(19)
(11)EP 3 146 333 B1

(12)EUROPEAN PATENT SPECIFICATION

(45)Mention of the grant of the patent:
29.04.2020 Bulletin 2020/18

(21)Application number: 15712965.1

(22)Date of filing:  31.03.2015
(51)International Patent Classification (IPC): 
G01N 33/50(2006.01)
G01N 33/574(2006.01)
(86)International application number:
PCT/EP2015/057135
(87)International publication number:
WO 2015/176860 (26.11.2015 Gazette  2015/47)

(54)

DIAGNOSTIC OF CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML) BY FLOW CYTOMETRY

DIAGNOSE VON CHRONISCHER MYELOMONOZYTÄRER LEUKÄMIE (CMML) MITTELS DURCHFLUSSZYTOMETRIE

DIAGNOSTIC DE LA LEUCÉMIE MYÉLOMONOCYTIQUE CHRONIQUE (CMML) PAR CYTOMÉTRIE DE FLUX


(84)Designated Contracting States:
AL AT BE BG CH CY CZ DE DK EE ES FI FR GB GR HR HU IE IS IT LI LT LU LV MC MK MT NL NO PL PT RO RS SE SI SK SM TR

(30)Priority: 22.05.2014 EP 14305755

(43)Date of publication of application:
29.03.2017 Bulletin 2017/13

(73)Proprietor: Institut Gustave Roussy
94800 Villejuif (FR)

(72)Inventors:
  • SELIMOGLU-BUET, Dorothée
    F-92130 Issy Les Moulineaux (FR)
  • WAGNER-BALLON (ÉPOUSE TERRAZZONI), Orianne
    F-92330 Sceaux (FR)
  • SOLARY, Eric
    F-75013 Paris (FR)
  • DROIN, Nathalie
    F-94800 Villejuif (FR)

(74)Representative: Regimbeau 
20, rue de Chazelles
75847 Paris Cedex 17
75847 Paris Cedex 17 (FR)


(56)References cited: : 
WO-A1-2013/139479
  
  • MARWAN QUBAJA ET AL: "The detection of CD14 and CD16 in paraffin-embedded bone marrow biopsies is useful for the diagnosis of chronic myelomonocytic leukemia", VIRCHOWS ARCHIV, SPRINGER, BERLIN, DE, vol. 454, no. 4, 26 February 2009 (2009-02-26), pages 411-419, XP019715682, ISSN: 1432-2307
  • Y. XU ET AL: "Flow Cytometric Analysis of Monocytes as a Tool for Distinguishing Chronic Myelomonocytic Leukemia From Reactive Monocytosis", AMERICAN JOURNAL OF CLINICAL PATHOLOGY, vol. 124, no. 5, 1 November 2005 (2005-11-01), pages 799-806, XP055154987, ISSN: 0002-9173, DOI: 10.1309/HRJ1XKTD77J1UTFM
  • S. VUCKOVIC ET AL: "Dendritic cells in chronic myelomonocytic leukaemia", BRITISH JOURNAL OF HAEMATOLOGY, vol. 105, no. 4, June 1999 (1999-06), pages 974-985, XP055154992, ISSN: 0007-1048, DOI: 10.1046/j.1365-2141.1999.01431.x
  • MARIAN A ROLLINS-RAVAL ET AL: "The value of immunohistochemistry for CD14, CD123, CD33, myeloperoxidase and CD68R in the diagnosis of acute and chronic myelomonocytic leukaemias", HISTOPATHOLOGY, vol. 60, no. 6, 20 February 2012 (2012-02-20), pages 933-942, XP055155000, ISSN: 0309-0167, DOI: 10.1111/j.1365-2559.2012.04175.x
  • MOESTRUP S K ET AL: "Surface expression of the alpha2-macroglobulin receptor on human malignant blood cells", LEUKEMIA RESEARCH, NEW YORK,NY, US, vol. 16, no. 3, 1 March 1992 (1992-03-01), pages 227-234, XP026298003, ISSN: 0145-2126, DOI: 10.1016/0145-2126(92)90060-K [retrieved on 1992-03-01]
  
Note: Within nine months from the publication of the mention of the grant of the European patent, any person may give notice to the European Patent Office of opposition to the European patent granted. Notice of opposition shall be filed in a written reasoned statement. It shall not be deemed to have been filed until the opposition fee has been paid. (Art. 99(1) European Patent Convention).


Description

BACKGROUND OF THE INVENTION



[0001] Hematopoiesis is maintained by a hierarchical system where hematopoietic stem cells (HSCs) give rise to multipotent progenitors, which in turn differentiate into all types of mature blood cells. Clonal stem-cell disorders in this system lead to Acute Myeloid Leukemia (AML), Myeloproliferative Neoplasms (MPNs), Myelodysplastic Syndromes (MDS) and Myelodysplastic/Myeloproliferative disorders.

[0002] Among these disorders, myelodysplastic/myeloproliferative neoplasms include four myeloid diseases grouped in 1999 by the WHO: chronic myelomonocytic leukemia (CMML), juvenile myelomonocytic leukemia (JMML), atypical chronic myeloid leukemia (aCML) and unclassified myelodysplastic/myeloproliferative syndromes (U- MDS/MPS) (Vardiman et al., Blood 114:937-951, 2009).

[0003] CMML is a rare disorder with an estimated incidence of 1 case per 100 000 persons per year. Median age at presentation is 70 years, and presenting manifestations may include those of bone marrow failure and systemic symptoms. Hepatomegaly and splenomegaly are found in some patients, and the white blood cell count is typically increased.

[0004] The current diagnosis of CMML relies on the criteria defined by WHO in 2008 (Vardiman et al., Blood 114:937-951, 2009). CMML definition is based on only one positive criterion, which is the elevation of monocytes to more than 1 x 109/L, measured over at least 3 months. Negative criteria exclude i) acute leukemia by cytological examination of the blood and bone marrow showing a percentage of blast cells lower than 20%, ii) chronic myeloid leukemia by demonstrating the lack of BCR-ABL fusion gene, and iii) the so-called Myeloid and Lymphoid Neoplasms with Eosinophilia (MLN-Eo) when eosinophilia is combined with monocytosis by checking the lack of gene rearrangement involving a PDGFR (Platelet-Derived Growth Factor Receptor) or FGFR (Fibroblast Growth Factor Receptor) gene.

[0005] However, some patients with myelofibrosis (MF) in proliferative phase and some patients with chronic inflammatory disease or late stage metastatic solid tumor and reactive monocytosis, meet this criteria, whereas patients with dysplastic CMML and low white blood cell (WBC) count and so less than 1 x 109/L of monocytes, do not. The differentiation with unclassified MDS/MPN can thus be problematic. Genetic analyses failed to identify a specific cytogenetic or genetic abnormality in CMML, although a characteristic molecular fingerprint based on the high frequency of mutations in TET2, SRSF2 and ASXL1 genes, has been established.

[0006] Marwan Qubaja et al, Virchows Archivn Springer, 2009, 454:411-419, relates to the detection of CD14 and CD16 for diagnosing CMML in paraffin-embedded bone marrow biopsies. In particular, they assayed granulocytic populations because striking differences in pmns numbers expressing MPO, CD15 and CD16 were observed in CMML patients specifically.

[0007] Additional efforts are needed to improve the disease definition and facilitate its rapid and accurate identification in daily clinical practice. Thus there is still a need for a new diagnosis method of CMML which is rapid, efficient and simple.

FIGURES



[0008] 

Figure 1: Overview of the gating strategy for human monocyte subsets analysis in PBMC by flow cytometry. (A) Monocytes selection based on morphological parameters (FSC versus SSC). (B) Monocytes defined as CD45+/ SSC intermediate cells. (C) Granulocytes and B cells selected as CD24+ cells. (D) Isolated CD16high granulocytes (PMN) and NK cells. (E) CD16 and CD14 staining. (F) Identification of the three monocytes subsets: CD14+ CD16-(classical), CD14+ CD16+ (intermediate) and CD14low CD16+ (non classical) monocytes.

Figure 2: Overview of the exclusion gating strategy for human monocyte subsets analysis in total blood cells by flow cytometry. A) Monocytes selection on morphological parameters (FSC versus SSC). (B) Selection of CD2+ T cells. (C) NK cells as CD56+ cells. (D) Isolated CD16high granulocytes (PMN). (E) Selection of B cells and granulocytes as CD24+ cells. (F) Monocyte population obtained on CD45 vs SSC dot-plot as CD45+/ SSC intermediate. (G) CD16 and CD14 staining (H) Identification of the three monocytes subsets: CD14+ CD16- (classical), CD14+ CD16+ (intermediate) and CD14low CD16+ (non classical) monocytes.

Figure 3: Monocytes population characterization. (A) MGG cytospin preparation of sorted monocytes according to their CD14 and CD16 expression profile. (B) Box plots showing surface marker expression, as stain index = (Median of Monocyte population - Median of Lymphocyte population (as negative peak)) / 2 x standard deviation of negative peak) in different monocyte subsets in healthy donors (young and age-matched controls). Different scales were used for different markers. (C) RT-PCR.

Figure 4: Representation of monocyte subsets from blood of (A) young controls, (B) aged-match controls, (C) CMML or (D, E, F, G, H, I, J, K) various hemopathies by flow cytometry based on CD14 and CD16 expression. Numbers depict percentage of distinct monocyte subsets.

Figure 5: Analysis of MO1 population in learning and validation cohort. (A) Dot plot of classical monocytes percentage (MO1) (upper panel) and the "intermediate" monocyte (M02) and the "non-classical" monocyte (MO3) (lower panel) for learning cohort. Black line represents mean ± SEM. (B) Receiver operating characteristic (ROC) curve analysis of diagnostic sensitivity and specificity of the MO1 percentage in blood. (C) Dot plot of classical monocytes percentage (MO1) for validation cohort. Black line represents mean ± SEM.

Figure 6: Representation of monocyte subsets from blood of (A) Responders and (B) No responders, by flow cytometry based on CD14 and CD16 expression. Numbers depict percentage of distinct monocyte subsets.

Figure 7: Representation of the MO1/MO3 ratio for the learning cohort. (A) Percentage of M01/M03 monocytes in a learning cohort of CMML compared to healthy blood donors (Co), age-matched healthy donors (Aged-Co), patients with diverse hematological malignancies (non-CMML) and those with a reactive monocytosis (reactive). (B) Receiver operating characteristic (ROC) curve analysis of diagnostic sensitivity and specificity of the M01/M03 percentage in blood.


DETAILED DESCRIPTION



[0009] Unless specifically defined, all technical and scientific terms used herein have the same meaning as commonly understood by a skill artisan in chemistry, biochemistry, cellular biology, molecular biology, and medical sciences.

[0010] The present inventors have surprisingly found that CMML patients display a higher proportion of a specific class of monocytes.

[0011] More specifically, the present inventors have found that the population of monocytes expressing CD14 but not CD16 (the so-called "classical" monocytes or CD14+/CD16-monocytes) are hyper-represented in the blood of CMML patients. The proportion of this class of monocytes in the blood of CMML patients is much higher than in blood of healthy subjects or of patients affected with other blood diseases. As such, the proportion of classical monocytes is sufficient to discriminate between CMML and other blood diseases, such as e.g. MDS or MPN or reactive monocytosis. Therefore, the proportion of CD14+/CD16-monocytes in the blood can be used as a positive diagnosis criterion for CMML.

[0012] The invention thus enables the skilled person to identify those subjects who are suffering from CMML by simply quantifying the CD14+/CD16- monocytes in a blood sample from said subjects. Whereas the method of prior art relied on the identification of five criteria, four of which negative, a unique positive criterion is used in the method of the invention. This parameter can be determined in less than 24 hours, instead of the current 3 months. Thus the method of the invention is particularly advantageous because it generates a diagnosis in a very short time and with a very high degree of confidence, whereas the method currently recommended by WHO is both time-consuming and prone to mis-identification. In particular, the method of the invention shows both high sensitivity and high specificity.

[0013] In a first aspect, the present invention thus provides an in vitro method of diagnosis of chronic myelomonocytic leukemia (CMML) in a patient, said method comprising the steps of:
  1. a) Detecting by flow cytometry a monocyte population in a blood or plasma sample of said patient (for example by an exclusion gating strategy),
  2. b) Quantifying by flow cytometry the monocytes expressing high levels of CD14 but not expressing CD16 (CD14+/CD16- monocytes) in said blood or plasma sample,
  3. c) Comparing the value of step b) to a reference value; and
  4. d) Diagnosing CMML based on said comparison.


[0014] A "subject" which may be subjected to the methodology described herein may be any of mammalian animals including human, dog, cat, cattle, goat, pig, swine, sheep and monkey. More preferably, the subject of the invention is human subject; a human subject can be known as a patient. In one embodiment, "subject" or "subject in need" refers to a mammal, preferably a human, that suffers from CMML or is suspected of suffering from CMML or has been diagnosed with CMML. As used herein, a "CMML suffering subject" refers to a mammal, preferably a human, that suffers from CMML or has been diagnosed with CMML. A "control subject" refers to a mammal, preferably a human, which is not suffering from CMML, and is not suspected of being diagnosed with CMML.

[0015] As used herein, the term "biological sample" or "sample" refers to a whole organism or a subset of its tissues, cells or component parts. «Biological sample" further refers to a homogenate, lysate or extract prepared from a whole organism or a subset of its tissues, cells or component parts, or a fraction or portion thereof. The biological sample to be measured by the disclosed test method is not particularly limited, as far as it can be collected from a mammal, preferably from a human; examples include humoral samples such as blood, bone marrow fluid, and lymph fluid, and solid samples such as lymph nodes, blood vessels, bone marrow, brain, spleen, and skin. A "biological sample" can be any tissue which may contain monocytes, e.g., whole blood, plasma, or bone marrow.

[0016] Since monocytes are mostly found in the blood, it is particularly advantageous to use blood as a biological sample for the method of the invention. Indeed, such a blood sample may be obtained by a completely harmless blood collection from the subject and thus allows for a non-invasive diagnosis of CMML. The blood sample used in the method of the invention is preferably depleted of most, if not all erythrocytes, by common red blood cell lysis procedures. The detection is performed on the remaining blood cells, which are white blood cells (e.g., neutrophils, monocytes, lymphocytes, basophiles, etc.) and platelets.

[0017] Any volume used commonly by the person of skills in the art for hematological analyses will be convenient for the present method. For example, the volume of the blood sample can be of 100 µL, 200 µL, 300 µL, 400 µL, 500 µL, 600 µL, 700 µL, 800 µL, 900 µL, or 1000 µL.

[0018] Due to the label of granulocytes by CD16 antibody, it is essential to take in account the number of total granulocytes in the sample. When a blood sample presents a high number of granulocytes, the CD16 antibody is no longer saturating and the labeling of monocytes and granulocytes is not strong enough, and the distinction between CD16 positive cells and negative ones will be difficult to establish. To avoid this problem, when blood samples present more than 12x 109/L of total granulocytes and preferably when blood samples present more than 10x 109/L of total granulocytes, blood samples are preferably diluted to have a final concentration of total granulocytes under 10 x 109/L.

[0019] It is known in the art that morphological changes of blood cells begin after 30 minutes of drawing. Such changes consist in granulocyte swelling, increases of band forms, and or loss of specific granulation sometimes associated with vacuolization, especially in eosinophils and monocytes. It will be clear to the skilled person that the results of the method may be affected by the nature and the extent of the changes taking place. It is therefore preferable that the blood sample used in the method of the invention be fresh. By "a fresh blood sample", it is herein referred to a sample of blood which has been drawn within the previous 48h, 24h or 5 hours, preferably 4 hours, 3 hours, 2 hours, 1 hour, 30 minutes, or 15 minutes. Preferentially, the fresh blood sample of the invention will be kept at 4°C until used.

[0020] As used herein, "diagnosis" or "identifying a subject having" refers to a process of determining if a subject is afflicted with a disease or ailment (e.g., CMML). More specifically, "diagnosing CMML" refers to the process of identifying if a subject suffering from a blood disorder suffers or not from CMML.

[0021] The first step of the method of the invention consists in detecting or purifying the monocyte population in the blood or plasma sample of the tested patient.

[0022] The term "monocytes" refers to a type of leukocytes (representing about 0,1 to 1 x 109/L of circulating leukocytes) produced by the bone marrow from hematopoietic stem cell precursors called monoblasts. They are produced in marrow, circulate briefly in blood, and migrate into tissues where they differentiate further to become macrophages.

[0023] Monocytes belong to the family of the peripheral mononuclear cell of the blood (PBMCs). PBMCs are a critical component in the immune system to fight infection and adapt to intruders. These cells can be extracted from whole blood using ficoll, a hydrophilic polysaccharide that separates layers of blood, which will separate the blood into a top layer of plasma, followed by a layer of PBMCs and a bottom fraction of polymorphonuclear cells (such as neutrophils and eosinophils) and erythrocytes.

[0024] Monocytes are fairly variable in size and appearance, but they show common expression of a number of markers. Three types of monocytes can be identified in human blood, based on the expression of the CD14 and CD16 markers: a) the "classical" monocyte or MO1 is characterized by high level expression of the CD14 cell surface receptor and no expression of CD16 (CD14+/CD16- monocyte), b) the "non-classical" monocyte or MO3 shows low level or no expression of CD14 with additional co-expression of the CD16 receptor (CD14low or- /CD16+ monocyte), and c) the "intermediate" monocyte or MO2 with high level expression of CD14 and the same level of CD16 expression as the MO3 monocytes (CD14+/CD16+ monocytes) (Zawada et al., Blood 118(12):e50-61, 2011; Ziegler-Heitbrock et al., Blood, 116(16): e74-80, 2010; Wong et al., Blood, 118(5): e16-31, 2011).

[0025] Thus most of the monocytes, like classical monocytes, express the cluster of differentiation CD14. This cluster of differentiation has the sequence SEQ ID NO:1 in human (NP_000582.1). Numerous antibodies against human CD14 are commercially available. CD14 is expressed at the surface of the monocytic cells and, at 10 times lesser extent, of the neutrophils. Monocytes are easily identified by specific antigens (e.g., CD14 or CD16) combined with morphometric characteristics (e.g. size, shape, granulometry, etc.). For example, when flow cytometry is used, forward scatter and side scatter information help to identify the monocyte population among other blood cells.

[0026] In a particular disclosure it is advantageous to analyze only the CD45 expressing-cells, in order to eliminate the contaminant blasts and to select mature cells, including all the monocytes. In this embodiment, the monocytes are detected in the CD45+/SSCintermediate population of cell present in the sample. After exclusion of other contaminating populations, the CD14 and CD16 expression can be assessed.

[0027] Thus, in this preferred disclosure the first step of the method of the invention comprises the detection and the measurement of CD45 expression at the cell surface and of the side scatter parameter (SSC) of the cells present in the blood or plasma sample, by flow cytometry.

[0028] The sequence of the cluster of differentiation CD45 is well-known. The CD45 molecules are single chain integral membrane proteins, comprising at least 5 isoforms, ranging from 180 to 220 kDa. They are generated by alternative splicing combinations of three exons (A, B, and C) of the genomic sequence. The non-restricted CD45 antigen, Leucocyte Common Antigen (LCA) consists of an extracellular sequence, proximal to the membrane, which is common to all CD45 isoforms. All the monoclonal antibodies that belong to the CD45 cluster react with this part of the antigen and are able to recognize all CD45 isoforms. These isoforms have extracytoplasmic sequences ranging from 391 to 552 amino acids long, with numerous N-linked carbohydrate attachment sites. The cytoplasmic portion contains two phospho-tyrosine-phosphatase domains.

[0029] Cells expressing CD45 at their surface are all human leucocytes (more precisely, lymphocytes, eosinophils, monocytes, basophils and neutrophils, with different level of expression). This cluster of differentiation is however absent from erythrocytes and platelets.

[0030] SEQ ID NO:7 represents the isoform 1 of the human CD45 (NP_002829.3) and SEQ ID NO:8 represents the isoform 2 of the human CD45 (NP_563578.2). The J33 monoclonal antibody binds to all the CD45 isoforms present on human leucocytes, in particular to isoforms 1 and 2 referred to in SEQ ID NO:7 and 8 respectively.

[0031] Expression of cell surface CD45 on monocytes may be assessed using specific antibodies, in particular using well known technologies such as cell membrane staining using biotinylation (or other equivalent techniques), followed by immunoprecipitation with specific antibodies, flow cytometry, western blot, ELISA or ELISPOT, antibodies microarrays, or tissue microarrays coupled to immunohistochemistry.

[0032] The expression of cell surface CD45 is detected by flow cytometry. Flow cytometry is a useful tool for simultaneously measuring multiple physical properties of individual particles (such as cells). Cells pass single-file through a laser beam. As each cell passes through the laser beam, the cytometer records how the cell or particle scatters incident laser light and emits fluorescence. Using a flow cytometric analysis protocol, one can perform a simultaneous analysis of surface molecules at the single-cell level.

[0033] In this embodiment, the use of fluorochromic agents attached to anti-CD45 antibodies to enable the flow cytometer to sort on the basis of size, granularity and fluorescent light is highly advantageous. Thus, the flow cytometer can be configured to provide information about the relative size (forward scatter or "FSC"), granularity or internal complexity (side scatter or "SSC"), and relative fluorescent intensity of the cell sample. The fluorescent light sorts on the basis of CD45-expressing, enabling the cytometer to identify and enrich for these monocytes.

[0034] It is possible to use all the anti-CD45, anti-CD14 and anti-CD16 antibodies at the same time, provided that these antibodies are labelled with fluorophores emitting in distinguishable wavelengths. This strategy enables the identification of all types of cells with respect to CD45, CD14 and CD16: those expressing CD45 and CD14 and not CD16 (MO1), those expressing CD45 and CD14 and CD16 (MO2 or a part of MO3), and those expressing CD45 and CD16 but not CD14 (most of the MO3).

[0035] In a preferred embodiment, the step a) of the invention requires to detect a substantially pure monocyte population, that is, a population of monocytes that is devoid of contaminant cells. As used herein, "contaminant cells" or "contaminant white blood cells" refer to the white blood cells which are present in the blood sample of the subject and which are not monocytes. Such contaminant cells include granulocytes, e.g. neutrophils, eosinophils, basophils, and lymphocytes, e.g., T cells, NK cells, B cells, but also precursors of these cell types.

[0036] "Granulocytes" are a type of leukocytes characterized by the presence of granules in their cytoplasm. The types of these cells are neutrophils, eosinophils, and basophils.

[0037] "T cells" or "T lymphocytes" are a type of lymphocyte that plays a central role in cell-mediated immunity. They can be distinguished from other lymphocytes, such as B cells and natural killer cells (NK cells), by the presence of a T-cell receptor (TCR) on the cell surface.

[0038] "B cells" or "B lymphocytes" are a type of lymphocyte in the humoral immunity of the adaptive immune system. They can be distinguished from other lymphocytes, such as T cells and natural killer cells (NK cells), by the presence of a protein on the B cells outer cell surface known as a B-cell receptor (BCR).

[0039] "Natural killer cells" (or "NK cells") are a type of cytotoxic lymphocytes that kill cells by releasing small cytoplasmic granules of proteins called perforin and granzyme. They constitute the third kind of cells differentiated from the common lymphoid progenitor generating B and T lymphocytes.

[0040] The remaining white blood cells are identified and counter-selected on the basis of the expression of specific markers.

[0041] The existence of markers which are specific for each of the contaminant cell types enables the identification of these cells in the blood sample of the subject. Identified contaminant cells can then be removed from the sample (i.e., physically) or from the analysis (i.e., by retaining only the data pertaining to the monocyte population for the analysis), so that the study then only focuses on the monocyte population. In this respect, although any of the above-mentioned analytical techniques can be used to identify the said contaminant white blood cells, flow cytometry is particularly adapted for this task, since it enables the skilled person to eliminate the contaminants and analyze the monocyte population with minimal effort.

[0042] In this respect, any antibodies directed against one or more antigens expressed by one or more of the contaminant cells can be used to identify the said contaminant white blood cells. In a particular embodiment, antibodies specific for well-known antigens expressed by granulocytes (CD24, CD15, CD16), T lymphocytes (CD2, CD3), B lymphocytes (CD24, CD19), and/or NK cells (CD2 and/or CD56) can be used in step a).

[0043] Using anti-CD15,anti-CD16, anti-CD56, anti-CD2 or anti-CD24 antibodies therefore enables to detect and therefore exclude the cells expressing CD2, CD56 and CD24 proteins, notably the CD2+ T lymphocytes, the CD2+ NK cells, the CD56+ NK cells, the CD24+ immature granulocytes as well as the CD15+ or CD16++ granulocytes.

[0044] In a preferred disclosure the antibodies used to identify and/or to remove the contaminant cells according to the method of the invention comprise anti-CD16, anti-CD56, anti-CD2, and anti-CD24 antibodies. Of note, anti-CD15 antibodies may be used instead of anti-CD16 antibodies in order to detect the granulocytes.

[0045] According to the present disclosure a cell "expresses CD56" (or CD15 or CD16 or CD2 or CD24) if CD56 (or CD15 or CD16 or CD2 or CD24) is present at a significant level on its surface (such a cell being also defined as a "CD56+ cell", or a "CD15+ cell", a "CD16+ cell", a "CD2+ cell" or a "CD24+ cell", respectively). In particular, a cell expresses CD56 (or CD15 or CD16 or CD2 or CD24) if the signal associated to surface CD56 (or CD15 or CD16 or CD2 or CD24) staining (e.g. obtained with an antibody anti-CD56 coupled to a fluorescent marker) which is measured for said cell is superior to the signal corresponding to the staining of one cell being known as not expressing CD56 (or CD15 or CD16 or CD2 or CD24).

[0046] In a preferred disclosure CD56+ cells (CD15+ cells, CD16+ cells, CD2+ cells or CD24+ cells) are such that the ratio between the surface CD56- (or CD15- or CD16- or CD2- or CD24-) associated signal measured for said cells and the surface CD56 (or CD15- or CD16- or CD2- or CD24-) -associated signal measured for cells being known as expressing CD56 (or CD15 or CD16 or CD2 or CD24) is positive (i.e., above 0). Cells expressing CD56 (or CD2 or CD24) at their surface are well known in the art. Cells expressing CD56 include NK cells, while cells expressing CD2 are, for example, T lymphocytes and cells expressing CD24 are for example B lymphocytes. Cells that do not express CD56 are for example B lymphocyte.

[0047] The sequences of the clusters of differentiation CD56, CD2 and CD24 are well known in the art, and can be retrieved under the accession numbers NP_000606, NP_001758, and NP_037362, respectively. The sequences of these proteins are represented by the sequences of SEQ ID NO: 4-6 respectively.

[0048] The cluster of differentiation CD15 is the fucosyltransferase 4 (alpha (1,3) fucosyl transferase). In human, it has the sequence SEQ ID NO:9 (NP_002024). Cells expressing CD15 are for example granulocytes.

[0049] CD16, the low affinity receptor for the Fc part of IgG (therefore also known as FcγRIII], is a glycoprotein expressed in monocytes, and also in NK cells and neutrophils. Two isoforms (A and B) exist. In human, the isoform A has the sequence SEQ ID NO:2 (NP_000560.5) and the isoform B has the sequence SEQ ID NO:3 (NP_001231682.1).

[0050] Several monoclonal antibodies have been produced against the isoforms A and B of CD16 / FcyRIII and the corresponding epitopes have been localized on these proteins (see e.g. Fleit et al., Clin Immunol Immunopathol., 59(2): 222-235, 1991; Fleit et al., Clin Immunol Immunopathol.,62(1 Pt 1): 16-24, 1992; Tamm A. et al., J Immunol., 157(4): 1576-1581, 1996). Antibodies against CD16 are available commercially.

[0051] As used herein, a cell "expresses CD16" if CD16 is present at a level on its surface (such a cell being also defined as a "CD16+ cell"). In particular, a cell expresses CD16 if the signal associated to surface CD16 staining (e.g. obtained with an antibody against CD16 coupled to a fluorescent marker) which is measured for said cell is higher than the signal corresponding to the same staining of at least one cell being known as no expressing CD16, such as B lymphocytes. In other terms, the ratio between the surface CD16-associated signal measured for said cell and the surface CD16-associated signal measured for at least one cell being known as not expressing CD16 (e.g., a B lymphocyte) is positive (i.e., superior to 0).

[0052] In a preferred disclosure of the invention, step a) comprises the steps of:
  • Excluding the CD2+ cells from the analysis (in order to eliminate the contaminant T lymphocytes and a part of the NK cells);
  • Excluding the CD56+ cells from the analysis (in order to eliminate the remaining contaminant NK cells);
  • Excluding the CD16++ or the CD15+ cells from the analysis (in order to eliminate the granulocyte cells); and / or
  • Excluding the CD24+ cells from the analysis (said cells corresponding to granulocytes and B lymphocytes).


[0053] In a preferred disclosure the antibodies used to identify and/or to remove the contaminant cells according to the method of the invention are chosen in the group consisting of: anti-CD15, anti-CD16, anti-CD56, anti-CD2, anti-CD24, and anti-CD16 antibodies.

[0054] The monocytes to be detected in step a) of the method of the invention are therefore preferably the CD45+, CD14+, CD15-, CD16-, CD2-, CD56-, and/or CD24- cells present in the blood or plasma sample of the subject.

[0055] Expression of these cell surface antigens may be notably assessed using well known technologies such as cell membrane staining using biotinylation or other equivalent techniques followed by immunoprecipitation with specific antibodies, flow cytometry, western blot, ELISA or ELISPOT, antibodies microarrays, or tissue microarrays coupled to immunohistochemistry. Other suitable techniques include FRET or BRET, single cell microscopic or histochemistery methods using single or multiple excitation wavelength and applying any of the adapted optical methods, such as electrochemical methods (voltametry and amperometry techniques), atomic force microscopy, and radio frequency methods, e.g. multipolar resonance spectroscopy, confocal and non-confocal, detection of fluorescence, luminescence, chemiluminescence, absorbance, reflectance, transmittance, and birefringence or refractive index (e.g., surface plasmon resonance, ellipsometry, a resonant mirror method, a grating coupler waveguide method or interferometry), cell ELISA, , radioisotopic, magnetic resonance imaging, analysis by polyacrylamide gel electrophoresis (SDS-PAGE); HPLC-Mass Spectroscopy; Liquid Chromatography/Mass Spectrometry/Mass Spectrometry (LC-MS/MS)).

[0056] In a preferred disclosure the detection of these cell surface antigens is performed by an exclusion gating strategy by flow cytometry. Flow cytometry is a powerful technology that allows researchers and clinicians to perform complex cellular analysis quickly and efficiently by analyzing several parameters simultaneously. The amount of information obtained from a single sample can be further expanded by using multiple fluorescent reagents. The information gathered by the flow cytometer can be displayed as any combination of parameters chosen by the skilled person.

[0057] According to this disclosure each of the antibodies (e.g., anti-CD15, anti-CD56, anti-CD2, anti-CD24, and/or anti-CD16 antibodies) is labelled with a specific fluorochrome, enabling the cytometer to identify the contaminant cells carrying the antigen recognized by said antibody, and thus the selection of the cells which do not carry the antigen. The fluorochromes which can be used in this embodiment are well known in the art. They include such fluorochromes as e.g., PE, APC, PE-Cy5, Alexa Fluor 647, PE-Cy-7, PerCP-Cy5.5, Alexa Fluor 488, Pacific Blue, FITC, AmCyan, APC-Cy7, PerCP, and APC-H7.

[0058] The identification of the various contaminant cells by flow cytometry can be performed sequentially or simultaneously. Preferably, the identification of the various contaminant cells in the sample is performed simultaneously.

[0059] According to a specific disclosure the cells present in the sample of the patient are contacted with antibodies, each of which recognizing a specific antigen expressed by the monocytes or by one or more of the contaminant cells (e.g., CD45, CD15, CD56, CD2, CD24, and/or CD16), and each of which being labelled with a specific fluorochrome. The sample is then analyzed by flow cytometry.

[0060] The diagnosis methods of the invention can be practiced with any antibody or antiserum detecting (or recognizing specifically) the antigens expressed by the monocytes or by the contaminating cells.

[0061] The present inventors have surprisingly found that the proportion of classical monocytes (CD14+/CD16- monocytes, or MO1) is sufficient to discriminate between CMML and other blood diseases, such as e.g. MDS or MPN or reactive monocytosis. They therefore propose to use the proportion of CD14+/CD16- monocytes in the blood as a positive diagnosis criterion for CMML.

[0062] According to the method of the invention, the absolute, raw numbers of CD14+/CD16- monocytes present in the blood or plasma sample of the subject may be used to determine if said subject has CMML. However, it is advantageous to normalize this value to the total population of monocytes in the said sample.

[0063] Accordingly, a preferred embodiment relates to a method for diagnosing CMML in a subject, wherein step b) further comprises the steps of quantifying all the monocytes (that is, calculating the number or the concentration of cells of the MO1, MO2 and MO3 populations) in said sample and calculating the ratio of CD14+/CD16- monocytes (MO1) to all monocytes. This ratio is then compared to a reference value to determine if the said subject suffers from CMML.

[0064] In another preferred embodiment, step b) of said method further comprises the steps of quantifying the MO3 monocytes in said sample and calculating the ratio of CD14+/CD16- monocytes (MO1) to the MO3 monocytes. This ratio is then compared to a reference value to determine if the said subject suffers from CMML.

[0065] The term "reference value", as used herein, refers to the expression level of a CMML diagnosis marker under consideration (e.g., CD14+/CD16- monocytes) in a reference sample. A "reference sample", as used herein, means a sample obtained from subjects, preferably two or more subjects, known to be suffering from CMML. The suitable reference expression levels of CMML diagnosis marker can be determined by measuring the expression levels of said CMML diagnosis marker in several suitable subjects, and such reference levels can be adjusted to specific subject populations. The reference value or reference level can be an absolute value; a relative value; a value that has an upper or a lower limit; a range of values; an average value; a median value, a mean value, or a value as compared to a particular control or baseline value. A reference value can be based on an individual sample value such as, for example, a value obtained from a sample from the subject being tested, but at an earlier point in time. The reference value can be based on a large number of samples, such as from population of subjects of the chronological age matched group, or based on a pool of samples including or excluding the sample to be tested.

[0066] In this regard, the present inventors have shown that it is particularly advantageous to use a threshold value of 93.6 % for the proportion of classical monocytes MO1 in the total monocyte population. The ratio of classical (MO1) to total monocytes or to MO3 monocytes in healthy subject, as well as in subjects suffering from other blood disorders, is well below this threshold. Hence, this value ensures that the method of the invention gives a diagnosis with both high sensitivity and high specificity. As used herein, sensitivity = TP/(TP + FN); specificity is TN/(TN + FP), where TP = true positives; TN = true negatives; FP = false positives; and FN = false negative. Clinical sensitivity measures how well a test detects patients with the disease (e.g., CMML); clinical specificity measures how well a test correctly identifies those patients who do not have the disease (e.g., CMML). It is obviously also possible to detect the percentage of MO2 and MO3 monocytes in the total population of monocytes and to compare this value to the threshold of 6.4%. Patients having less than 6.4% of monocytes MO2 and MO3 should have more than 93,6% of monocytes MO1 and are therefore likely to suffer from CMML. Detecting the MO2+MO3 monocyte numbers is therefore a way to reduce to practice the method of the invention.

[0067] Thus in a preferred disclosure the reference value of the method is 93.6%. More preferably, the said reference value is 93,7%, 93,8%, 93,9%, 94 %, 94.5 %, 95 %, 95.5 %, 96 %, 96.5 %, 97 %, 97.5 %, 98 %, 98.5 %, 99 %, or 99.5 %. In other words, a subject has CMML if the ratio of CD14+/CD16- monocytes to all the monocytes or to MO3 monocytes of said subject is higher than 0.936, preferably higher than 0.937, 0.938, 0.939, 0.94, 0.945, 0.95, 0.955, 0.96, 0.965, 0.97, 0.975, 0.98, 0.985, 0.99, or 0.995.

[0068] In the context of the present disclosure a cell "expresses CD14" if CD14 is present at a significant level at its surface (such a cell being also defined as a "CD14+ cell"). In particular, a cell expresses CD14 if the signal associated to surface CD14 staining (e.g., obtained with an antibody anti-CD14 coupled to a fluorescent marker) which is measured for said cell is similar or identical to the signal corresponding to the same staining of at least one cell being known as expressing CD14.

[0069] In a preferred disclosure CD14+ cells are such that the ratio between the surface CD14-associated signal measured for these cells and the surface CD14-associated signal measured for cells being known as not expressing CD14 is positive (i.e., superior to 0). Cells expressing CD14 at their surface are well known in the art. They are for example classical and intermediate monocytes. Cells that do not express CD14 are for example T lymphocytes.

[0070] In the context of the present disclosure a cell "expresses CD16" if CD16 is present at a significant level at its surface (such a cell being also defined as a "CD16+ cell"). Assessment of CD16 expression can be performed as mentioned previously for CD14+ cells. Cells expressing CD16 at their surface are well known in the art. They are for example monocytes, NK cells, and neutrophils.

[0071] On another hand, a cell is said to be "CD16 " or "CD16low" if the signal associated to surface CD16 staining (e.g., obtained with an antibody anti-CD16 coupled to a fluorescent marker) which is measured for said cell is similar or identical to the signal corresponding to the same staining of at least one cell being known as not expressing CD16.

[0072] In a preferred disclosure CD16- cells are such that the ratio between the surface CD16-associated signal measured for these cells and the surface CD16-associated signal measured for at least one cell being known as not expressing CD16 is of about 1. Preferably, the surface CD16-associated signal of the target cells is compared to an average surface CD16-associated signal measured on a population of cells being known as not expressing CD16, so that the ratio between the surface CD16-associated signal measured for the target cells and the average surface CD16-associated signal measured on a population of cells being known as not expressing CD16 is of about 1. Cells that do not express CD16 at their surface are well known in the art. They are for example B lymphocytes.

[0073] The quantification of CD14+/CD16- monocytes thus preferably involves contacting the patient's sample with an anti-CD14 antibody and an anti-CD16 antibody so as to determinate the level of surface CD14 and CD16 expression.

[0074] The term "antibody" as used herein is intended to include monoclonal antibodies, polyclonal antibodies, and chimeric antibodies. Antibody fragments can also be used in the present diagnosis method. This term is intended to include Fab, Fab', F(ab') 2, scFv, dsFv, ds-scFv, dimers, minibodies, diabodies, and multimers thereof and bispecific antibody fragments. Antibodies can be fragmented using conventional techniques. For example, F(ab')2 fragments can be generated by treating the antibody with pepsin. The resulting F(ab')2 fragment can be treated to reduce disulfide bridges to produce Fab' fragments. Papain digestion can lead to the formation of Fab fragments. Fab, Fab' and F(ab')2, scFv, dsFv, ds-scFv, dimers, minibodies, diabodies, bispecific antibody fragments and other fragments can also be synthesized by recombinant techniques.

[0075] The antibodies used in the method of the invention can be of different isotypes (namely IgA, IgD, IgE, IgG or IgM).

[0076] They may be from recombinant sources and/or produced in transgenic animals. Conventional techniques of molecular biology, microbiology and recombinant DNA techniques are within the skill of the art. Such techniques are explained fully in the literature.

[0077] Commercial antibodies recognizing specifically the antigens expressed by blood cells can be furthermore used. Some of them are listed in the experimental part below (said list being however not exhaustive nor limitating).

[0078] These antibodies can be detected by direct labeling with detectable markers. Alternatively, unlabeled primary antibody can be used in conjunction with a labeled secondary antibody, comprising antisera, polyclonal antisera or a monoclonal antibody specific for the primary antibody. Immunohistochemistry protocols and kits are well known in the art and are commercially available.

[0079] In a preferred disclosure these antibodies are tagged with a detectable marker, preferably a fluorescent or a luminescent marker. Examples of detectable markers / labels include various enzymes, prosthetic groups, fluorescent materials, luminescent materials, bioluminescent materials, and radioactive materials. Examples of suitable enzymes include horseradish peroxidase, alkaline phosphatase, beta-galactosidase, or acetylcholinesterase examples of suitable prosthetic group complexes include streptavidin/biotin and avidin/biotin, examples of suitable fluorescent materials include umbelliferone, fluorescein, fluorescein isothiocyanate, rhodamine, dichlorot[pi]azinylamine fluorescein, dansyl chloride or phycoerythrin, an example of a luminescent material includes luminol, examples of bioluminescent materials include luciferase, luciferin, and aequorin, and examples of suitable radioactive material include 125I, 131I, 35S or 3H.

[0080] The present diagnostic tool may also assist physicians in identifying patients who are likely to progress towards even more serious form of CMML and thus may suggest those patients require heavier or more aggressive treatment.

[0081] As used herein, the terms "treat", "treating", "treatment", and the like refer to reducing or ameliorating the symptoms of a disorder (e.g., CMML, and/ or symptoms associated therewith. It will be appreciated that, although not precluded, treating a disorder or condition does not require that the disorder, condition or symptoms associated therewith be completely eliminated.

[0082] As used herein "treating" a disease in a subject or "treating" a subject having a disease refers to subjecting the subject to a pharmaceutical treatment, e.g., the administration of a drug, such that the extent of the disease is decreased or prevented. For examples, treating results in the reduction of at least one sign or symptom of the disease or condition. Treatment includes (but is not limited to) administration of a composition, such as a pharmaceutical composition, and may be performed either prophylactically, or subsequent or the initiation of a pathologic event. Treatment can require administration of an agent and/ or treatment more than once.

[0083] The invention thus also relates to in vitro methods for selecting a therapy for a patient with CMML comprising the steps of:
  1. a) Detecting by flow cytometry the monocyte population in a blood or plasma sample from the patient (for example by an exclusion gating strategy, as described above),
  2. b) Quantifying by flow cytometry the CD14+/CD16- monocytes in said sample from the patient, e.g., by one of the methods described above, and
  3. c) Selecting a CMML therapy based on the level of the CD14+/CD16- monocytes.


[0084] In one embodiment, the patient is selected for a treatment with a CMML therapy (e.g., a DNA methyltransferase inhibitor) if the CD14+/CD16- monocytes are present in the sample at a high level. In some embodiments, the patient is treated for CMML using therapeutically effective amount of the CMML therapy. Thus, in some embodiments, the patient is selected for a treatment with a CMML therapy (e.g., a DNA methyltransferase inhibitor) if the patient's sample displays CD14+/CD16- monocytes at a high level, and (following the selection) the patient is treated for CMML using therapeutically effective amount of the CMML therapy.

[0085] Therapies for CMML include various chemotherapeutic regiments such as e.g., topotecan, hydroxyurea, anthracyclines-Ara C, cytarabine, bortezomib, farnesyl tranferase inhibitors, histone deacetylase inhibitors, arsenic trioxide, and DNA methyltransferase inhibitors, such as 5- azacitidine, 5-aza- 2'-deoxyazacytidine, or decitabine. Preferably, a therapy for CMML is a DNA methyltransferase inhibitor. More preferably, said inhibitor is decitabine.

[0086] The invention also relates to an in vitro method for assessing the efficacy of a therapy in a patient suffering from a CMML, said method comprising the steps of:
  1. a) Quantifying by flow cytometry the CD14+/CD16- monocytes in a blood or plasma sample obtained from said subject during or after said treatment,
  2. b) Quantifying by flow cytometry the CD14+/CD16- monocytes in a blood or plasma sample obtained from said subject before said treatment, and
  3. c) Assessing the efficacy of therapy based on the comparison of the value of step a) with a value of step b).


[0087] The invention is also drawn to an in vitro method of adapting the CMML therapy of a CMML-suffering subject, comprising:
  1. a) Assessing the efficacy of said therapy as described above, and
  2. b) Adapting the therapy based on the result of step a).


[0088] According to a preferred embodiment, a decreased level of the CD14+/CD16- monocytes after treatment compared to the level determined before treatment is indicative of the efficiency of the CMML therapy for said subject. On the other hand, a level of the CD14+/CD16- monocytes which is unchanged or even increased after the treatment is indicative of a treatment which is inefficient. In this case, it may be necessary to select a more aggressive therapy or even to consider a bone marrow transplantation or stem cell transplantation.

[0089] Thus, said adaptation of the CMML therapy may consist in:
  • the continuation, a reduction or suppression of the said CMML therapy if the therapy has been assessed as efficient, or
  • an augmentation of the said CMML therapy or a change to a more aggressive therapy, if said therapy of step a) has been assessed as non-efficient.


[0090] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention pertains. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, suitable methods and materials are described below. In case of conflict, the present specification, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and not intended to be limiting.

[0091] Having generally described this invention, a further understanding of characteristics and advantages of the invention can be obtained by reference to certain specific examples and figures which are provided herein for purposes of illustration only and are not intended to be limiting unless otherwise specified.

EXAMPLES


Material and methods


Samples selection



[0092] Three French university hospital laboratories participated in this study.

Settings of the flow cytometers



[0093] A setting harmonization between the three different center instruments was realized. The optimal PMT voltage for each fluorescence channel was first determined using the Navios of one center (HM). Using these voltage settings, Versacomp beads (Beckman Coulter) labeled with each antibody were run on the Navios, without compensation. The median fluorescence intensity of the positive peak was recorded for each of the eight fluorescence channels. Then these target values were used as the median fluorescence intensity target values for setting up PMT voltages on the two other Navios instruments. Thereafter, each center calculated its own spectral compensation matrix.

[0094] Instruments setting were checked daily using Flow-Check Pro and Flow-Set Pro beads (Beckman Coulter) as recommended by the manufacturer.

Patient peripheral blood samples



[0095] Blood samples of the learning cohort were prospectively collected on ethylenediaminetetraacetic acid (EDTA) from patients with CMML diagnosis according to the WHO 2008 classification (n = 43), age-matched healthy donors (n = 26), patients with another hematopoietic malignancy (n = 16), and patients with reactive monocytosis (n = 32). These samples were collected after informed consent according to the Declaration of Helsinki. The learning cohort also including monocytes sorted from blood donor buffy coats (n = 23).

[0096] The validation cohort included 186 blood samples collected from CMML patients (n=28), patients with a myelodysplastic syndrome (MDS; n=28), patients with a reactive monocytosis (n=63) and age-matched healthy donors (n = 67).

[0097] Other hemopathies are composed of: 5 lymphoid hemopathies (3 monoclonal gammapathy, ,1 lymphocytose LGL, 1 LLC) 1 bicytopenia 3 hyperleucocytoses, 1 AREB, 1 JMML, 1 atypical MPN, 2 Vaquez, 4 myelofibrosis, 2 TE.

[0098] CMML diagnosis and stratification, counting promonocytes as blasts, were based on WHO 2008 criteria (Vardiman et al., Blood 114:937-951, 2009). Peripheral IMC (immature myeloid cells) represent the sum of peripheral blood blasts, promyelocytes, myelocytes, and metamyelocytes, according to MDAPS (MD Anderson Prognostic Scoring System) (Onida et al., Blood 99:840-849, 2002).

Multi-fluorochrome staining of learning cohort samples



[0099] Roughly three millions of peripheral blood mononuclear cells (PBMC) were sorted from peripheral blood samples by Ficoll Hypaque, washed with ice-cold phosphate buffered saline (PBS), and incubated at 4°C for 30 minutes with human Trustain FcX (Biolegend) as recommended by the manufacturer. PBMC were then labeled with anti-CD45, -CD24, -CD14, -CD16, -CD115, -CD62L, -CD64, -CCR2 and -CX3CR1 antibodies (BD Biosciences, table 1) and analyzed by flow cytometry using a LSRII (BD Biosciences). Acquisition was stopped after collection of 50,000 events in monocyte gate (defined in Figure 1).
Table 1. Human Antibodies used for the phenotyping of PBMC
AntigenAntibody nameClone (Isotype)FluorochromeCompanyReference
Human monocytes, PBMC
CX3CR1 Rat Anti-Human CX3CR1 2A9-1 (IgG2b) FITC Biolegend 341606
CCR2 Mouse Anti-Human CD192 TG5/CCR2 (IgG2b, K) PerCP-CY5.5 Biolegend 335303
CD62L, Mouse Anti-Human CD62L DREG-56 (IgG1, K) PE-CY7 Biolegend 304822
CD45 Mouse Anti-Human CD45 J.33 (IgG1) Krome orange Beckman Coulter A96416
CD24 Mouse Anti-Human CD24 ALB9 (IgG1) R-PE, texas Red Beckman Coulter B12699
CXCR1 Mouse Anti-Human CD181 8F1/CXCR1 (IgG2b) APC Biolegend 320612
CD14 Mouse Anti-Human CD14 M5E2 (IgG2a) Pacific blue Becton Dickinson 558121
CD16 Mouse Anti-Human CD16 3G8 (IgG1) APC-CY7 Becton Dickinson 560195
CD64 Mouse Anti-Human CD64 10.1 (IgG1) Alexa fluor 700 Becton Dickinson 561188
CSF-1R Rat Anti-Human CD115 9-4D2-1E4 (IgG1, K) PE Biolegend 347304
Human monocytes, whole blood
CD45 Mouse Anti-Human CD45 J.33 (IgG1) Krome orange Beckman Coulter A96416
CD24 Mouse Anti-Human CD24 ALB9 (IgG1) PE Beckman Coulter IM1428U
CD2 RatAnti-Human CD2 39C1.5 (IgG2a) APC Beckman Coulter A60794
CD14 Mouse Anti-Human CD14 RM052 (IgG2a) PE-CY7 Beckman Coulter A22331
CD16 Mouse Anti-Human CD16 3G8 (IgG1) Pacific Blue Beckman Coulter A82792
CD56 Mouse Anti-Human CD56 N901 (IgG1) PC5.5 Beckman Coulter A79388
CD64 Mouse Anti-Human CD64 22 (IgG1) FITC Beckman Coulter IM1604U


[0100] Table 1 shows the characteristics of each antibody that was used to perform this protocol, including antigen, antibody name, conjugated fluorochrome, catalog number and information about the provider company.

[0101] The figure 1 discloses the gating strategy for human monocyte subsets analysis in PBMC by flow cytometry. This analysis was based on an ongoing exclusion gating strategy. Labeled leukocytes were acquired using a LSRII Flow cytometer and analyzed with Kaluza software. (A) Monocytes were first roughly selected on morphological parameters (FSC versus SSC) including a part of lymphocytes and polymorphonuclears (PMN). Doublets were excluded using a FSC-int vs FSC peak (data not shown). (B) Monocytes were defined as CD45+/ SSC intermediate cells. (C) Granulocytes and B cells were both selected as CD24+ cells. (D) CD16high granulocytes (PMN) and NK cells were next isolated. (E) After exclusion of the contaminating populations of panels C and D, the remaining population was then subjected to the criteria CD16 and CD14 and the double negative population was depleted. (F) The remaining population was divided on the CD14 and CD16 expression between CD14+ CD16-(classical), CD14+ CD16+ (intermediate) and CD14low CD16+ (non classical) monocytes.

Multi-fluorochrome staining of validation cohort samples



[0102] Briefly, 200 µL of whole peripheral blood have been labeled with anti-CD45, -CD24, -CD2, - CD14, -CD16 and -CD56 (Beckman Coulter, table 1) according to the manufacturer recommendations. After 30 minutes of incubation in the dark, red blood cells were lysed and fixed with 1mL of Versalyse and 25µL of iotest (Beckman Coulter). Samples were analyzed within 24h of collection by flow cytometry (Navios, Beckman Coulter). Acquisition was stopped after collection of 40,000 events in the CD14+, CD16- (MO1) monocyte gate (defined in Figure 2). Centers provided flow cytometry standard listmode data (FCS) for each sample generated on-site.

[0103] The figure 2 discloses an overview of the exclusion gating strategy for human monocyte subsets analysis in total blood cells by flow cytometry.

[0104] Six color-labeled leukocytes were acquired using CXP-Navios software with a Navios Flow cytometer and analyzed with Kaluza software. Sequence of dot-plots shows the gating strategy used to identify the monocytes subpopulations.(A) Monocytes were first roughly selected on morphological parameters (FSC versus SSC) including a part of lymphocytes and polymorphonuclears (PMN). Doublets were excluded using a FSC-int vs FSC peak (data not shown). (B) On the remaining population selected (singulets gate), CD2+ T cells were first selected. (C) Then, NK cells were defined as CD56+ cells. (D) Isolated CD16high granulocytes (PMN) are isolated. (E) Finally, B cells and immature granulocytes were both selected as CD24+ cells. (F) Platelets clumps, cell debris and red blood cells were excluded as CD45low events. These populations were considered as contaminating populations. A monocyte population was then defined on CD45 vs SSC dot-plot as CD45+/ SSC intermediate. (G) After exclusion of the contaminating populations of panels B, C, D and E, the remaining population was then subjected to the criteria CD16 and CD14 and the double negative population was depleted. (H) Finally, from the remaining population, defined as pure monocyte populations, were identified the three monocytes subsets.

[0105] In order to have enough cells to analyze in appropriate concentration, we labelled 200µL of whole blood but used only 1mL of versalyse.

[0106] Also, we diluted the blood samples when leucocyte concentration was more than 10G/L (because of CD16 titration by granulocytes).

Flow cytometry analysis of monocytes subsets



[0107] The FCS files obtained from both learning and validation cohorts were analyzed centrally (DSB) in a blind fashion using Kaluza software (Beckman Coulter). The analysis was based on an exclusion gating strategy (as detailed in Figures 1 and 2). First, monocytes were gated on a CD45 versus side-angle scatter (SSC) dot plot as CD45high/SSC intermediate cells. To exclude contaminating cells in the monocyte population when analyzing PBMCs, we defined a NK-CD16pos gate, a PMN-CD16pos gate and a CD24pos gate, to exclude NK cells, remaining granulocytes, and B lymphocytes & immature granulocytes, respectively (cf. Figure 1). To exclude contaminating cells in the monocyte population when analyzing whole blood samples, we defined a LT-CD2pos gate, a NK-CD56pos gate, a PMN-CD16pos gate and a CD24pos gate to exclude T lymphocytes, NK cells, granulocytes, and B lymphocytes & immature granulocytes, respectively (cf. Figure 2). These contaminating gates were excluded using Boolean equation.

[0108] It is better to analyze the CD2 and CD56 markers versus SSC in order to avoid the depletion of monocytes that can be positive for these markers (Lacronique-Gazaille et al, Haematologica 92(6):859-860, 2007).

[0109] Moreover, it is advantageous to use the CD24 marker in order to avoid contamination by immature granulocytes, which can be found in some CMML samples (Droin et al., Blood 115(1):78-88, 2010).

[0110] On the remaining cells, three monocyte subsets were identified according to their relative expression of CD14 and CD16: CD14+/CD16- or classical monocytes (MO1), CD14+/CD16+ or intermediate monocytes (M02), and CD14low/CD16+ or non-classical monocytes (M03) (Wong et al., Blood, 118(5): e16-31, 2011).

[0111] Expression of some monocyte markers such as CD14 and CD64 is restricted to monocyte subsets, mainly MO1 and M02. A positive selection, based on the expression of one of these markers, leads to misgating the CD14low/CD64low MO3 subset.

[0112] It is better to collect at least 40,000 events in the MO1 gate to ensure an accurate estimation of the monocyte subset repartition.

Percentage of classical monocytes cut-off



[0113] The cut-off of classical monocyte percentages was obtained from a Receiver Operating Characteristics (ROC) curve using MedCalc software. MO1 percentages of both CMML patient and "not CMML patients" (young and age-matched controls, others hemopathies and reactive monocytosis) were used.

Results


Quantification of monocytes subsets in CMML



[0114] First, we focused on the biology of human monocyte subsets from peripheral blood mononuclear cells (PBMC) by flow cytometry. Using an exclusion strategy to deplete the contaminating populations (described in Figure 1), we identified monocytes as a CD45+/SSC intermediate population. Within this population, MO1 (CD14+/CD16-), MO2 (CD14+/CD16+) and MO3 (CD14low/CD16+) were identified as previously described (Wong et al., Blood, 118(5): e16-31, 2011). Each of these three latter populations was cell-sorted and analyzed by morphology after May-Grünwald-Giemsa (MGG) staining to assure the monocyte purity after these gating strategies (cf. Figure 3A). Moreover, these three monocytes subsets were identified by distinct expression profiles of trafficking (CCR2, CX3CR1) and myeloid function or differentiation (CD64, CD62L, CD115, CD181) markers as well at protein membrane level (cf. Figure 3B) and at mRNA level (cf. Figure 3C).

[0115] We assessed the level of MO1 population in a learning cohort of 140 patients. Similar monocyte subset profiles were obtained from 49 young or aged-control donors, consisting of 86.3 ± 0.9% (SEM) MO1 for healthy young donors (n=23) and 82.7 ± 1.4% MO1 for aged-controls (n=26) (cf. Figure 4A, 4B and Figure 5A). Compare to controls, the monocyte subset profiles of 43 CMML patients were utterly different with a strong increase in MO1 percentage: 96.75 ± 1.6% of MO1 population and a nearly total absence of MO2 and MO3 populations (cf. Figure 4C and Figure 5A). All other hemopathies showed a normal repartition of monocyte subsets with 83.9 ± 2% of MO1 population (n=16) and 78.9 ± 1.88% of MO1 in reactive monocytosis (n=30, p<0.001) (cf. Figure 4D and Figure 5A). The Krushall-Wallis test showed a significant difference in the distribution of MO1 level across the group (controls, other hemopathies or reactive monocytosis) and CMML samples but no difference across the distinct group of not CMML samples.

[0116] The MO1 percentage for CMML patients was observed to be independent of the absolute number of circulating monocytes, the gene mutation pattern, the proliferative versus dysplastic status of the disease according to the FAB criteria (leukocyte count cut-off value 13.109/L), and the disease subtype (type 1 versus type 2) according to WHO criteria (not shown).

[0117] Our data show that a specific phenotypic signature of monocyte subsets can be found in CMML peripheral blood.

Percentage of classical monocyte subset as a specific and sensitive tool for CMML diagnostic



[0118] To determine if quantitative analysis of MO1 percentage in PBMC could distinguish CMML samples from other ones, a ROC curve analysis was designed with datas from the learning cohort. ROC curve revealed that the area under the curve was 0,974 (cf. Figure 5B), what indicates that the test is strongly accurate in classifying cases as CMML or not CMML. ROC curve analysis reveals that a cutoff value of 93,9% of MO1 monocytes discriminates patient with CMML with a sensitivity of 95.6% and a specificity of 99%.

[0119] More precisely, Figure 5 discloses the analysis of the MO1 population in learning and validation cohort.

[0120] The learning cohort is composed of young controls (n=232) and aged-match controls (n=26); other hemopathies group (n=16); Reactive monocytosis (n=32); CMML (n=43). The performance of MO1 percentage measurement assay in discriminating patients with CMML from those without CMML (controls, others hemopathies, reactive monocytosis) was evaluated. The area under the curve (AUC) is 0,974, suggesting that the test is strongly accurate in discriminate the two groups. ROC curve analysis reveals that a cutoff value of 93,9% of MO1 monocytes discriminates patient with CMML with a sensitivity of 95.6% and a specificity of 99%.

[0121] The validation cohort is composed of aged-match controls (n=67); patients with a myelodysplastic syndrome (MDS; n=28), patients with a reactive monocytosis (n=63); and CMML patients (n=28).

[0122] The results demonstrate that MO1 percentage in blood provides diagnostic accuracy in distinguishing CMML patients from those with monocytosis due to reactive monocytosis or associated with other hemopathies. These results were confirmed with the validation cohort included 186 blood samples (cf. Figure 5C) and showed for the cutoff value of 93,9% of MO1 monocytes, a very strong discrimination of CMML patients with a sensitivity of 89.3% and a specificity of 92%.

Discriminant value of the ratio of classical to non-classical fraction (M01/M03)



[0123] As shown on figure 7A, the M01/M03 ratio was increased in CMML compared to all other tested cohorts (Kruskal-Wallis test, p<0.0001 for every subgroup compared to the CMML group in the learning cohort).

[0124] In the learning cohort, the use of the M01/M03 ratio to define CMML generated a ROC curve with an AUC of 0.967. The AUC of the ROC curve generated with MO1 percentage was 0.977, which was not statistically different (cf. figure 7B).

[0125] Altogether, the MO1/ MO3 ratio is therefore also able to distinguish CMML from any other subgroup of healthy or diseased peoples, but is not more efficient than MO1 percentage.

Percentage of classical monocyte subset as a specific and sensitive tool for monitoring the sensitivity of a subject having CMML to treatments



[0126] The analysis of MO1 percentage in blood in CMML patient under treatments (treatment by demethylating agents, azacitidin or decitabin) indicates if the patient is responder or not (cf. Figure 6).

Percentage of classical monocyte subset in blood and bone marrow



[0127] Table 2 indicates that analysis of MO1 percentage by the gating strategy analysis by flow cytometry as tool for CMML diagnosis can be done with samples of whole blood or samples of bone marrow. Table 2 shows similar results of MO1 percentage in 12 patients.
Table 2 shows MO1 percentage in whole blood and in bone morrow of the same 12 patients
 Whole bloodBone marrow
SampleMO1 %MO1 %
1 96,6 97,0
2 99,2 98,1
3 96,1 96,9
4 97,4 98,5
5 99,1 94,0
6 92,8 87,3
7 97,8 97,0
8 98,4 98,6
9 98,2 98,3
10 95,9 93,5
11 86,8 84,0
12 92,6 93,8


[0128] All the results set forth in the present application have been confirmed in a larger cohort of 307 patients (Fig 7 ; data not shown).

SEQUENCE LISTING



[0129] 

<110> INSTITUT GUSTAVE-ROUSSY

<120> DIAGNOSTIC OF CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML) BY FLOW CYTOMETRY

<130> B367541 D33492

<150> EP 14305755.2
<151> 22/05/2014

<160> 9

<170> Patent In version 3.5

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Claims

1. An in vitro method of diagnosis of chronic myelomonocytic leukemia (CMML) in a subject, said method comprising the steps of:

a) Detecting by flow cytometry a monocyte population in a blood or plasma sample from said subject;

b) Quantifying by flow cytometry the CD14+/CD16- monocytes in said blood or plasma sample;

c) Comparing the value of step b) to a reference value; and

d) Diagnosing CMML based on said comparison.


 
2. The method of claim 1, wherein said detecting step a) is performed by an exclusion gating strategy by flow cytometry.
 
3. The method of claims 1 or 2, wherein said detection step a) comprises contacting said sample with antibodies recognizing antigens expressed by granulocytes, T lymphocytes, B lymphocytes, and/or NK cells.
 
4. The method of claim 3, wherein said antibodies are selected from the group consisting of: the anti-CD56 antibodies, the anti-CD2 antibodies, the anti-CD24 antibodies, anti-CD15 and the anti-CD16 antibodies.
 
5. The method of any one of claims 1-4, wherein said monocytes are CD45+ cells, CD15- cells, CD16-cells, CD2- cells, CD56- cells, and/or CD24- cells.
 
6. The method of any one of claims 1-5, wherein step b) further comprises the steps of quantifying all the monocytes in said sample and calculating the ratio of CD14+/CD16- monocytes to all monocytes.
 
7. The method of any one of claims 1-6, wherein said subject is diagnosed as having CMML if the ratio of CD14+/CD16- monocytes to all monocytes is higher than 0.936.
 
8. The method of any one of claims 1-7, wherein the quantification of step b) comprises a step of contacting said sample with an anti-CD14 antibody and/or an anti-CD16 antibody.
 
9. An in vitro method for selecting a therapy for a patient with CMML comprising the steps of:

a) Detecting by flow cytometry a monocyte population in a blood or plasma sample from said patient;

b) Quantifying by flow cytometry the CD14+/CD16- monocytes in said sample, and

c) Selecting a therapy based on the level of the CD14+/CD16- monocytes.


 
10. An in vitro method for assessing the efficacy of a therapy in a patient suffering from a CMML, said method comprising the steps of:

a) Quantifying by flow cytometry the CD14+/CD16- monocytes in a blood or plasma sample obtained from said patient during or after said treatment.

b) Quantifying by flow cytometry the CD14+/CD16- monocytes in a blood or plasma sample obtained from said patient before said treatment, and

c) Assessing the efficacy of therapy based on the comparison of the value of step a) with a value of step b).


 
11. An in vitro method of adapting the CMML therapy of a CMML-suffering subject, comprising:

a) Assessing the efficacy of said therapy according to the method of claim 10; and

b) Adapting the therapy based on the result of step a).


 
12. The method of any one of claims 9 to 11, wherein said therapy is selected from the group consisting of: topotecan, hydroxyurea, anthracyclines-Ara C, cytarabine, bortezomib, farnesyl tranferase inhibitors, histone deacetylase inhibitors, arsenic trioxide, and DNA methyltransferase inhibitors, such as 5-azacitidine, 5-aza-2'-deoxyazacytidine, and decitabine.
 
13. The method of claim 12, wherein said therapy is a DNA methyltransferase inhibitor or decitabine.
 


Ansprüche

1. In-vitro-Verfahren zur Diagnose von chronischer myelomonozytärer Leukämie (CMML) bei einem Patienten, wobei das Verfahren die folgenden Schritte umfasst:

a) Erfassung einer Monozytenpopulation in einer Blut- oder Plasmaprobe vom Patienten mittels Durchflusszytometrie;

b) Quantifizierung der CD14+/CD16--Monozyten in der Blut- oder Plasmaprobe mittels Durchflusszytometrie;

c) Vergleich des Wertes von Schritt b) mit einem Referenzwert; und

d) Diagnose von CMML auf der Grundlage dieses Vergleichs.


 
2. Verfahren nach Anspruch 1, wobei der Erfassungsschritt a) durch eine Ausschlusstorstrategie mittels Durchflusszytometrie durchgeführt wird.
 
3. Verfahren nach Anspruch 1 oder 2, wobei der Erfassungsschritt a) das Inkontaktbringen der Probe mit Antikörpern umfasst, die Antigene erkennen, die von Granulozyten, T-Lymphozyten, B-Lymphozyten und/oder NK-Zellen exprimiert werden.
 
4. Verfahren nach Anspruch 3, wobei die Antikörper aus der Gruppe ausgewählt werden, die besteht aus: den Anti-CD56-Antikörpern, den Anti-CD2-Antikörpern, den Anti-CD24-Antikörpern, den Anti-CD15- und den Anti-CD16-Antikörpern.
 
5. Verfahren nach einem der Ansprüche 1 bis 4, wobei die Monozyten CD45+-Zellen, CD15--Zellen, CD16--Zellen, CD2--Zellen, CD56--Zellen und/oder CD24--Zellen sind.
 
6. Verfahren nach einem der Ansprüche 1 bis 5, wobei Schritt b) ferner die Schritte der Quantifizierung aller Monozyten in der Probe und die Berechnung des Verhältnisses von CD14+/CD16--Monozyten zu allen Monozyten umfasst.
 
7. Verfahren nach einem der Ansprüche 1 bis 6, wobei bei dem Patienten eine CMML diagnostiziert wird, wenn das Verhältnis von CD14+/CD16--Monozyten zu allen Monozyten höher als 0,936 ist.
 
8. Verfahren nach einem der Ansprüche 1 bis 7, wobei die Quantifizierung von Schritt b) einen Schritt des Inkontaktbringens der Probe mit einem Anti-CD14-Antikörper und/oder einem Anti-CD16-Antikörper umfasst.
 
9. In vitro-Verfahren zum Auswählen einer Therapie für einen Patienten mit CMML, das die folgenden Schritte umfasst:

a) Erfassen einer Monozytenpopulation in einer Blut- oder Plasmaprobe vom Patienten mittels Durchflusszytometrie;

b) Quantifizieren der CD14+/CD16--Monozyten in der Probe mittels Durchflusszytometrie, und

c) Auswählen einer Therapie auf der Grundlage des Pegels der CD14+/CD16--Monozyten.


 
10. In vitro-Verfahren zum Bewerten der Wirksamkeit einer Therapie bei einem Patienten, der an einer CMML leidet, wobei das Verfahren die folgenden Schritte umfasst:

a) Quantifizieren der CD14+/CD16--Monozyten in einer Blut- oder Plasmaprobe mittels Durchflusszytometrie, die vom Patienten während oder nach der Behandlung gewonnen wurde.

b) Quantifizieren der CD14+/CD16--Monozyten in einer Blut- oder Plasmaprobe mittels Durchflusszytometrie, die vom Patienten vor der Behandlung gewonnen wurde, und

c) Bewerten der Wirksamkeit der Therapie auf der Grundlage des Vergleichs des Wertes von Schritt a) mit einem Wert von Schritt b).


 
11. In vitro-Verfahren zum Anpassen der CMML-Therapie eines Patienten, der an CMML leidet, umfassend:

a) Bewerten der Wirksamkeit der Therapie nach dem Verfahren von Anspruch 10; und

b) Anpassen der Therapie auf der Grundlage des Ergebnisses von Schritt a).


 
12. Verfahren nach einem der Ansprüche 9 bis 11, wobei die Therapie aus der Gruppe ausgewählt wird, die aus Folgendem besteht: Topotecan, Hydroxyurea, Anthracycline-Ara C, Cytarabin, Bortezomib, Farnesyltranferase-Inhibitoren, Histondeacetylase-Inhibitoren, Arsentrioxid und DNA-Methyltransferase-Inhibitoren, wie zum Beispiel 5-Azacitidin, 5-Aza-2'-deoxyazacytidin und Decitabin.
 
13. Verfahren nach Anspruch 12, wobei die Therapie ein DNA-Methyltransferase-Inhibitor oder Decitabin ist.
 


Revendications

1. Procédé in vitro pour diagnostiquer une leucémie monomyélocytaire chronique (CMML) chez un sujet, ledit procédé comprenant les étapes suivantes :

a) détection par cytométrie de flux d'une population de monocytes dans un échantillon de sang ou de plasma provenant dudit sujet ;

b) quantification par cytométrie de flux des monocytes CD14+/CD16- dans ledit échantillon de sang ou de plasma ;

c) comparaison de la valeur de l'étape b) avec une valeur de référence ; et

d) diagnostic d'une CMML sur la base de ladite comparaison.


 
2. Procédé selon la revendication 1, dans lequel ladite étape de détection a) est effectuée au moyen d'une stratégie d'exclusion par fenêtrage par cytométrie de flux.
 
3. Procédé selon la revendication 1 ou 2, dans lequel ladite étape de détection a) comprend la mise en contact dudit échantillon avec des anticorps reconnaissant des antigènes exprimés par des granulocytes, des lymphocytes T, des lymphocytes B, et/ou des cellules NK.
 
4. Procédé selon la revendication 3, dans lequel lesdits anticorps sont choisis dans le groupe constitué par : les anticorps anti-CD56, les anticorps anti-CD2, les anticorps anti-CD24, les anticorps anti-CD15 et les anticorps anti-CD16.
 
5. Procédé selon l'une quelconque des revendications 1 à 4, dans lequel lesdits monocytes sont des cellules CD45+, des cellules CD15-, des cellules CD16-, des cellules CD2-, des cellules CD56-, et/ou des cellules CD24-.
 
6. Procédé selon l'une quelconque des revendications 1 à 5, dans lequel l'étape b) comprend en outre les étapes de quantification de tous les monocytes dans ledit échantillon et de calcul du ratio des monocytes CD14+/CD16- par rapport à tous les monocytes.
 
7. Procédé selon l'une quelconque des revendications 1 à 6, dans lequel ledit sujet est diagnostiqué comme ayant une CMML si le ratio des monocytes CD14+/CD16- par rapport à tous les monocytes est supérieur à 0,936.
 
8. Procédé selon l'une quelconque des revendications 1 à 7, dans lequel la quantification de l'étape b) comprend une étape de mise en contact dudit échantillon avec un anticorps anti-CD14 et/ou un anticorps anti-CD16.
 
9. Procédé in vitro pour sélectionner un traitement pour un patient souffrant de CMML, comprenant les étapes suivantes :

a) détection par cytométrie de flux d'une population de monocytes dans un échantillon de sang ou de plasma provenant dudit sujet ;

b) quantification par cytométrie de flux des monocytes CD14+/CD16- dans ledit échantillon ; et

c) sélection d'un traitement sur la base du niveau des monocytes CD14+/CD16-.


 
10. Procédé in vitro pour déterminer l'efficacité d'un traitement chez un patient souffrant d'une CMML, ledit procédé comprenant les étapes suivantes :

a) quantification par cytométrie de flux des monocytes CD14+/CD16- dans un échantillon de sang ou de plasma obtenu auprès dudit patient pendant ou après ledit traitement ;

b) quantification par cytométrie de flux des monocytes CD14+/CD16- dans un échantillon de sang ou de plasma obtenu auprès dudit patient avant ledit traitement ; et

c) détermination de l'efficacité du traitement sur la base de la comparaison de la valeur de l'étape a) avec la valeur de l'étape b).


 
11. Procédé in vitro pour adapter un traitement contre la CMML chez un sujet souffrant d'une CMML, comprenant :

a) la détermination de l'efficacité dudit traitement conformément au procédé de la revendication 10 ; et

b) l'adaptation du traitement sur la base du résultat de l'étape a).


 
12. Procédé selon l'une quelconque des revendications 9 à 11, dans lequel ledit traitement est choisi dans le groupe constitué par : le topotécan, l'hydroxyurée, les anthracyclines Ara C, la cytarabine, le bortézomib, les inhibiteurs de farnésyle transférase, les inhibiteurs d'histone désacétylase, le trioxyde d'arsenic, et les inhibiteurs d'ADN méthyltransférase, tels que la 5-azacitidine, la 5-aza-2'-désoxyazacytidine, et la décitabine.
 
13. Procédé selon la revendication 12, dans lequel ledit traitement est un inhibiteur d'ADN méthyltransférase ou la décitabine.
 




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Cited references

REFERENCES CITED IN THE DESCRIPTION



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Patent documents cited in the description




Non-patent literature cited in the description