State of the Art The aim of every tumor therapy is to stop unrestrained cell proliferation and to eliminate as many tumor cells as possible. For the most part, chemotherapeutic agents only attack proliferating cells whereas many tumors are resistant to chemotherapy per se or have developed chemotherapy resistance during treatment. Adjuvants (post-operative) and neoadjuvant (pre-operative) tumor therapy attempts fail in 15-50% of tumor patients (Desombre, E. R. et al, Cancer, 1980, 46: 2783-2790; Osborne C. K., et al, Cancer, 1980,46: 2884- 2888).

The classical prognosis factors in female patients with primary breast cancer are tumor size, degree of differentiation, hormone receptor status and lymph node disease (Graeff et al, p. 11 in Prognostic and relevant therapy factors in breast cancer, Novartis Pharma Publishers, Nurnberg, 1997). In everyday clinical practice, it is always surprising that tumors, which actually should be associated with a good prognosis determined using the above-mentioned prognosis factors, can take on an aggressive disease course.

Thus, after nodal-negative breast cancer, 30% of the female patients suffer a relapse within 10 years after the diagnosis (Foekens, p. 49 in Prognostic and relevant therapy factors in breast cancer, Novartis Pharma Publishers, Nürnberg, 1997).

Therefore, intensive work is being conducted world-wide on the preparation of molecular markers and/or their phenotypic equivalents which permit a prediction as to which female patients belong to high-risk groups and would profit from an adjuvant therapy.

Summary of the invention An object of the present invention is to provide indicators that are suitable to predict the responsiveness to a form of chemotherapy and/or the suspected failure thereof.

Further, an object of the present invention is to provide a diagnosis kit that provides prognosis factors which overcomes the above-mentioned disadvantages, i. e. permits an improved stratification of patients for treatment of benign and malignant neoplasias.

According to the invention, this is solved by a kit containing antibodies against a proliferation marker and a second marker selected from the group consisting of hormone receptors, apoptotic marker, marker for transformed cells, for the generation of a proliferation marker index and a marker index for the second detection antibody. These parameters are set in relation to each other and, as a result, the optimal form of therapy can be determined.

Preferably, the antibody against the proliferation marker is an antibody against the Ki-67 protein, MCM family, PCNA or phosphorylated histones.

The second antibody is preferably an antibody against the estrogen receptor, the progesterone receptor, CD30, bcl-2, Her-2/neu, and caspase cleaved cytokeratine 18 as defined by the mAb m30. The kit according to the invention may contain antibodies against several of these receptors, but it has been found that in most situations it is sufficient that the kit contains antibody or antibodies against one or two of these receptors, since the combination of a marker index for one or two of these markers in combination with a proliferation marker index has shown to be very effective in the stratification of patient for treatment.

In a preferred embodiment of the invention, the kit contains one or more antibodies against the Ki-67 protein and one or more antibodies against hormone receptors with which the Ki- 67 marker index and the hormone receptor status are generated. These parameters are related to each other and, as a result, the optimal form of therapy is determined.

In this connection, kits comprising one or more antibodies of the MIB@-family as the antibodies against the Ki-67 protein represent suitable embodiments of the invention. However, kits comprising another antibody as the first detection antibody that are capable of detecting the Ki-67 protein, for example the Ki-67 antibody, are encompassed within the kit according to the invention. As antibody or antibodies against the hormone receptors for determining the hormone receptor status, antibodies against steroid hormone receptors such as estrogen receptor, progesterone receptor or androgen receptor can be use. Antibodies against the respective hormone receptors may be used alone or in combination.

Preferably the kit according to the invention contains antibodies against estrogen receptor and progesterone receptor. Antibodies against one or more of these hormone receptors as they are already commercially available or known in the art may preferably be used as antibodies.

The determination of the optimal form of therapy for a patient using the indexes provided by use of the kit includes as any diagnosis a general status of the patient physical and psychical. However, the result of the indexes provided by use of the kit gives a clear indication as to which form of treatment will be optimal for a patient. Thus, it has e. g. been found that patients with a low marker index for the Ki- 67 protein and a positive hormone receptor status, in general should be subjected to an anti-hormonal therapy, whereas a cytostatic therapy in general should be used for patients with a high marker index for Ki-67 protein and a positive as well as negative hormone receptor status.

A high marker index for the Ki-67 protein means that 25% or more of the tumor cells, preferably 30% or more of the tumor cells, are labeled with antibodies against the Ki-67 protein.

Detailed description of the Invention The present invention relates to a kit for the stratification of patients for treatment of benign and malignant neoplasias.

In particular, the present invention provides a kit allowing the stratification of patients for treatment of benign and malignant neoplasias by generating a marker index for a proliferation marker and a marker index for a second marker selected from the group consisting of hormone receptors, apoptotic marker, marker for transformed cells and setting the same into relation for the determination of the subsequent form of treatment.

The proliferation marker to be detected with the first antibody (s) contained in the kit is for example a protein which is expressed only during the cell cycle. However, specific forms of a protein also represents a proliferation marker when this specific form can only be found in cells being in the cell cycle. A different form of the protein may exist in resting cells, however, the antibody (s) to be contained in the kit does/do not bind to this form. An example for these different forms is phosphorylated histones.

In resting cells, histones are not phosphorylated while in dividing cells they are phosphorylated.

Examples for a protein being expressed in the cell cycle only are the Ki-67 protein, MCM proteins of the MCM family, and PCNA.

The second marker index to be detected with the second antibody (s) contained in the kit is for example a protein being overexpressed in a neoplastic cell, or a protein expressed in a form normally not present in the cell. In addition, the protein representing the second marker may preferably be a tissue specific marker or a protein not present in the neoplastic cell. Furthermore, the protein to be detected may preferably be expressed in the neoplastic cells only.

Preferable examples of the above second marker are estrogen receptor, progesterone receptor, bcl-2, Her-2/neu, CD30, and caspase cleaved cytokeratine 18 as defined by the mAb m30.

For example, intracellular, specific steroid-binding proteins (steroid receptors) are prerequisites for the effect of the hormonal signal of steroid hormones. Receptors for estrogens (estrogen receptors), progesterones (progesterone receptors) and androgens (androgen receptors) are localized in cells of the target organs of these hormones, for example in tissues of the mammary and genital apparatus. The detection of estrogen and progesterone receptors in carcinomas of these tissues indicates a steroid sensitivity of the tumor.

It is well known that the estrogen receptor and the progesterone receptor may represent a prognosis factor.

However, it has been determined that treatment attempts derived from these prognosis factors fail in 15-50% of the tumor patients (Desombre, E. R. et al, Cancer, 1980,46: 2783- 2790; Osborne C. K., et al, Cancer, 1980 46: 2884-2888).

At the consensus conference in St. Gallen, 1995, it was decided that patients with a negative hormone receptor status should be subjected to an adjuvant chemotherapy (Possinger, p. 33 in Prognostic and relevant therapy factors in breast cancer, Novartis Pharma Publishers, Nürnberg, 1997).

The recommendation for a positive receptor status is the use of an anti-estrogen treatment, for example, with tamoxifen in tumors smaller than 1 cm (low risk patients) and in tumors with 1 to 2 cm (good risk patients).

For high risk patients (tumors larger than 2 cm), a combination of cytostatic and anti-estrogen therapy is recommended.

As a result of constantly improving, pictorial diagnostic methods, the use of the tumor size as a risk parameter has become increasingly problematic in past years because tumors can be discovered at an increasingly smaller state.

Therefore, objective parameters for the biological mode of behavior of neoplasias must be developed. Such a parameter has been found to exist in the so-called growth fraction of a tumor that can be measured by portrayal of the Ki-67 protein.

The nuclear Ki-67 protein (Gerdes, J., et al, Int. J. Cancer, 1983,31: 13-20) is detectable in all active phases of the cell cycle, i. e. G1, S, G2 and mitosis, whereas resting phase cells (Go) are consistently negative for this protein (Gerdes, J., et al J. Immunol. 1984,133: 1710-1715). This means, that Ki-67 protein expression (Ki-67 marker index) can serve as a measure for the growth fraction of a given cell population. Thus, antibodies against the Ki-67 protein have found broad application in histopathology, especially in numerous studies on the use as a marker for malignancy assessment in human neoplasias (Sawhney, N. and Hall, P. A., J. Pathol, 1992,168: 161-162; Schwarting, R., Lab. Invest., 1993,68: 597-599; Lelle, R. J., et al., Cancer, 1987,59: 83- 88; Lokhorst, H. M., et al., J. Clin. Invest, 1987,79: 1401- 1411; Gerdes, J. et al., Am. J. Path., 1987 128: 330-334 and 129: 486-492).

In retrospective studies on various tumor entities, the role of the Ki-67 marker index as a prognosis marker is discussed in a different manner: While a unanimous correlation between the survival time of patients and the Ki-67 marker index was described for malignant non-Hodgkin's lymphomas (Gerdes, J. et al., 1987, Lancet, ii 448-449; Grogan, T. M. et al., 1988 Blood, 71: 1157-1160; Hall, P. A. et al., J. Pathol. 1988, 154: 223-235), this has been controversially discussed in part for breast cancer: Harberg et al. (Prognostic and relevant therapy factors in breast cancer, Novartis Pharma Publishers, Nürnberg, 1997) found no correlation in multi-variant analysis, whereas Querzoli, P. et. al., J. Clin. Pathol. 1996 Nov; 49 (11): 926-930; Veronese, S. M. et al., Anticancer Res. 1995 Nov; 15 (6B): 2717-2722; Clahsen, P. C. et al., J. Clin Oncol. 1998 Feb; 16 (2): 470-479; Rozan, S. et al., Int. J.

Cancer 1998 Feb; 79 (1): 27-33; Jansen, R. L. et al., Br. J.

Cancer 1998 Aug; 78 (4): 460-465; Molino, A. et al., Int. J.

Cancer 1997 Aug; 74 (4): 433-437; conclusively prove that the portrayal of the Ki-67 protein in paraffin sections with the monoclonal antibody MIB-1 in the multi-variant statistic analysis is an independent prognosis parameter in breast cancer.

In a preferred embodiment, the kit according to the invention contains antibodies against the Ki-67 protein, especially antibodies belonging the MIB@-family such as MIB-1, MIB-2, MIB-5, MIB-7, MIB-21 and MIB-24. However, the antibody Ki-67 and other commercially obtainable antibodies are encompassed in the kit according to the invention as long as these antibodies detect the Ki-67 protein. The antibody against a hormone receptor can be a customary antibody against, for example, steroid hormone receptors such as estrogen receptor, progesterone receptor or androgen receptor, for example, clone ER1D5 from Dako or clone LHI from MEDAC.

The antibodies can be present as monoclonal or polyclonal antibodies. Furthermore, they can be biochemical or molecular biologically altered or be synthetic, whereby portions which are not necessary for the detection of proliferation marker, e. g. the Ki-67 protein and/or the second antibody, e. g. Her-2/neu, bcl-2, or hormone receptors are optionally entirely or partially absent and/or these portions are replaced by others which impart further favorable properties to the antibodies.

The necessary methods and processes for this are known to the skilled person; DNA recombinant technology is especially suited for this.

The method of detection may preferably occur directly on a section of the sample. The sample material can be present for example as a biopsy, a tissue homogenate, a fine-needle aspirate or tumor resection or can be performed by flowcytometry, etc.

Detection can be carried out directly or indirectly with known immunohistological and immunofluorescing processes.

For this, the reagents contained in the kit according to the invention can be directly labeled with generally known molecules, including enzymes such as alkaline phosphatase and peroxidase and fluorescent dyes such as FITC, TRITC, rhodamine, Texas-Red, ALEXA@-dyes, Cy@-dyes. However, labeling can also occur indirectly by using secondary antibodies or the antibodies against the Ki-67 protein and/or against the hormone receptor which are labeled with molecules such as biotin, digoxigenin or the like and are then detected with a secondary reagent.

The samples can be cyctological preparations such as smears or cyto-centrifugical preparations or tissue homogenates and can be present as frozen sections or as paraffin sections.

Preferably, cytopreparations and/or microscopic sections of a biopsy of the respective tumor section of a patient is detected with an Ab which may be included in the kit according to the invention and simultaneously and/or sequentially staining either in one section with the aid of directly-labeled Ab or in sequential sections of the material, whereby sequential sections should preferably be consecutive sections.

The determination of the indices can occur at the same time, sequentially or after one another. A simultaneous determination in one section is possible when both antibodies are present, for example, in a directly labeled form. A sequential determination or a determination one after the other is possible in a section, or sequential or consecutive sections are used.

The determination of the indices and/or the hormone status The determination of a marker index is generally known to the skilled person, e. g. the determination of the hormone receptor status is described, for example, by Stegner, p. 128 in Kindermann and Lampe, Immunohistochemical Diagnosis of Gynaecological Tumors, Thieme Publishers, Stuttgart, 1992.

The index is determined by counting a number, n, of tumor cells and comparing this with the number, m, of labeled tumor cells. The ratio of m/n in percent then results in the label index for the Ki-67 protein. The value, n, should be sufficient and preferably comprises 200 to 1000 tumor cells.

This determination of both indices can occur in an automated as well as manual manner.

The kit according to the invention can comprise the following components: Antibodies against the Ki-67 antigen, for example MIB-1, antibodies against the estrogen receptor, a secondary antibody coupled with a fluorescent label (or enzyme or substrate such as digoxiginin or biotin) that specifically detects MIB-1 and/or the estrogen antibodies as well as materials for depicting the enzyme, if for example a peroxidase or alkaline phosphatase is used, that allows detection over known enzyme substrates.

The kit can also contain directly conjugated antibodies that are conjugated with a fluorescent dye or an enzyme. These conjugates include enzymes and fluorescent dyes as they are mentioned above.