of the first amplification product is amplified with at least a first primer of an internal amplification primer pair, which can selectively hybridize to one or more amplicon in the first amplification product, under conditions that, in the presence of a second primer of the internal amplification primer pair, and a fluorescent probe allows the generation of a second amplification product. Detection of fluorescence from the second amplification product(s) provides a means for real-time detection of the generation of a second amplification product and for calculation of the amount of gene specific second amplification product produced. Alternatively, the first amplification products used for the real time PCR reaction(s) may be contacted with both 1) a combination of a probe and DNA sequence-specific internal primer pair that recognizes only a methylated CpG island in the first amplicon and 2) a combination of a probe and DNA sequence-specific internal primer pair that recognizes an unmethylated CpG island for each of the DNA sequences in the panel of DNA sequences. 
     Thus, in one embodiment, the real-time PCR amplification in an invention two-step assay is, in fact, a group of real-time PCR reactions, which may be conducted together or using two separate aliquots of the first amplification product, for each of the first amplicons (i.e., for each DNA sequence in the panel that were selected for the assay). In this embodiment, determination of the methylation status of a DNA sequence, such as one containing a CpG island, employs both a methylation-determining and an unmethylation determining internal primer pair for each amplicon contained in the first amplification product, one to determine if the gene is unmethylated and one to determine if the gene is methylated. The real time PCR reactions in the second amplification step of the invention methods can conveniently be conducted sequentially or simultaneously in multiplex. Separate, usually dilute, aliquots of the first amplification reaction may be used for each of the two methylation status determining reactions. For example, the reactions can conveniently be performed in the wells of a 96 or 384 microtiter plate. For convenience, the methylated and unmethylated status determining second reactions for a target gene may be conducted in adjacent wells of a microtiter plate for high throughput screening. Alternatively, several genes, for example 2 to 5 genes, may be simultaneously amplified in a single real time PCR reaction if the probes used for each first amplicon are distinguishably labeled. 
     For example, two to five distinguishable fluorescence signals from the second amplification product(s) may be accumulated to determine the cumulative incidence or level of methylation of the DNA sequences, especially of CpG islands therein, in the several genes included in the assay. These cumulative results are compared with the cumulative results similarly obtained by conducting the two step QM-MSP assay on comparable DNA sequences (e.g., promoter DNA sequences) obtained from comparable normal tissue of the same type or types as used in the assay. 
     Any of the known methods for conducting cumulative or quantitative “real time PCR” may be used in the second amplification step so long as the first amplicons in the first amplification product are contacted with one or more members of a set of polynucleotide probes that are labeled with distinguishable optically detectable labels, one or more members of the set being designed to selectively hybridize to one or more of the DNA sequences being tested, while the set cumulatively binds to the various DNA segments being tested contained in the first amplicons of the first amplification product. In addition, the first amplicons may also be contacted with such a set of probes and one or more members of a set of DNA sequence-specific methylation status-dependent inner primer pairs, wherein the set of inner primer pairs collectively bind to the various first amplicons in the first amplification product. In round two QM-MSP, additional genes can be co-amplified provided that each gene primer set incorporates a different color fluorescent probe. 
     It should be recognized that an amplification “primer pair” as the term is used herein requires what are commonly referred to as a forward primer and a reverse primer, which are selected using methods that are well known and routine and as described herein such that an amplification product can be generated therefrom. 
     As used herein, the phrase “conditions that allow generation of an amplification product” or of “conditions that allow generation of a linear amplification product” means that a sample in which the amplification reaction is being performed contains the necessary components for the amplification reaction to occur. Examples of such conditions are provided in Example 1 and include, for example, appropriate buffer capacity and pH, salt concentration, metal ion concentration if necessary for the particular polymerase, appropriate temperatures that allow for selective hybridization of the primer or primer pair to the template nucleic acid molecule, as well as appropriate cycling of temperatures that permit polymerase activity and melting of a primer or primer extension or amplification product from the template or, where relevant, from forming a secondary structure such as a stem-loop structure. Such conditions and methods for selecting such conditions are routine and well known in the art (see, for example, Innis et al., “PCR Strategies” (Academic Press 1995); Ausubel et al., “Short Protocols in Molecular Biology” 4th Edition (John Wiley and Sons, 1999); “A novel method for real time quantitative RT-PCR” Gibson U. E. et al.  Genome Res  (1996) 6:995-1001; “Real time quantitative PCR” Heid C. A. et al.  Genome Res  (1996) 6:986-994). 
     As used herein, the term “selective hybridization” or “selectively hybridize” refers to hybridization under moderately stringent or highly stringent conditions such that a nucleotide sequence associates with a selected nucleotide sequence but not with unrelated nucleotide sequences. Generally, an oligonucleotide useful as a probe or primer that selectively hybridizes to a selected nucleotide sequence is at least about 15 nucleotides in length, usually at least about 18 nucleotides, and particularly about 21 nucleotides in length or more in length. Conditions that allow for selective hybridization can be determined empirically, or can be estimated based, for example, on the relative GC:AT content of the hybridizing oligonucleotide and the sequence to which it is to hybridize, the length of the hybridizing oligonucleotide, and the number, if any, of mismatches between the oligonucleotide and sequence to which it is to hybridize (see, for example, Sambrook et al., “Molecular Cloning: A laboratory manual” (Cold Spring Harbor Laboratory Press 1989)). 
     The phrase “comparable normal tissue” as used herein means that histologically apparently normal tissue(s) are collected from tissue site(s) in the subject adjacent to the site(s) from which the tumor tissue is collected. Alternatively, the “comparable normal tissue” can be collected from sites(s) of unrelated healthy donors that anatomically related to the site(s) of subject tumor tissue used (e.g., same tissue type), or the results representing the accumulated incidence of the tumor marker in anatomically related apparently normal tissue site(s) of normal subjects can be compared with the results of the assay obtained from the subject&#39;s own tumor-associated tissue. Similarly, the phrase “a comparable normal DNA sample” as used herein means that the plurality of genomic DNA sequences that is being tested for methylation status, such as in a plant or insect, is matched with a panel of genomic DNA sequences of the same genes from a “normal” organism of the same species, family, and the like, for comparison purposes. For example, a substantial cumulative increase or decrease in the methylation level in the test sample as compared with the normal sample (e.g., the cumulative incidence of the tumor marker in a test DNA panel compared with that cumulatively found in comparable apparently normal tissue) is a reliable indicator of the presence of the condition being assayed. 
     The invention methods can be used to assay the DNA of any mammalian subject, including humans, pets (e.g., dogs, cats, ferrets) and farm animals (meat and dairy), and race horses. The invention methods can also be used to assay the DNA of plants (“DNA methylation in plants” Finnegan E. J. et al.  Annu Rev Plant Physiol Plant Mol Biol  (1998) 49:223-247) and insects (“DNA methylation learns to fly” Frank Lyko  Trends in Gen  (2001) 17:169-172). 
     The invention methods are illustrated using primary breast cancer as an example (Fackler M. J. et al,  Int. J. Cancer  (2003) 107:970-975; Fackler M. J. et al.  Cancer Res  (2004) 64:4442-4452). In breast cancer, samples can be collected from such tissue sources as ductal lavage and nipple aspirate fluid where the DNA amount is limiting, for example as little as about 50 to about 100 cells, as well as in larger samples, such as formalin-fixed paraffin-embedded sections of core biopsies. The maximum input DNA is approximately 600 ng. Using invention methods of QM-MSP, the level and incidence of hypermethylation CpG islands in RASSF1A, TWIST, Cyclin D2, HIN1, and RAR-β, genes in samples where DNA is limiting or when extreme sensitivity is desired can be co-amplified for the purpose of detecting progression of primary breast cancer in a subject. Scoring the cumulative methylation of these gene promoters within a sample gives high sensitivity and specificity of detection of primary breast cancer and a global indication of promoter hypermethylation in tumors relative to normal tissue. The invention methods are designed to evaluate samples that contain extremely limited amounts of DNA, such as those from ductal lavage or nipple aspiration. In the process, the extent of gene hypermethylation in primary breast cancer has been evaluated and the method is readily adaptable to clinical testing. Although this technique is illustrated with respect to breast tissues, the technique can be used to evaluate gene (e.g., gene promoter) hypermethylation within a wide range of tissues. 
     Recently it has been shown that some of the genes whose promoters are most frequently hypermethylated (30-90%) in breast carcinomas, but not in normal breast epithelium or circulating blood cells, are Cyclin D2, RARB, TWIST, RASSF1A and HIN1. Widschwendter and Jones (supra) reviewed over 40 genes lost in breast cancer due to promoter hypermethylation. A study of 103 cases of breast cancer recently observed that in 100% of cases of invasive carcinoma, and in 95% of cases of ductal carcinoma in situ (DCIS) one or more gene promoters in a panel of markers consisting of RASSF1A, HIN1, RAR-β, Cyclin D2 and TWIST were hypermethylated. In fact, the vast majority of tumors (80%) have promoters that are hypermethylated for two or more of these five genes, prompting the observation that tumor tissue may have a pattern of methylation of multiple promoters (Fackler M. J. et al.  Int J Cancer  (2003) in press, online). Thus, it was conceived that profiling the cumulative methylation of multiple gene promoters associated with a particular type of cancer, such as primary breast cancer, would serve to better distinguish benign from malignant tissues and to provide a more powerful approach than characterizing the status of one or more gene markers (Fackler M. J. et al.  Cancer Res  (2004) 64:4442-4452). 
     Studies also have demonstrated the feasibility of assessing gene promoter hypermethylation in ductal lavage (DL) samples (Evron E. et al.  Lancet  (2001) 357:1335-1336). These studies found TWIST, Cyclin D2 or RARB gene promoter hypermethylation in cells derived from subjects with ductal carcinoma. However, the status of more than 3 genes in any single sample could not be assessed because of the limited available DNA. For example, the DL samples used in the current study contained 50-1000 epithelial cells such that assessment of the status of many genes would be virtually impossible. Therefore, a new strategy was designed to better evaluate sources of material where DNA is limited (e.g. ductal lavage, plasma, fine-needle or core biopsy, or nipple aspiration fluid). 
     While QM-MSP was performed in a 96 well platform in the Examples illustrating the invention, a 384 well platform, or larger can be used for high throughput if QM-MSP is formatted for a larger setting. The QM-MSP technique is applicable to frozen or archival paraffin-embedded clinical tissues ( FIGS. 5-7 ), as well as ductal lavage material ( FIGS. 8, 11-12 ), plasma (data not shown), serum ( FIGS. 10-11 ), nipple aspiration fluid ( FIG. 9 ), and fine needle aspirates ( FIGS. 11 and 13 ). Other sources of sample DNA are also suitable for QM-MSP monitoring including but not limited to core tissue biopsies, bronchial washings, buccal cavity washings, cervical scrapings, prostatic fluids, and urine. Conditions that are unrelated to cancer which are suitable for monitoring by the invention include but are not limited to eclampsia and pre-eclampsia (“DNA Methylation Changes in Sera of Women in Early Pregnancy Are Similar to Those in Advanced Breast Cancer Subjects” Muller H. M. et al.  Expert Rev Mol Diagn  (2004) 3:443-458. 
     In a study of 14-28 tissue samples per group, the extent of gene promoter hypermethylation between normal tissues (derived from reduction mammoplasty) and malignant tissues (primary invasive ductal carcinoma) for RASSF1A, TWIST, Cyclin D2, and HIN1 ( FIG. 5  and Table 5) was studied (Fackler M. J. et al.  Cancer Res  (2004) 64:4442-4452). Significant differences were observed in the level of promoter hypermethylation between normal and tumor tissues for each of these four genes, based on comparison of mean and median normal values (Table 5). 
     Importantly, one of the powers of the invention method of QM-MSP is that it provides a means for defining the normal range of promoter methylation, as shown for RASSF1A, TWIST, HIN1 and Cyclin D2 genes in normal breast tissue (Table 5 and  FIG. 5 ) (Fackler M. J. et al.  Cancer Res  (2004) 64:4442-4452). Techniques that give higher sensitivity usually also give higher “background,” picking up signals that are missed by other methods. This was also observed in our current study, where a higher incidence of methylation in normal mammoplasty was observed than previously (Fackler M. J. et al.  Int J Cancer  (2003) in press, online) found using the gel-based MSP. Even so, with QM-MSP, the median of promoter methylation was 0% M for all genes. By setting an upper threshold for normal, the occasional low-level methylation that occurs in some normal tissues is acknowledged and criteria are set that define “positive” results as being in tumor. In the current study, cutoffs were established such that approximately 5-10% of normal samples fell above the cutoff. Using this criterion, the incidence of positive showing in tumor tissue was 68% for RASSF1A, 67% for TWIST, 57% for Cyclin D2, and 57% for HIN1 (Table 5). 
     More informative than evaluating the methylation status of a single gene, studies of cumulative multi-gene promoter hypermethylation indicated that striking differences exist between normal and malignant tissues ( FIGS. 6A and 6B )) (Fackler M. J. et al.  Cancer Res  (2004) 64:4442-4452). The panel of four genes (RASSF1A, TWIST, Cyclin D2, and HIN1) was amplified in 9 normal breast tissues and 19 primary carcinomas and the cumulative amount of gene promoter hypermethylation was determined for each of these samples ( FIGS. 6A and 6B  and Table 6). There was a highly significant (p=0.0002) difference between levels of cumulative gene promoter hypermethylation in normal tissues and that in malignant tissues when evaluating RASSF1A, TWIST, Cyclin D2 and HIN1 together as a panel. The invention methods employing cumulative methylation profiling of a panel of four genes was able to detect 84% of tumors; whereas single gene analyses yielded positive results in only 57-68% cases, depending on the gene analyzed ( FIGS. 5 and 6A -B). To our knowledge, this result is the first study to describe quantitation of cumulative methylation of gene promoters associated with a particular type of carcinoma, and shows its importance in distinguishing between normal and tumor tissues (Fackler M. J. et al.  Cancer Res  (2004) 64:4442-4452). 
     Molecular alterations in histologically normal appearing breast tissue adjacent to tumor have been previously reported, although their significance is not yet clear (Umbricht C. B. et al.  Oncogene  (2001) 20:3348-3353; Deng G. et al.  Science  (1996) 274:2057-2059; Heid C. A. et al.  Genome Res  (1996) 6:986-94). In the present study, the cumulative amount of gene promoter hypermethylation for RASSF1A, TWIST, Cyclin D2, and HIN1 gene promoters was studied in 6 pairings of tumor and apparently histologically normal adjacent tissue (Table 6,  FIG. 7 ). All 6 genes showed hypermethylation in tumor tissue. The adjacent normal tissues were also positive for promoter hypermethylation in 4 of 6 individuals, although the levels were considerably lower than in the nearby tumor tissue (p=0.01, based on the Mann-Whitney test). Therefore, this study suggests that adjacent normal tissue contains hypermethylated genes, albeit at a lower level than the adjacent tumor tissues. Thus, elevated methylation in histologically normal tissue adjacent to tumor may be an indicator the state of tissue cell populations undergoing disease. The high degree of sensitivity, precision and linearity that may be achieved using the invention methods, makes it possible to quantify disease progression, for example, the pre-existence of molecular alterations that render the tissue at a higher risk for breast cancer, or are normal age-related changes. It is important to note that no age-related abnormalities in these genes were observed in studies conducted as described herein (our unpublished data). 
     Application of the invention QM-MSP methods to ductal washings showed that it is possible to co-amplify up to 5 genes ( FIG. 8  and Table 7), from limited amounts of DNA (Fackler M. J. et al.  Cancer Res  (2004) 64:4442-4452). Using this approach, it was observed that most genes were successfully amplified in the samples. Analysis for cumulative gene promoter hypermethylation showed that little or no methylation was detected in the majority of samples taken from individuals having benign lesions (1 of 8 cases had low level methylation). By comparison, 2 of 4 samples with features of ductal carcinoma in situ (DCIS) had extremely high levels of cumulative gene hypermethylation. It can be concluded from this analysis that QM-MSP can be applied to analysis of multi-gene promoter hypermethylation in cells derived from washings of breast ducts. Furthermore, the QM-MSP method can be applied to investigate multiple gene promoter hypermethylation that could not have been evaluated using conventional MSP methods due to limiting quantities of input DNA being available. 
     Of interest, however, 2 of 4 cases of DCIS failed to demonstrate any detectable methylation when tested according to the invention methods ( FIG. 8 , Table 7)) (Fackler M. J. et al.  Cancer Res  (2004) 64:4442-4452). In our previous study of 44 histological sections of DCIS tissue, 95% of the samples were hypermethylated for one or more of the RASSF1A, TWIST, Cyclin D2, HIN1, and RARB gene promoters (Fackler M. J. et al.  Int J Cancer  (2003) in press, online). The reasons for the failure to detect methylation in all four samples could be that the number of cells present in ductal washings was below our sensitivity of detection. Conversely, although from the same breast, the washings could have been from a duct that was not the one bearing the DCIS. Additional promoters associated with breast cancer tissue, APC1, ESR1, BRCA1, BRCA2, P16 and HIC1 already have been added to this multiplex reaction panel successfully and are undergoing detailed examination ( FIGS. 9-13 ; Primer SEQ ID 46-93)  FIGS. 1-2 ). 
     The invention is further described by the following example, which is meant to illustrate, and not to limit, the invention. 
     Example 1 
     Materials and Methods 
     Probes as shown in Tables 1 and 2 above were purchased from Applied Biosystems (Applied Biosystems, Foster City, Calif.) and other primers were purchased from Invitrogen (Invitrogen Corporation, Carlsbad, Calif.). Q-MSP primers and probes for β-Actin and methylated Cyclin D2 and RASSF1A genes were described in Lehmann et al. (supra). All other sequences were designed in known regions of promoter hypermethylation in breast carcinoma. 
     Tissues and Cells: 
     Paired primary tumors and adjacent normal tissues (frozen tissue), paraffin-embedded normal breast tissue obtained from routine reduction mammoplasty, and primary breast cancer tissues were obtained from the Surgical Pathology archives of The Johns Hopkins Hospital after receiving approval from the institutional review board. The percentage of epithelial cells ranged from 20-50%. Ductal lavage (DL) samples were obtained from the Johns Hopkins Cytopathology Laboratory. Human sperm was obtained from a normal donor. The MDA-MB231 breast cancer cell line was obtained from ATCC and cultured as directed. 
     Sectioning and DNA Extraction from Formalin-Fixed Paraffin-Embedded Tissue 
     The composition of the unstained slides from each archival formalin-fixed, paraffin-embedded tissue block was confirmed by histopathological examination of surrounding hematoxylin and eosin (H &amp; E) section. For each tumor, the lesion was identified on an initial H &amp; E section, and confirmed to remain on a serial H &amp; E section taken following preparation of unstained sections for nucleic acid extraction. For DNA extraction, one 5-micron tissue section was deparaffinized in xylene (20 min), scraped from the slide and extracted in 100 μl TNES (10 mM Tris, pH 8.0, 150 mM, NaCl, 2 mM EDTA, 0.5% SDS) containing 40 μg proteinase K for 16 hr at 50° C. The tissue extract was heat inactivated at 70° C. for 10 min and clarified by centrifugation at 14K rpm for 10 min; 50 μl of the supernatant was used directly as a source of DNA for sodium bisulfite treatment. 
     For extraction of DNA from 50-1000 ductal cells, ductal washings were collected in up to 20 ml of isotonic saline. The cellular suspension was cytocentrifuged onto glass slides and stained with Papanicolaou&#39;s stain (Pap Stain) for diagnostic cytological evaluation. The slide coverslip was then removed by treatment with xylene, and cells were scraped and transferred to 50 μA TNES containing 40 μg/ml proteinase K, and 200 ng of salmon sperm carrier DNA. 
     For frozen tissues and MDA-MB231 cells to be used as methylated control DNA, DNA was extracted with phenol/chloroform using a procedure described in Maniatis T. et al. “Molecular cloning: a laboratory manual” (New York Cold Spring Harbor 1982). 
     Human sperm DNA (HSD) (unmethylated control) was purified using the PUREGENE® DNA Purification Kit (Gentra Systems, Minneapolis Minn.) with minor modifications to the manufacturer&#39;s protocol. Briefly, fresh seminal fluid was diluted to 25 ml with TE, and incubated at 37° C. for 1 hr. The specimen was centrifuged at 3000 rpm for 15 min at 4° C. The cellular pellet was rigorously vortexed, resuspended in Cell Lysis Solution containing dithiothreitol and proteinase K, and incubated at 55° C. overnight. The cell lysate was incubated with RNase A solution for 1 hr at 37° C. Proteins were salted out. The DNA was precipitated with isopropanol, washed in ethanol, and rehydrated with DNA Hydrating Solution (supplied by the manufacturer). HSD was stored at 4° C. 
     Sodium Bisulfite Treatment of DNA 
     Tissue, control and cell line DNAs were treated with sodium bisulfite and analyzed using methylation-specific PCR (MSP) as described by Herman et al. (supra). This process converts non-methylated cytosine residues to uracil, while methylated cytosines remain unchanged. Bisulfite-modified samples were aliquoted and stored at −80° C. 
     Probes and Primers 
     Quantitative Multiplex Methylation-Specific Polymerase Chain Reaction (MSP) 
     The QM-MSP procedure required two sequential PCR reactions ( FIG. 1 ). In the first PCR reaction (the multiplex step) (RXN 1) 1 μl sodium bisulfite-treated DNA was added to 24 μA reaction buffer [1.25 mM dNTP, 16.6 mM (NH 4 ) 2 SO 4 , 67 mM Tris, pH 8.8, 6.7 mM MgCl2, 10 mM β-mercaptoethanol, 0.1% DMSO, and 2.5-5 U Platinum Taq (Invitrogen)] containing 100 ng of each gene specific primer pair (forward and reverse primer for each of the six gene promoters RASSF1A, RAR-β, TWIST, Cyclin D2, HIN1, and β-Actin control) (SEQ ID NOS:1-12). The PCR conditions were 95° C. for 5 min, followed by 35 cycles of 95° C. for 30 sec, 56° C. for 30 sec, and 72° C. for 45 sec, with a final extension cycle of 72° C. for 5 min. The PCR products were diluted up to 125 μl with water and stored at −20° C. For this QM-MSP reaction, the total input DNA concentration ranged from 50 ng purified DNA) to ˜40 pg (for some ductal lavage samples). 
     For the second reaction (round two of the QM-MSP step) (Rxn 2), 1 μl of the diluted PCR product from reaction 1 was used directly, or after further dilution of up to 1:10 4  (when 50 ng DNA was used in reaction 1). The diluted DNA was added to the real-time-MSP reaction buffer containing 16.6 mM (NH 4 ) 2 S0 4 , 67.0 mM Tris, pH 8.8, 6.7 mM MgCl 2 , 10.0 mM (β-mercaptoethanol, 0.1% DMSO, 200 μM dNTP, 1.25 U Platinum DNA Taq Polymerase (Invitrogen) and IX ROX (Invitrogen). 600 nM of each of two internal primers (forward and reverse) (SEQ ID NOS: 13, 14, 16, 17, 19, 20, 22, 23, 25, 26, 28, 29, 31, 32, 34, 35, 37, 38, 40, 41, 43 and 44) and 200 nM labeled probes (Applied Biosystems) (SEQ ID NOS:15, 18, 21, 24, 27, 30, 33, 36, 39, 42 and 45) were also present. The separate reactions were carried out in wells of a 96-well reaction plate in an ABI Prism 7900HT Sequence Detector (Applied Biosystems). The reactions proceeded at 95° C. for 5 min, then 35 cycles of 95° C. for 15 s and 60-65° C. (depending on the primer set) for 1 min, with a 10 min extension at 72° C. For each gene included in the reaction plate, the following were used to create standard curves and to provide controls: 1) serially diluted stock multiplexed HSD/231DNA (described below, to establish a standard curve), 2) 40,000 copy (40 K) controls, 3) no template control and 4) a known DNA (mixed to 1% methylated copies; Table 3) to ensure consistency between runs. In addition, 5) 100% methylated (MDA-MB231 cell DNA), 6) 0% methylated (HSD DNA, 99-100% unmethylated), and 7) sample lacking template DNA from the first PCR reaction (diluted 1 to 5) were present. All of the above samples were analyzed with primer sets for both methylated and unmethylated DNA. 
     Preparation of Standards 
     A stock of multiplexed DNA was prepared as follows: PCR was performed in a reaction mix that contained all six gene primer pairs as well as a mixture of 50 ng each of sodium bisulfite treated genomic MDA-MB231 and HSD DNA. Serial dilutions of this stock DNA were used to establish a standard curve in the quantitative real-time PCR reaction (Rxn 2). To do this, the cycle threshold (C T ; the cycle in which the signal exceeds the background) of each dilution was determined during the round two QM-MSP reaction and then plotted to generate a line for the standard curve. For each reaction plate, the standards were diluted from the same stock stored frozen at −80° C. for all assays and new dilutions were made each time. 
     Copy Number Controls. 
     For the preparation of this control, unmethylated (U) or methylated (M) genomic DNAs were amplified for each gene in a separate reaction using a gene-specific pair of methylation-status specific external primers (Forward, Reverse and Probe) and 50 ng of sodium bisulfite-treated genomic DNA derived from either MDA-MB231 (100% methylated) or human sperm DNA (100% unmethylated). A single band was observed by gel electrophoresis. The reaction products were then purified with a Qiaquick® PCR purification kit (Qiagen Inc., Valencia, Calif.), and eluted in 100 μl water. The eluate was quantitated using the NanoDrop spectrophotometer (NanoDrop Technologies, Montchanin, Del.) and the DNA concentration (μg/μl) was determined based on the OD 260 . The molecular weight (μg/μmol) of the PCR product was calculated using Biopolymer Calculator v4.1.1 (C. R. Palmer available on the world wide web at the address paris.chem.yale.edu/extinct). Using Avogadro&#39;s definition (1 μmol=6×10 17  molecules), DNA copies per microliter were calculated: DNA copies/μl=(DNA concentration)(6×10 17  molecules)/molecular weight. The concentration of each gene template control was adjusted to 3×10 10  copies per microliter in 1 mg/ml salmon sperm carrier DNA, and stored at −80° C. Unmethylated and methylated DNA for each of the six genes were obtained and stored separately. A cocktail was then prepared that contained 4×10 6  copies per microliter of each gene in 1 mg/ml salmon sperm DNA. For each reaction plate, the DNA cocktail was then diluted 100-fold to 40,000 copies per well. Salmon sperm DNA did not interfere with the PCR reaction (data not shown). A known quantity of DNA (40,000 copies per well, denoted “40K” control), prepared as described above, was used to transform the standard curve to represent copy number. The cycle threshold (C T ) of the 40 K control was determined during the Q-MSP reaction and plotted on the line obtained for the standard curve. The copy number for each dilution was then “back calculated,” based on where the 40K C T  intersected the standard curve. Sample 40 K had approximately equal amounts of unmethylated and methylated DNA for each of the six genes along with carrier salmon sperm DNA (10 μg/ml). 
     Calculation of % Methylation 
     The relative amount of methylation for each unknown sample was calculated as % M=(100)(# copies M/# copies methylated+unmethylated DNA). To determine the # copies of methylated and unmethylated DNA, sample DNA was mixed with Q-MSP reaction buffer following the multiplex reaction, then assayed with methylated primers and unmethylated primers (in separate wells) in the round two QM-MSP reaction, and a C T  was determined for each. Using the ABI Prism SDS 2.0 software supplied by Applied Biosystems with the 7900 HT Sequence Detector, the number of copies of methylated and unmethylated DNA was extrapolated from the respective standard curves using the sample C T  and applying the absolute quantification method according to the manufacturer&#39;s directions. Only values falling within the range covered by the standard curve were accepted. 
     Statistical Analysis and Graphical Representation of Data 
     Statistical analyses and plotting of data were performed using GraphPad Prism (GraphPad Software Inc., San Diego, Calif.). P values&lt;0.05 were considered significant and all tests were two-tailed. The nonparametric Mann-Whitney test was used to test whether the samples are from identical distributions, indicating their medians are equal. Sample means were compared using the unpaired t test, assuming unequal variances (Welch&#39;s correction). For testing of means, data were transformed as a function of Ln e  (% M+1) where stated to fulfill the assumption of normality. The Fisher&#39;s exact test was used to test whether the differences between the incidence of positivity for methylation in tumor and normal were significant. 
     Results 
     Quantitative-Multiplex PCR (QM-MSP) Assay is a Two-Step Reaction: 
     Validation of the QM-MSP Assay— 
     Multiplex PCR, the first step in the QM-MSP assay, was accomplished by performing two sequential PCR reactions as shown schematically in  FIG. 1 ). In the first PCR reaction, a cocktail of six pairs of gene-specific primers were used to co-amplify Cyclin D2, RARB, TWIST, RASSF1A, HIN1, and Actin (as a control) (Tables 1 and 2). These external primer pairs were complimentary to the sequences flanking the CpG islands that were to be queried in the second PCR reaction. External primers were selected to exclude CG dinucleotides, Thereby rendering DNA amplification independent of the methylation status. 
     Both U and M Primers are Equally Efficient in Amplifying DNA— 
     Primer sets specifically for methylated (M) and unmethylated (U) DNA were designed for comparable performance; to confirm this, the delta C T  (C T M−C T  U) was plotted as a function of sample dilution over a wide range of dilutions (10 −3  to 10 −8 ) of the standard stock HSD/231 DNA. Analyses were performed as is shown for RASSF1A in  FIGS. 2A-B . The delta C T  was approximately the same for all dilutions, as shown by the horizontal nature of the line, indicating that the primer sets were equally efficient over 5 logs of template quantities ( FIG. 2A ). In addition, for both unmethylated and methylated standard curves the slopes are approximately −3.33, which is reflective of a two-fold increase in PCR product per cycle during the linear phase of real-time PCR. Finally, a correlation coefficient (R2) of 0.999 indicates that linearity exists over the entire range of template concentration as shown in  FIG. 2B ). Similar results were obtained for the other five genes in our study (data not shown). 
     Specificity and Sensitivity— 
     To assess the sensitivity and specificity of the QM-MSP method, a mixing experiment was performed using column-purified, PCR-amplified fragments of sodium bisulfite-modified DNA as template as shown in Table 3 below. The amount of unmethylated DNA was kept constant (100,000 copies per well) and the amount of methylated DNA was decreased (1000-0.1 copy per well). Although the general efficiency of real time PCR is known to fall off at less than 100 copies, it was expected that some level of methylation would be detected below 100 copies, although probably not in a linear manner. For RASSF1A and TWIST, methylation was detected at 1 methylated in 100,000 unmethylated copies and for Cyclin D2 and HIN1 at 10 methylated in 100,000 unmethylated copies. Therefore, the overall sensitivity of the method is 1-10 in 100,000. 
     
       
         
           
               
             
               
                 TABLE 3 
               
               
                   
               
               
                 Determination of the sensitivity of QM-MSP. 
               
               
                   
               
             
            
               
                   
               
            
           
           
               
               
            
               
                 # Copies M and U 
                 % Methylation c   
               
            
           
           
               
               
               
               
               
            
               
                 Template a   
                 RASSF1A 
                 Twist 
                 Hin-1 
                 Cyclin D2 
               
               
                   
               
               
                 1000/100,000 
                 0.9220 
                 2.7604 
                 4.8024 
                 1.5760 
               
               
                  100/100,000 
                 0.0602 
                 0.2482 
                 0.6273 
                 0.1525 
               
               
                  10/100,000 
                 0.0078 
                 0.0272 
                 0.0024 
                 0.0025 
               
               
                   1/100,000 
                 0.0072 
                 0.0012 
                 0.0000 
                 0.0000 
               
               
                   .1/100,000 
                 0.0000 
                 0.0000 
                 0.0000 
                 0.0000 
               
               
                 HSD (100% U control) 
                 0.0000 
                 0.0003 
                 0.0000 
                 0.0000 
               
               
                 231 (100% M control) 
                 99.9981 
                 100.0000 
                 100.0000 
                 100.0000 
               
               
                 Water 
                 0.0000 
                 0.0000 
                 0.0000 
                 0.0000 
               
               
                   
               
            
           
           
               
               
               
            
               
                 #Copies M and U b   
                 RASSF1A 
                 Twist 
               
               
                   
               
               
                 300/29700 
                 0.7823 
                 1.2190 
               
               
                 30/2970 
                 0.7195 
                 0.9376 
               
               
                 3/297 
                 0.2390 
                 0.1451 
               
               
                   
               
               
                   a,b Purified methylated (M) and unmethylated (U) stock DNA template were mixed in the proportions indicated. 
               
               
                   a Unmethylated DNA was kept constant as the amount of methylated DNA was decreased. 
               
               
                   b A 1% M control was kept constant as the total quantity of DNA decreased. 
               
               
                   c The % Methylation of RASSF1A, TWIST, HIN1 and Cyclin D2 from the QM-MSP assay is shown. The assay sensitivity is 1-10 in 100,000 for methylated DNA and detects as few as 1-3 copies of methylated DNA. 
               
            
           
         
       
     
     The highly specific performance of the methylated primers was demonstrated using the HSD control (100% unmethylated DNA), and 0.1/100,000 sample (diluted to &lt;1 copy of methylated in the presence of 100,000 copies of unmethylated DNA), both of which showed 0% M in the QM-MSP reaction (Table 3,  FIG. 3 ). Likewise, no unmethylated signal (0% U) was detected in MDA-MB231 methylated DNA control (100% methylated DNA). It was expected that the 1000/100,000 sample would be read as 1% methylated (1000 copies of methylated and 100,000 copies of unmethylated). That some samples were slightly higher (e.g. 4.8% for HIN1, 2.8% for TWIST) probably reflects difficulty in accurately diluting samples from a starting concentration of 3×10 10  copies per μl (diluted over 5-10 logs). 
     To characterize the behavior of the QM-MSP assay below the lower limit of linearity (specifically, whether a 1% M template produces a 1% M assay result as the total quantity of DNA template diminishes), a “1%” standard was serially diluted and samples were tested beginning at a template quantity estimated to contain 300 copies of methylated DNA to ˜29700 unmethylated copies (300/29700), using column-purified DNA as a template (Table 3). The lowest quantity tested contained three copies methylated to ˜297 copies unmethylated DNA (3/297). The results for RASSF1A and TWIST (Table 3) revealed that at ratios of 300/29700 and 30/2970 total copies, the assay result (% M) was approximately 1% for each. Methylation was still detectable at the lowest ratio template quantity tested, at three copies of methylated DNA, consistent with the previous experiment (1 copy of methylated DNA was detected in 100,000 copies of unmethylated DNA). We found a bias towards underreporting of the % M below 30 copies of methylated DNA, probably reflecting the relative lack of efficiency of the methylated reaction compared to the unmethylated reaction that contained nearly 100-fold more copies of the gene (Table 3). This result was predicted, since linearity is generally known to be lost below 100 copies of DNA template in real-time PCR. 
     Genomic DNA is a more challenging template than PCR-amplified DNA because breakage of genomic DNA is known to occur in the process of sodium bisulfate conversion. To evaluate the sensitivity of the QM-MSP method with genomic DNA, DNA mixing experiments were performed with approximately 40 pg methylated DNA (˜13 copies derived from 231 cell DNA) and 600-60000 pg unmethylated genomic DNA (˜200-20,000 copies of HSD). Using the QM-MSP method, 40 pg of methylated RASSF1A genomic DNA was easily detected even in the presence of a 1500-fold excess of unmethylated DNA as shown in  FIG. 4 ), when the conversion estimate of 6 pg/2 copies/cell of DNA was used. 
     Comparison Between QM-MSP and Q-MSP 
     It is possible that performing a two-step multiplex PCR method could yield results that differed from those obtained with a direct one-step PCR method because of the addition of the multiplex step. We performed QM-MSP and direct Q-MSP assay on a panel of five tumor DNAs and calculated the percentage of methylation by the (U+M) method to estimate total DNA. With few exceptions, there was excellent concordance between the percentage of methylation values obtained for the RASSF1A, TWIST, HIN1 or Cyclin D2 genes (Table 4). 
     
       
         
           
               
             
               
                 TABLE 4 
               
             
            
               
                   
               
               
                 Comparison between Q-MSP and QM-MSP 
               
            
           
           
               
               
               
            
               
                   
                 % M 
                   
               
            
           
           
               
               
               
            
               
                   
                 Q- 
                 QM- 
               
               
                   
                 MSP 
                 MSP 
               
               
                   
                   
               
            
           
           
               
               
               
            
               
                 RASSF1A 
                   
                   
               
               
                 1 
                 95 
                 99 
               
               
                 2 
                 80 
                 81 
               
               
                 3 
                 39 
                 41 
               
               
                 4 
                 12 
                 21 
               
               
                 5 
                 28 
                 34 
               
               
                 HSD 
                 0 
                 0 
               
               
                 231  
                 100 
                 100 
               
               
                 Water 
                 0 
                 0 
               
               
                 TWIST 
               
               
                 1 
                 96 
                 70 
               
               
                 2 
                 0 
                 0 
               
               
                 3 
                 54 
                 26 
               
               
                 4 
                 1 
                 3 
               
               
                 5 
                 0 
                 5 
               
               
                 HSD 
                 0 
                 0 
               
               
                 231  
                 100 
                 100 
               
               
                 Water 
                 0 
                 0 
               
               
                 HIN1 
               
               
                 1 
                 95 
                 82 
               
               
                 2 
                 81 
                 74 
               
               
                 3 
                 82 
                 48 
               
               
                 4 
                 41 
                 16 
               
               
                 5 
                 47 
                 43 
               
               
                 HSD 
                 0 
                 0 
               
               
                 231  
                 100 
                 100 
               
               
                 Water 
                 0 
                 0 
               
               
                 Cyclin 
               
               
                 D2 
               
               
                 1 
                 47 
                 25 
               
               
                 2 
                 0 
                 0 
               
               
                 3 
                 1 
                 0 
               
               
                 4 
                 19 
                 22 
               
               
                 5 
                 2 
                 0 
               
               
                 HSD 
                 0 
                 0 
               
               
                 231  
                 100 
                 100 
               
               
                 Water 
                 0 
                 0 
               
               
                   
               
            
           
         
       
     
     The percentage of methylation (% M) was calculated as: (the number of copies of methylated DNA divided by the number of copies of unmethylated DNA+methylated DNA)×100, using absolute quantitation. The positive control for unmethylated DNA was human sperm DNA (HSD), and for methylated DNA was MDA MB231 (231). 
     Quantitation of Methylation in Breast Carcinoma and Comparison to Normal Breast Tissue 
     Paraffin-embedded, formalin-fixed tissues from routine reduction mammoplasty (14 to 28 samples each) and frozen primary breast carcinoma tissues (19 to 21 samples each) were analyzed by QM-MSP for gene promoter hypermethylation of RASSF1A, TWIST, Cyclin D2, and HIN1 (Table 5,  FIGS. 5A-B ). Head to head comparison of DNA extracted from frozen or fixed tissue showed no significant differences in methylation (data not shown). RASSF1A hypermethylation ranged from 0-71% (mean=18.5%) in tumors and 0-56% (mean=2.6%) in normal tissues (p=0.0001); TWIST hypermethylation ranged from 0-72% (mean=21.1%) in tumors and 0-1.6% (mean=0.11%) in normal tissues (p=0.0001); HIN1 hypermethylation ranged from 0-82.2% (mean=24.5%) in tumors, and 0-18% (mean=2.3%) in normal tissues (p=0.003); and Cyclin D2 hypermethylation ranged from 0-44.5% (mean=5.0%) in tumors, and 0-0.2% (mean=0.02%) in normal tissues (p=0.02). Highly significant differences in the medians were also present for all genes, RASSF1A (p=0.0001), TWIST (p=0.001), HIN1 (p=0.003), and Cyclin D2 (p=0.0009) (using the Mann-Whitney test on untransformed data). 
     A laboratory cutoff (% M) was established for each gene such that about 90-95% of normal breast tissues would be at or below the cutoff (Table 5). Using the cutoff of 2% M for RASSF1A and HIN1, 0.5% for TWIST, and 0.2% for Cyclin D2 in normal tissues, values above the cutoff were considered “positive” for hypermethylation. Among tumors, 68% (13 of 19) were positive for RASSF1A, 67% (14 of 21) for TWIST, 57% (12 of 21) for Cyclin D2, and 57% (12 of 21) for HIN1. By comparison, 7% (2 of 28) of normal mammoplasty samples were positive for RASSF1A, 6% (1 of 18) for TWIST, 7% (1 of 16) for Cyclin D2, and 14% (2 of 14) for HIN1. Some samples had low-level methylation that was below the cutoff. Using 0% M as a cutoff for each gene, tumor vs. normal hypermethylation was 89% positive vs. 7% for RASSF1A, 68% vs 17% for TWIST, 71% vs. 12% for Cyclin D2, and 76% vs. 21% for HIN1. Using these cutoffs, a significant difference in the incidences of positivity between tumor and normal tissues was observed (RASSF1A p&lt;0.00002, TWIST p&lt;0.0002, Cyclin D2p&lt;0.002, and HIN1 p&lt;0.02; Fisher&#39;s exact). 
                     TABLE 5                  Normal versus Malignant Breast Tissues- Quantitation       of the Level of Gene Promoter Hypermethylation                                                                 Positive for                       Lower 95%   Upper 95%   methylation a             Range %   Median %   Mean ± SEM %   CI %   CI %   # (%)                                                     Normal                               Breast       RASSF1A   0-56   0 b     2.6 ± 2.0   (0)   6.7   2/28 (7)       TWIST    0-1.6   0 c     0.11 ± 0.09   (0)   0.29   1/18 (6)       HIN1   0-18   0 d     2.3 ± 1.5   (0)   5.5    2/14 (14)       Cyclin D2    0-0.2   0 e     0.019 ± 0.014   (0)   0.48   1/16 (7)       Breast       Carcinoma       RASSF1A   0-71     7.0 b     18.5 ± 4.7        8.7   28.2   13/19 (68)       TWIST   0-72     5.0 c     21.1 ± 5.5        9.6   32.6   14/21 (67)       HIN1   0-82     9.9 d     24.5 ± 6.1        11.8   37.3   12/21 (57)       Cyclin D2   0-44     0.26 e     5.0 ± 2.5   (0)   10.3   12/21 (57)                 a Based on cutoffs of 2% M for RASSF1A and HIN1, 0.5% M for TWIST, and 0.2% M for Cyclin D2;         b p = 0.0001 for RASSF1A,         c p = 0.001 for TWIST,         d p = 0.003 for HIN1, and         e p = 0.0009 for Cyclin D2.            
Cumulative Gene Promoter Hypermethylation Scores in Primary Breast Cancer
 
     To determine the cumulative amount of gene promoter hypermethylation, QM-MSP was performed and the sum of all % M within the panel of genes was used to provide an overall cumulative score for each sample. This was represented graphically relative to MDA-MB231 DNA, which is 100% methylated for RASSF1A, TWIST, Cyclin D2 and HIN1. Therefore, this control DNA has a relative score of 400 in  FIG. 6A . The cumulative methylation profiles of nine normal mammoplasty samples were compared to those of 19 invasive tumors (Table 6;  FIG. 6 ). Normal tissues ranged from 0-18 units, and tumors ranged from 1-248. Among the nine normal tissues tested for four genes (36 values) the cumulative score had a mean of 2.61±2.05 (median=0) ( FIG. 6B ). Among the 19 tumors tested for four genes (76 values) the cumulative score had a mean of 72.8±15.03 units (median=74) out of a possible 400 units (as above, Table 6 and  FIGS. 6A and 6B ). The difference in log-transformed means between normal and malignant breast tissue was highly significant (p−0.0001, unpaired t test with Welch&#39;s correction). 
     We explored the use of 4.7 units as a cumulative score cutoff value. This was based on the individual gene cutoffs above (2% each for RASSF1A and HIN1, 0.5% for TWIST and 0.2% for Cyclin D2=4.7%). Using this cutoff, 84% (16) tumor samples were positive. Although 3 of 19 tumors fell below the cutoff, all of the “negative” tumors were methylated at low levels for one or more genes in this panel ( FIG. 6A ). Among normal samples, 89% (8) were negative. Thus in this group of 28 samples (9 normal and 19 tumor), the sensitivity of detection of tumor was 0.84 and specificity was 0.89, an overall accuracy of 0.86 (24 of 28). 
     
       
         
           
               
             
               
                 TABLE 6 
               
               
                   
               
             
            
               
                 Cumulative Promoter Hypermethylation in Normal, 
               
               
                 Adjacent “Normal” and Malignant Breast Tissues 
               
            
           
           
               
               
               
               
               
               
               
               
            
               
                   
                   
                   
                   
                 Lower 
                 Upper 
                 Positive for 
                   
               
               
                   
                 Range 
                 Median 
                 Mean ± SEM 
                 95% CI 
                 95% CI 
                 methylation b   
               
               
                 Tissue 
                 Units a   
                 Units a   
                 Units a   
                 units a   
                 units a   
                 # (%) 
                 n 
               
               
                   
               
               
                 Normal 
                 0-18  
                  0 c   
                 2.61 ± 2.05 d   
                 (0)  
                 7.35 
                  1/9 (11) 
                 9 
               
               
                 Carcinoma 
                 0-248 
                 74 c   
                 72.8 ± 15.03 d   
                 41.3 
                 104.4 
                 16/19 (84) 
                 19 
               
               
                   
               
            
           
           
               
            
               
                 Normal Mammoplasty and Malignant Breast Tissues 
               
               
                 Comparison of Paired Tumor and Adjacent Normal Breast Epithelium 
               
            
           
           
               
               
               
               
               
               
               
               
            
               
                   
                   
                   
                   
                 Lower 
                 Upper 
                 Positive for 
                   
               
               
                   
                 Range 
                 Median 
                 Mean ± SEM 
                 95% CI 
                 95% CI 
                 methylation §   
               
               
                 Tissue 
                 Units* 
                 Units* 
                 Units* 
                 units* 
                 units* 
                 # (%) 
                 n 
               
               
                   
               
               
                 Adjacent 
                 2-29  
                  9 e   
                  11.7 ± 4.07 
                 1.2 
                 22.1 
                 4/6 (67)  
                 6 
               
               
                 “Normal” 
               
               
                 Carcinoma 
                 5-258 
                 133 e   
                 129.2 ± 39.9 
                 26.5 
                 231.8 
                 6/6 (100) 
                 6 
               
               
                   
               
               
                   a Relative units of methylation is the sum of percent methylation for each of four genes in the panel; 
               
               
                   b Based on a cutoff of ≦ 4.7 units. 
               
               
                   c p = 0.0001, 
               
               
                   d p = 0.0002; 
               
               
                   e p = 0.03. 
               
            
           
         
       
     
     In an independent experiment, six pairs of tumor and adjacent tissue from the surgical margins, which were histologically normal, were examined to determine the cumulative amount of gene promoter hypermethylation in RASSF1A, TWIST, Cyclin D2, and HIN1 (Table 65,  FIG. 7 ). The cumulative methylation ranged from 2-29 units within adjacent normal tissues and 5-258 units within tumor tissues, out of a possible 400 units ( FIG. 7 ). Using the cutoff established for cumulative normal in mammoplasty samples (≦4.7 units, see above), all six tumors were positive. The adjacent “normal” tissues were also positive in four of six individuals. While the cumulative methylation levels within adjacent “normal” tissues were significantly lower than the nearby tumor (p=0.03 by Mann-Whitney), the tumor-adjacent tissues had a significantly higher level of methylation than normal mammoplasty samples (p=0.01 by Mann-Whitney; Table 6 and  FIG. 7 ). 
     Detection of Multi-Gene Promoter Hypermethylation in Breast Duct Cells 
     To test the applicability of this test to small clinical samples, we extracted DNA from ductal lavage (DL) cells that had been scraped from cytospin preparations after cytological evaluation and performed QM-MSP to test for RASSF1A, TWIST, Cyclin D2, RAR-β, and HIN1 gene promoter hypermethylation (Table 7,  FIG. 8 ). The total number of epithelial cells present in the samples varied from 50-1000. The level of gene promoter methylation was quantitated for each sample and the cumulative promoter methylation profile was established. High level hypermethylation was detected in two of four cases of DCIS. Among diagnostically benign samples, six of seven showed no cumulative hypermethylation at all, compared to one of seven which revealed low level RASSF1A methylation (Table 7 and  FIG. 8 ). 
     
       
         
           
               
             
               
                 TABLE 7 
               
             
            
               
                   
               
               
                 Quantitative Multiplexed Methylation-Specific PCR Analysis of Ductal Breast Cells 
               
            
           
           
               
               
            
               
                 % Methylation 
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 ID 
                 RASSF1A 
                 TWIST 
                 Cyclin D2 
                 HIN1 
                 RARB 
               
               
                   
               
            
           
           
               
               
               
            
               
                 Ductal Lavage Cells From High Risk Women  a   
                 Cytology 
                 Mammography 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
               
            
               
                 1 
                 0 
                 0 
                 0 
                 0 
                 0 
                 Benign 
                 Normal 
               
               
                 2 
                 0 
                 0 
                 0 
                 0 
                 0 
                 Benign 
                 Normal 
               
               
                 3 
                 0 
                 0 
                 0 
                 0 
                 0 
                 Benign 
                 Normal 
               
               
                 4 
                 0 
                 0 
                 0 
                 0 
                 0 
                 Benign 
                 Normal 
               
               
                 5 
                 0 
                 0 
                 0 
                 0 
                 0 
                 Benign 
                 Normal 
               
               
                 6 
                 0 
                 0 
                 0 
                 0 
                 0 
                 Benign 
                 Normal 
               
               
                 7 
                 0.4 
                 0 
                 0 
                 0 
                 0 
                 Benign 
                 Normal 
               
               
                   
               
            
           
           
               
               
               
            
               
                 Ductal Lavage Cells From Women With Carcinoma  b   
                 Cytology 
                 Histopathology 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
               
            
               
                 8 
                 0 
                 0 
                 0 
                 0 
                 0 
                 Benign 
                 DCIS 
               
               
                 9 
                 0 
                 0 
                 0 
                 0 
                 0 
                 Benign 
                 DCIS 
               
               
                 10 
                 4 
                 0 
                 12 
                 75 
                 0 
                 Inadequate 
                 Invasive Carcinoma 
               
               
                 11 
                 47 
                 31 
                 4 
                 65 
                 89 
                 Markedly atypical 
                 Invasive Carcinoma 
               
               
                   
               
            
           
         
       
     
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     Although the invention has been described with reference to the above example, it will be understood that modifications and variations are encompassed within the spirit and scope of the invention. Accordingly, the invention is limited only by the following claims.